Poet and doctor Glenn Colquhoun gave the following extraordinary oration at this year’s meeting of the Royal College of General Practitioners conference in Wellington. Glenn has kindly agreed to let us republish it.
THE Wolffian ducts are embryonic structures in mammals. Under the influence of testosterone they form the internal genitalia of the male: the epididymis, the vas deferens and the seminal vesicles. They also have a role in the generation of the kidney as well as of the Mullerian duct, a precursor of the female reproductive tract. Disturbances of testosterone metabolism give rise to a number of disorders affecting their development including complete androgen insensitivity syndrome, 17B hydroxysteroid dehydrogenase deficiency, LH receptor mutations and 5a reductase deficiency.
Most of this I learnt this in medical school. I don’t know why I remember it now. More useful information has long since disappeared but the Wolffian ducts remain a magnificent testimony to the fact that I once knew something, a great pyramid perhaps, hinting at a previous civilization. I regret few people with disorders of their Wolffian ducts have ever been patients of mine. In fact, apart from a few of the old favourites, I don’t often see much of what I learnt about in medical school at all.
The things no one told me about take up too much time: WINZ forms, ACC forms, insurance forms, medical certificates – disorders of paperwork completely ignored by the syllabus. Nevertheless I am beguiled, most of my day I sit and listen to people talk. Of all the conditions I do see that no one ever taught me about, ache is by far and away the most common. Too often in my practice it has forced me to leave the tar-seal of the textbook. At those times I have returned to what I have learnt from life by living it, mainly from making a hash of it. It is the most reliable source of ache I know.
Before I go any further I should try to explain what I mean by ache but that won’t be easy. I can’t quantify it or measure it and most of my life I have called it other things: God, sin, failure, pain, joy, and that-voice-inside-that-won’t-be-quiet. Most commonly it is located in that small groove between my stomach and my chest – retro-sternally I suppose, although it can climb into the back of my eyes and it can equally descend. It does not make me feel happy or sad but is usually a mixture of both, at times a loneliness, at others an exhilaration; sometimes it is a dog barking at the approach of danger. It seems to exist on a ledge, a place I come to at the edge of myself and from which I am capable of connecting to what is beyond me. If I was to have a tow bar this would be a good place to put it.
The more I am aware of it in me the more I see it in others. At first I thought I was projecting my inner life onto them but the longer I work in medicine the more consistently I bump into it. It may be in the specific demand a patient makes but it is usually more subtle than that, submerged, looking at me with crocodile eyes from the swamp of whatever else is going on saying, ‘It’s me. I’m here. I’m hungry.’ Sometimes people point at it and roar saying, ‘Fix that – it must be a disease.’ Usually people are only aware of a vague disturbance instead, dressing it up in a number of other complaints. I’m not even sure it is a disease, more some sort of pregnancy. Nonetheless, it requires a careful midwifery. Having said all of that I suspect the best way for me to explain ache to you is for me to show you what it feels like.
Most Sundays, as a child, I lay on the lounge room floor with my father and watched television. There was usually a Western on at midday and I would be equally engrossed in the actions of the seventh cavalry and my father beside me. In summer he would wear only a pair of shorts and his large brown body would loom over me like the USS Enterprise docked beside my tug. Sometimes I would lie on his back and survey his moles, wondering at his smell and architecture. It has always seemed an apt memory. He was my landscape.
I grew up a man’s son. My father was a builder off the farm at Ardmore, south of Auckland, all muscle and meat. His hands were twice the width of mine, even as an adult. Hard work was a way for him to make sense of the world as well as an answer to arguments. Despite my aversion to hard work I like to think I am a chip off the old block. He took me with him to work from the time I was a child. At first I nailed pieces of wood together then graduated in time to digging drains, painting the soffit, mixing concrete, framing up, putting on the roof and hanging doors. He taught me how to be with men and to talk like them at the same time, looking down at me sitting on a nail-box. ‘You drink a mean milkshake, old king,’ he would say in a way that made me want to have this achievement alone chiselled into my tombstone.
When he was thirty-eight he was diagnosed with Parkinson’s disease. I was thirteen and over the next thirty years he was dismantled plank by plank. I watched him fall into irrelevancy then ruin then idiocy. It seemed an irony that the illness attacked what he was best at, being in his body. In his later, most disabled, years I remember spending nights with him at times, placing his urodome, getting up to his calls in the middle of the night to find him in a ball of sweat, helplessly trying to get the blanket off his feet, or wedged under the bed where he had been trying to stand up for the last hour.
There is a desperate beauty in the failing body. Being afforded the view is one of the great privileges of medicine. Breasts fall, bellies sag, the skin fills with subtle arcs and whorls as though it was sketched. Bones become more prominent. Eyes wetten, yellow and seem to protrude as though we are weathered back to something older and more eternal and more humble. Immortality can be hard to live with. Flesh seems relieved in the end to be rid of the responsibility. This is the beauty of the tide gone out over the tight lap of the sea against its belt. Sometimes people seem to make an appearance in their own skin for the first time as though they were stepping out from behind a curtain to take a bow. When the body you are watching fail is a parent all this seems even more poignant, as though the sky and sea itself are melting. Hot on the heels of this realization comes the next: that we are somehow expected to take their place. In that case there can be no parents at all – only children whose old ones have gone on. We are all uncertain.
My father was seven stone when he died – all Alps and no plain. Looking down on him towards the end with everything said and all else withered away only what was necessary remained: a sure knowledge of our helplessness and love to ballast that, an awareness that this is all we are and that this is all we are. He was powerless in the long-run, fighting a rear-guard action nonetheless, the wagons drawn up in a circle and the ammunition running down. He kept hammering away at the bolt while we slipped away one by one. I still see him patched up at the Alamo, giving me a wink now and then, taking a break from the gun battle to drink a mean milkshake, Mexicans everywhere crawling over the roof. Perhaps ache has something to do with this.
My ex-wife is blue-eyed and Australian, qualities alone for which a man should marry. There is still much I do not know about her and much that I cannot say but her life had been very different to mine. Somewhere in the making of her sense of self had been sown a great pain and she grew around it to survive and because she had no other choice. It made her extraordinarily watchful and extraordinarily imaginative. In the worlds she created for herself she existed untroubled. She was continually troubled when asked to live in the one most of us think is the only alternative. I have never met anyone so real in all my life and suspect I never will again. She took me into the dark and I stayed long enough for my eyes to adjust and see that it was full. The problem was everyone expected her to live in the light. We are righteous about that.
For ten years we were a team. I intervened at every border between her and the world of the everyday and she inducted me into the ten heavens and hells of the mind. The irony is she knew my world better than me, like a tourist who has seen more of our country than we have. She could not live here however. She loved people and when she allowed herself to be with them they would feel her searchlight eyes bore into them to find their hidden joys and sorrows, pressing a finger to her lips to reassure them that she would keep their secrets. But the energy to do this exhausted her and she would have to withdraw and rest to repeat the exercise on a daily basis. For her being social was not a thing to be taken for granted. She was not scared of us. She was scared of all of us.
In lots of ways I am more proud of the man I was then than any I have been before or since. I walked between our worlds and smoothed her transition, held her hand, made up excuses, beckoned, defended and listened. Painstakingly, I made her believe in a life outside her head and when she had come to trust me fully I failed her spectacularly. Eaten from the inside out I did not recognise how wrung out I had become or indeed that one could become so exhausted. I left her when she was safest. People will say that I fell in love with somebody else which is true but the other truth is that I was more tired than I have ever been in my life. Destroying in such a way the trust I had begged for so long has bestowed an exquisite pain. It was a terrible loss of innocence.
In many ways love itself is all ache. When it is destroyed the mushroom cloud can leave our skies red for an unreasonably long time. Its loss is also a very public and personal humiliation, a failure of what is expected of us by those watching and by ourselves. And failure, of course, is one of the great furnaces of ache – almost a precondition. This may be because we usually have to be stopped in our tracks in order to notice what is right in front of our eyes and failure is a useful sledgehammer, or it may be that something has to be just out of reach for ache to be fully realised and failure opens up that gap. Over time our sorrows accumulate. Ache becomes part of our shape – a weird anatomy. It can be felt, seen, perceived and mapped by those who know its language. We wear those we have loved in the same way. Sometimes they protrude and bump into people on their way past. Sometimes we bend around their invisibility and others only notice that we walk funny. If nothing else the hopeless in love are good company, sensing the rot in each other and making everyone else feel good about themselves by comparison. Getting better is much more dangerous. Perhaps all ache at the end of the day is a reaching.
For the first two years of her life I sung my daughter to sleep. The old numbers were my favourites:
I’m calling to tell you it’s over,
yes darling, you’re now free to go.
You’re saying you’re sorry you hurt me
but you hurt me much more than you know.
It seemed to work more often than not and made me feel that I was a loving father. The truth in retrospect was that in the solitude of that dimly lit room I could unleash the talent that had never been recognised by my sisters on a defenceless child. I had watched for her milestones carefully and ticked them off with pleasure when they arrived: smiling, sitting, crawling, walking and then her first word. As soon as one was reached I would be restless for the next. I dearly awaited her first three word sentence. A three word sentence would contain a subject, object and predicate and seemed unreasonably important considering I would do just about anything to limit her sentences to three words now. Not long before she turned two I remember holding her in my arms one night beside her cot. She was snug in her pyjamas with her large brown eyes almost shut. I had just finished the chorus, eyes half shut myself, lost in the honey-dew of my voice:
I’m just on the blue side of lonesome,
right next to the Heartbreak hotel,
in a tavern that’s known as Three teardrops,
on a bar-stool not doing so well.
When I looked down my daughter was staring up at me wide-eyed. She opened her mouth slowly and with a purpose I had not seen before. I knew something profound was about to happen. ‘Don’t sing daddy,’ she begged, shattering the ambiance I had created. I was parent enough to appreciate her first subject, object and predicate but am still wounded somehow that for eighteen months she had been desperately searching for the language to tell me to shut up.
When she was two I took her to the swimming pools. It was her favourite place and I became used to concealing my body in the deep end of the children’s pool like some old hippopotamus. The braver she became in the water the further she would roam from me and the more delighted she would grow in that independence and the feel of the water on her body. She began to ripple out from me in ever increasing circles. One day I watched her splash with joy in the water like some demented bird, her arms flapping and her body shaking at the feel of the water on her naked skin. She was delighted and oblivious and had moved far enough away from me that I saw her for the first time and knew in that moment I would lose her. Her fundamental relationship was with the world. Her job was to grow and taste and experience and mine was to be fed on for long enough to allow her to do that well. She would never love me in quite the same way that I would love her. Hot on the heels of this insight was the realization that I had consumed my parents in exactly the same way. For a period of time I seemed to be exquisitely skewered, blind to my parents for forty years and unseen by my daughter in return. I also knew that this is how life is supposed to work. We love our children and pay back our parents at the same time. The debt of one generation is repaid in the next. We are pip then apple then apple core. It was just as well I was in a swimming pool because I wanted to cry.
What I wanted to cry about was all the knowing and not knowing I seemed to hold at that moment but could not discharge. Dramatic irony is that bit in a movie where we see what is going to happen next but the character in the story doesn’t. We want to reach out into the celluloid, tap them on the shoulder and tell them there is an axe murderer in the shower. Being a parent is like that. Often ache drives us to speak, to place some meaning in its gaps but there are times when nothing can be said and we come to a hard edge of the world. The throb is palpable from here but the view can be bleak or spectacular depending on how we look at it. When we love our children we bring so much inside knowledge that they cannot and should not be aware of. It can be overwhelming. My daughter is the only person I am happy to be ignored by for the rest of my life.
It seems to me that there are two fundamental ways of approaching the nature of ache. The first way is to say that ache is about our limitation as human beings. It occurs when something rises beyond us and we are not able to reach out to it in the usual ways. That is why it is found in the face of death, love, failure and the unsaid. It arrives when we are forced to consider the irreducible gap in human existence. As human beings we do not know where we came from, or why we are here, or where we are going but despite this we still make small islands of meaning to stand on. We could not function otherwise. Ache is the knowledge that something fundamental to our existence will always be just out of our knowing. It is inherent in the act itself of creating a place to stand and binds us together in the midst of our isolation.
The second way of approaching ache is to say that it is solid and reliable and all we are doing when we sense it is responding to a physics we cannot otherwise describe. It is a response to our connection with all things and exists most reliably at our edges. If physics and biology teach us anything at all it is that our edges are fluid. We are highly coiled – little different from the universe beyond that seems so separate. We may be elaborate knots but we unravel. Perhaps ache is a tug on our loose threads. Maybe that is why it feels so tangible. Perhaps it is the memory of energy for itself, a recognition of a fundamental kinship in others and in landscape and in the great throb of existence. Perhaps it is a gravity, a response to unseen shape that dents space-time and draws us together.
But what has any of this got to do with medicine? Despite the fact that ache is part of the human condition the truth is it hurts. Even at the best of times it bites. Sometimes it hurts because the separation is too sharp and the connection is too far away for consolation. And sometimes it hurts because we ignore it, pretending it does not exist or worse still, that it is a doubt or enemy to be squashed and bent out of shape. Then it gnaws, filling us with subterranean roar, manifest in all sorts of non-apparent ways. It is also anatomical, an organ system specific to the individual. Many times it tells us what is really going on with someone when we cannot find out otherwise. More importantly it is often the point from which a person can begin to get better again. The art of medicine it seems to me is in part the art of the encounter. It requires the ability to come alongside another human being and then provide space for magic to result. When all else fails ache can guide us to where that space is. Perhaps it is a tool of instinct. It can be an attitude, a position from which to regard the world and then it can be diagnostic. Maybe it is a radar of sorts.
But ache used wisely in the consultation is also therapeutic. When someone has lost someone they love, when they are facing their own death, when they are failing at their job or the past is continually making a hash of the present then being able to see what really ails and sitting in the ache with them for a time is about all that we can do. Ache builds and rages like the weather. When we wait with people in its path we are saying that some things are inescapable and transforming but we survive them. I am not saying that we should relive our grief with patients but at times we may need to admit we are in the abyss with them so that they recognize they are not alone. When all else fails then simply the process of being in the same space and sharing the fire is important. People can figure it out from there. This is not doing nothing, ache recognizes ache.
But of course the most pressing reason that ache is an issue in medicine is the fact that people keep coming to see us with it. I have learnt to be terrified when patients begin their consultation by saying, ‘This won’t take a minute.’ Ten minutes later too many are sobbing. It seems ache in one form or another takes up half my day. Maybe that is a product of where I work. Maybe it is my father and ex-wife and daughter and every other stray ache in me telling me to ask one more question. Ache is important in medicine because it is pounding on the door.
Perhaps all I am saying is that spirituality is hugely important in medicine and seems at times to be forgotten. At the end of the day I think ache is that point beyond which human beings need faith to function. Faith and doubt may be more important in our practice than we think. It seems a deep irony to me that my adult life has been spent in long retreat from organized religion and my shattered childhood dreams of the ministry and yet I find myself now in a profession where each day I sit and listen to people love, cry, praise, confess and ache – desperately hoping that one of them will have a sore ear or at the very least a disorder of their Wolffian ducts. But I shouldn’t be surprised. Biology comes and goes and we do what we can as health professionals but spirituality is at the core of being well because it can alter our story and give us the emotional ability to make sense of whatever befalls us. It also reassures us that whatever shape we end up in we are not just human beings. At the heart of medicine is compassion, not science, not politics nor policy, not commerce but the assorted wreckage of human beings, their frailty and the long slow unwinding of our bodies. It is a profession of skin and ache and spiritual by its very nature. The consultation is its holy place, a source of communion and a science lab for the physics we have not yet described that occurs between people.
Every community requires an Aunty Huia. At eighty, her garden is still the best in Te Tii, where I once lived. The front yard is crammed with fruit trees and the backyard teems with kumara, silver-beet, cabbages, riwai, pumpkin and corn depending on the season. I can never remember what crop should be planted in which season but am always grumpily reminded that I should if I expect people to think I am a doctor. It is no use discussing medical school curricula with her. She is deliberately unreasonable. The sea barks like a dog beyond this down a short embankment where her aluminium dingy waits tied to an old eucalypt which reminds me of her except for the colour. Up until a couple of years ago her great joy was to row out into the inlet in this vessel to check her mullet net, a pleasure she blames me for curtailing every time I see her after I told her she shouldn’t go out alone following a series of TIA’s. The mullet at least are grateful. The inside of her whare is always neat apart from the flax work poking out of half finished piupiu or kete. Sometimes a dribble of wool drools from whatever article of clothing she is knitting for whoever she decides needs it.
I have been told off by Aunty Huia more than anybody else in my life. Everyone who has lived at Te Tii has for that matter. She is the last keeper of the old ways and has high standards. No one would have it any other way. Even the seventy year olds are frightened of her and still sit up straight if she raises an eyebrow. I know we will lose her one day. The ghosts are nibbling her edges but they will be sorry. The feeling tightens in me like a fist at times because we will be bereft, lonely and rudderless, doing anything to annoy her one more time. At times she leaves the impression that she has half left anyway and is only hanging around because she is the last and who else is going to clean up our mess. Her eyes look meaningfully at the distance, her ears aware of better conversations than we can give her now – mind you, any underestimation of her location in this world would be swiftly dealt with.
Recently I drove back to Northland for a few days. Aunty Huia had been in a car accident three weeks earlier and was not well. Her leg was sore and she had a headache. In hospital I pull up a chair beside her bed and we talk. First she growls me for coming. It is a waste of time and of petrol and who on earth is looking after my daughter. She makes a point of starting the conversation in Maori so she can switch to English with a sigh as I lag behind. There is nothing wrong with her … why can’t she be left alone? After this she is silent and I tell her I love her, that everybody loves her and that she is important to us. ‘Oh come on, man! … Gee … I don’t know.’ She turns her head and looks away for a while. We sit and say nothing. Noise will come later: the diagnosis of her sub-dural haemorrhages, her fear of incapacity, the worry she will not be able to finish the knitting she has promised to a charity in Romania, the explanations to her family. But for the time being we have to sit. She stares out the window at workmen demolishing an old nursing home next door, its timbers akimbo. It is the same attitude my wife took looking through the blinds at St George St the last time I backed out of the driveway. Olive wants to stay with her mum and doesn’t want a bath and I brush too hard against her knots. Dad kicks open the saloon doors and fires off a few rounds, cursing Mexicans without knowing it is not appropriate anymore and I kneel beside my bed as a ten year old boy for hours to feel God like I am supposed to. Everything that happens next flows from here. And that is how I would like to finish, beside this wise and brave and cranky old woman clinging on, our ache beautiful, damned, incandescent and unspoken – heard in ways we do not yet understand; an exquisite skewering reminding us that one day we will change shape and with luck remember. In the meantime we talk about the nursing home beyond and its rot and the pity of it all and for a time the conversation is so extraordinarily brave I am left undone.