Recollections of Experiences at Queen Square

A career in a CNS related specialty had never crossed my mind when I applied for a job in a department of neurosurgery at Queen Square. However, after twelve months of obligatory pre-registration appointments, it was clear the weakest part of my education to date had been neurology. For a newly registered houseman, there were and probably still are no junior posts in neurology. But neurosurgery might provide an opportunity. After being well advised on how to apply, good fortune provided me with a six-month post in the Institute of Neurosurgical Studies, starting in the autumn of 1968 at the National Hospital annexe at Maida Vale, an undistinguished edifice just off the Edgware Road and quite close to the Lords cricket ground. The chiefs were Professor Valentine Logue (VL) and Lindsay Symon. The Senior Registrar with whom I had most contact while on this job was Robin Illingworth who was a mild and careful instructor. 
The major benefit of this first six months was learning how to examine the CNS and obtain consistent results which were in keeping with the findings of those who were more experienced. It was a most fascinating exercise in patience and logic requiring a proper knowledge of the wiring diagram which makes up the connections of the CNS. There were no computerised images and the existing neuroradiological studies were either angiogram or an air study. Neither of these studies show the internal structure of the brain. Thus, a precise clinical examination, invented early in the twentieth century at Queen Square remained the best tool for localising regions of malfunction within the brain. 
The examination of the CNS had to be undertaken according to a form which started with mental functions and ended with the examination of the physical nerves. Since surgical diseases like tumours, haematomas and abscesses tend to be localised to a single site, the requirements of the CNS examination were fairly simple and the examination protocol for neurosurgeons was also relatively uncomplicated. Medical diseases such as multiple sclerosis can be distributed throughout the nervous system and neurologists had to apply a far more detailed and complex examination with an appropriately more complex examination protocol. Today following the introduction of computerised imaging, the localising details of a clinical examination have become less important as the images show precisely where a disease is located. The clinical examination’s importance has shifted slightly from establishing a diagnosis to recording the course of a disease before and after treatment, since not all clinical changes are to be discovered on images. 
My first clinical examination was a baptism of fire. Firstly, the department had decided to take the evening out to celebrate my predecessor’s appointment to a new job. So, I was left to get on with examining a lady from Istanbul with a vestibular schwannoma. Having picked up the neurologist’s examination protocol by mistake, the examination took four hours, partly because of unnecessary detail, partly because of my inexperience and partly because of her limited grasp of English and an element of naughtiness. Later, after her surgery she remained unresponsive to the houseman but woke up at once and chatted when her consultant came round. It would become clear during the ensuing six months, that there was a real skill to the neurological examination and few people were more gifted at it than VL. An example is the way in which he examined a patient with proptosis. He would start by standing behind the seated patient and gently extending the neck. If one eyelid became visible before the other as the neck was extended, the existence of proptosis was confirmed. He would then stand in front of the patient with 5 x 8-inch index card. This would be bent in half along the long axis. A mark was written at the location of the bend. A similar mark was made on the patient’s skin just above the root of the nose. The two marks were then aligned, and the location of the pupils similarly marked on the card. With the card in place, it could be seen if the proptosed pupil lay above or below the level of the normal side. Finally, the card would be folded again and the difference of the pupil marks from the centre of the card noted. This all took very much less time than it does to describe. By this means, VL could tell if there was a focal space occupying lesion in the orbit and in which quadrant it was located. 
After a lifetime in a neuroscience milieu, it seems not unfair to state that a gentle eccentricity is a characteristic of many involved in that milieu. The Maida Vale hospital was undoubtedly impregnated with this feature. The young doctors had their housekeeping done for them by the residence maid, Dorothy. This included the collection and return of our laundry. My friend John Jarrett who would later become a 2 

distinguished neurophysiologist had rooms close to mine. We also had exactly the same collar size – 15. Back in those days, collars were separate and fixed to your shirt with a stud and starch was king. Dorothy could never decide who owned which collar so that I was often in possession of John’s and as he had five years seniority his were rather better than mine. She had one most treasured memory and that was she had looked after Lord Brain when he worked at the Maida Vale hospital. Eventually, she suffered a fracture of the neck of a femur and after convalescence went to live with a sister. This did not go well as she reappeared at Maida Vale. 
Some of the patients were also more than a little eccentric. There was the wife of one of the government ministers from a southern European country. She had Cushing’s Disease and had lost her looks on account of her condition. She was in a constant turmoil that her amorous husband would take advantage of her hospital admission to become close to some girl of better looks than morals, a reasonable suspicion. She had all sorts of imaginary symptoms until one of the ward auxiliaries and I hit on the use of linctus simplex. We told her it would soothe whatever symptom was causing her current discomfort and it invariable worked. VL caught me smiling at said auxiliary and since he missed little demanded an explanation, and I told him of the linctus. He grinned. 
Then there was the young gentleman from somewhere in the Middle East. He was the son of a rich man and the rumour was that in his home country driving his large expensive motor car, he had run over and killed a poor child. His father hurried him abroad after it was shown his vision was failing and there was every indication that he had a brain tumour. However, every time an angiogram was ordered he moved on to the next neurological centre of excellence. He would not accept this investigation which involved lots of needles and discomfort. It was noteworthy that his accompanying sister slept together with him in his private room. Only while he enjoyed a reasonably comfortable hospital bed, she slept on a mat on the floor under the bed placed so that her body was at a right angle to his. 
There was yet another young man from the middle east who had dived into his swimming pool having forgotten or not been informed that there was no water. He sustained a serious neck fracture from which he could not recover. It was his case I think that resulted in the hospital insisted on having the money to cover admission for Middle Eastern patients delivered prior to admission and had it stored in the hospital safe. 
Although this was a surgical unit, such lowly persons as I were not permitted to assist the consultants during operations. However, we did assist the senior registrars. I assisted Robin Illingworth on many occasions and became aware of the obsessional nature of the neurosurgeon’s personality. Following surgery, a specified number of compresses together with a single elastic crepe bandage were applied with seven large safety pins to fasten it. VL insisted on the technique and woe betide the junior who deviated from it. Adhesive plaster was particularly frowned upon. As a new boy, being inculcated with the need to be obsessional, I observed Mr. Illingworth’s technique for closing the scalp. This was done in two layers as introduced by Harvey Cushing. I noticed, for my sins that Mr. Illingworth always placed 29 skin stitches so that on one occasion I asked him if this was another part of the numerically precise technique in use on the department. He denied the accusation with more than a little annoyance. Nonetheless, it says much about his obsessive personality that until I left, he never again used 29 stitches and about mine that I know this because I counted every time. 
During my time at Maida Vale and Queen Square there was the opportunity to meet and listen to some of the legendary giants of the profession. Neurologists and neurosurgeons are somewhat concerned with their tendency to ancestor worship and the concern is justified. However, it seems to do no harm and increases the incentive to be familiar with what has been done by past generations and explaining why professionally we are where we are today. One of these giants was Sir Charles Symonds. Universally respected as the greatest clinical neurologist of his generation, his appearance and manners well lived up to that reputation. What happened was this. A patient, an elderly lady had been admitted to the Maida Vale hospital under VL’s care. The reason for the referral was that Logue was qualified both as a physician and a surgeon so medical cases could come to his ward. Moreover, referring to a surgeon did not involve the loss of face for the Oxford neurologist concerned, which a referral to a neurologist in London would have occasioned. I wrote her notes. She had a motor disturbance involving the pyramidal, extrapyramidal, and cerebellar pathways; in other words, all three motor systems. She could see a little with one eye but was blind when using both. This was because her eyes were fixed in an abnormal position divergent from each other and with almost no range of movement. Her pupils were tiny and unreactive. For nearly a fortnight her diagnosis remained a mystery despite being 3 

seen by every available London neurologist. VL was making increasingly irritated remarks about getting the bed back, but his senior registrar kept his resolve. Then, I think on a Monday afternoon Sir Charles arrived to see her. He smiled and greeted her with formal courtesy. Requested permission to lift her head and placing his left hand behind her head lifted her and her whole body followed, all of a piece. He laid her back to rest and said, ‘Thank you Madam’ and that was it. His total time with her was less than a minute. At the meeting afterwards it was quite clear that he knew the diagnosis, Steele Richardson syndrome. That performance was truly the stuff of legend. 
After three months at the Maida Vale hospital, one transferred to the National Hospital in Queen Square. This was still an ancient building back in 1968 without any of the current modern extensions. The Royal College of Surgeon’s examination hall threatened across the square. The little park in the centre is the location of one of the first bombs dropped on London from a Zeppelin, in the First World War in 1915. Was this an acknowledgement of the German’s view of the importance of neurologists for national defence? Certainly, like Maida Vale there were eccentricities galore. For the first four days when attending lunch nobody would talk to me and nobody would tell me why, until I noticed that everyone else took off their white coats and hung them up outside the dining room. Following suit led to being welcomed to the family. 
Another eccentricity was that when a neurologist referred a patient for surgery, it was assumed that the surgery, no matter how simple, would be performed by the consultant concerned. Failure in this respect led to a cessation of referrals. This had the negative effect of hindering the training of neurosurgical junior staff. There was also a rumour reflecting how many prima donnas were amongst the senior staff that there was one way and one way only for all the consultants to be seated for dinner and willing to talk to the person on either side. 
One of the pleasantest and most instructive social events during a Queen Square appointment were the dinners where two guests of honour, distinguished emeritus colleagues were invited. One of these was the then 85year old Sir Francis Walsh. He was courteous and amusing. However, he wrote a thank you letter posted on the junior doctor’s notice board thanking them for his supper and assuring them that he was confident that in their hands, neurology could once again be raised to the heights of yesteryear. This was however a touch unfair. Walsh was a clinician and research at Queen Square had been lagging. In 1962 the first professor of neurology at the institute of neurology was appointed. Roger Gilliat was a daunting person. In his short biographical reminiscence at the Royal College of Physicians it is noted that “Where he felt strongly, he found peaceful disagreement difficult and at times it almost seemed as if views in opposition to his own were to be regarded as a challenge to battle rather than a challenge to his substantial powers of gentle persuasion”. This author can confirm the truth of this having been queried the professor about one of his patients, at the time on the neurosurgical ward. Gilliat wanted what to know my boss’s thoughts in respect of a number of questions on which I had not been briefed. It was not a comfortable encounter. 
Junior doctors back then lived in a residence by the side of the hospital which is now the site of the Institute of Neurology building. This was a residence that was shared with some unusual residents including in my time an ex-tank driver from the Israeli army who had been employed as a ward auxiliary. I was in the residence for three months in early 1969 and this young lady used to come to the doctor’s private common room and choose the TV channels, until a Lebanese junior surgeon suggested that one of his colleagues, Rab Hide a surgeon from Glasgow and at the time Wylie McKissock’s senior registrar, was a leader in the ‘Scottish El Fatah’. She did not return. A more persistent and unusual group of residents were the old ladies. They were in the doctor’s residence having been taken in during the war when the German bombing destroyed their homes. They were from Camden and by 1969 were all pretty aged and suffering from various illnesses. Their health was the responsibility of the RMO (a neurologist) while the RSO (me) was responsible for injuries to the epileptic maids of whom Queen Square as a neurological hospital had a fair number. To return to the old ladies there was one with advanced heart failure. Walking to the local grocer and back (about 200 yards) took her a whole morning. There came a time when a daily extending line of milk bottles suggested her demise and the appropriate arrangements were made. My rooms were on the top floor next door to another of these old dears. On a Saturday afternoon I was luxuriating in a hot bath when my bleep went. It was the work of an instant to start emptying the bath and opening the bathroom door with my vitals covered by the most minimal of hand towels; an appearance which would have produced shock in the elderly ladies from the South Wales where my family had its origins. Imagine then the shock of finding the old duck slowly limping her stiff osteoarthritic 4 

legs on the way to her door. She was amongst other things stone deaf and was hindering my response to the emergency bleep. It was not possible to touch her and she did not hear my yells, so I jumped up and down and she detected the vibrations. Turning round she surveyed my almost unclad person and remarked, “Dr you know I’m a bit deaf and I know I play my radio rather loud. If it’s a bother, please knock on the wall.” Totally ignoring my nearly naked sopping wet dripping self she then turned around and entered her room leaving me free to pursue my duty. The building has now gone to be replaced by an efficient, secure but not really attractive concrete monster. 
It was in the aforementioned junior doctors’ common room that I met Sir Charles Symonds for the second time. It was over a year later and of course he had no recollection of the first. The occasion was the celebration of his eightieth birthday to be marked by a celebration dinner in the doctor’s mess. I arrived slightly late for the pre-drinks get together and was taken over to meet Sir Charles, who looking down on me said “You must be a surgeon, you look so dashing”. I was wearing my Dad’s old dinner jacket with a white shirt with gold studs. Obviously, he knew I was a surgeon because he’d never noticed me before, but it was a flattering introduction. We fell to talking and as I knew he was fascinated by subdural bleeding, I mentioned an odd case I’d seen, and he requested details. The patient had come to a general practice surgery in my hometown Swansea where I’d been employed for four weeks during the summer. The man was fifty-six years old and a window cleaner. Several months before, he had fallen from his ladder and banged his head suffering otherwise no other inconvenience. He came to the surgery complaining of vague problems with concentrating and excitement without mentioning the fall. About a week later it was necessary to visit his home where I found him dazed in the kitchen. His wife was missing a couple of teeth and a very large neighbour was in tears over having had to punch the man to get him under control. The patient had apparently gone completely wild and punched his wife in the mouth for no very good reason. It was possible to chat with him and he exhibited the classical flight of ideas characteristic of mania. The local psychiatric hospital unusually was happy to admit him and he raised no objections. Arrangements were made for dental care for the wife and my locum came to an end and I went to London to start work at the Maida Vale hospital. About a year later on a visit home I was accosted in the street by a substantial grey-haired woman who yelled Dr. Ganz at me. I had absolutely no idea who she was although you couldn’t help but notice her missing front teeth. “Oh Dr. Ganz she said it all went so well he’s quite better now”. I stood there in a state of total ignorance with a silly smile on my face trying to look as though I was pleased for her. Then she said, “It was getting him into Cefn Coed which sorted him out”. Cefn Coed is the local psychiatric hospital and he was the only patient I’d ever admitted there so of course it all came back. They had examined him further with images and shown he had a subdural bleed which was relieved. He was cured. After finishing this tale Sir Charles looked at me and then said something I’ve never forgotten. He remarked “Every time I talk to a new doctor, I learn a new presentation of sub-dural bleeding.” This short introductory encounter was followed by a glorious dinner where the wine and liqueurs flowed all too freely, and the following day payment would be extracted. 
The Department of Neurosurgical Studies was lodged in a prefabricated annex attached to the main Queen Square building. For the junior member of staff, it had one function important above all others, it was the site of the journal club. This was attended by ALL staff including a senior neurosurgeon who came in from a small department in Romford in Essex. Absence or lateness were totally forbidden and for my sins I was the only member of staff to commit this crime in the eighteen months I worked at Queen Square. The morning after the aforementioned dinner I arrived no less than fifteen minutes late. VL turned towards me radiating ire as I entered grey faced into the room. However, after a single glance at my complexion he commanded me to take coffee and retire to my usual corner seat where I could have a cigarette; such being the custom back then. After the meeting he enquired as to the state of my health, which my appearance had all too easily revealed. It was necessary to admit that there had been a party the night before and perhaps I’d “enjoyed myself too well but not too wisely”. He smiled and remarked that his annual party for junior staff was that evening and I was expected. This was not an invitation which could be refused. The party was to be held in his club instead of his home as he was making it an all-male affair. This was done as a courtesy to his visiting trainee from Canada who was in England without his wife, which would have potentially isolated him in a get-together where everyone else was there with a partner. So, I turned up for this damned dinner with one of those hangovers where you hate yourself, mankind and especially whoever was in your immediate neighbourhood. It got worse. VL insisted that I sit next to him on the grounds that since I was now doing a research year, he hadn’t seen much of me. Think of it! You have a filthy hangover and have to sit next to the one person who 5 

really can control your future career. I staggered towards my chair and gripped the back and squinted at the table with all its snow-white linen and glittering tableware. In front of every place there was a large round wine glass, misted from the cold, filled with a clear bubbling liquid with a thin sliver of orange floating on the surface. He looked down at me and said ‘Don’t argue! Drink some!’. I obeyed and imbibed some of the delicious, iced orange champagne cocktail believed to be made to VL’s own recipe. It was pure magic. The hangover simply rose up, departed leaving me in a state of grace. Clearly these senior London consultants knew a thing or two and not just about their job. I felt confirmed in my choice of career.