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22 August 2018

For Rosemary and Charles, looking smart for the doctor was of the utmost importance

I found it hard to comprehend how she had managed to dress so fastidiously every day in the face of such muscle weakness.

By Phil Whitaker

Rosemary had been seen the week before by a colleague, with a sudden decline in her mobility associated with bladder symptoms. A urine infection is the commonest cause of older patients going “off legs” so the antibiotic treatment prescribed ought to have worked. Only it hadn’t.

I visited. Rosemary was smartly dressed and sitting in her powered recliner chair. Her husband of 64 years, Charles, was in his habitual place on the sofa, tie and jacket in perfect order. We went through everything in detail, but urine infection still seemed the most likely cause. I sent a sample to the lab for analysis, and switched her to a different antibiotic in case the first choice had failed due to resistance. Rosemary was finding it increasingly difficult to get around even inside the bungalow so I called in the reablement team – physiotherapists, occupational therapists, and carers who can support people through acute illness at home.

The physio phoned a few days later. She was concerned that Rosemary’s mobility was precarious, and felt she was at high risk of a fall. I got hold of the urine result from the lab: no infection isolated. Something else must be going on.

Charles and Rosemary were in their time-honoured places when I called again, as well turned out as ever. I wondered briefly if they made a special effort because the doctor was calling, or whether they dressed this formally all the time. I needed to do a more thorough examination than was possible in a recliner chair, so I asked Rosemary if we could go through to her bedroom.

She made it up with difficulty, having tilted the chair right forward into what she termed “launch position”. Hands grasping her wheeled walking frame, she started to make her way across the sitting room. Charles watched from his end of the settee. I was immediately struck by her gait: she seemed unable to bring her legs forward for each step, having instead to “throw” them using the momentum of her upper body. Once on her bed I defined marked weakness of her hip flexor muscles on both sides. And there were abnormalities of her reflexes, with complete loss of knee jerks. Running the handle of my tendon hammer over the soles of her feet caused her toes to splay out and up, rather than curl down as would be normal – so-called up-going plantars.

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I’d never encountered this pattern before, but it stirred memories of a rare condition called subacute combined degeneration of the spinal cord, a malfunction of the body’s nerve centre caused by one of two possible vitamin deficiencies. I took urgent blood samples to check Rosemary’s levels, and back at surgery I refreshed my knowledge. Vitamin supplements would halt the decline, but she wouldn’t regain what she had lost. I found it hard to comprehend how she had been managing to dress so fastidiously every day, and get herself through to the lounge in the face of such profound muscle weakness.

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Her blood tests came back normal the following morning but events had already taken over, with a fall resulting in admission overnight. There was no injury, and at least being in hospital would ensure she got swift investigation. An MRI defined the problem. Rather than her spinal cord being affected by a crucial vitamin deficiency, it was actually being compressed at multiple levels by severe degeneration in her vertebrae. The orthopaedic surgeons reviewed her, but with the extensive nature of the cord compression, and her frailty, there was nothing operative they could do.

The virtual loss of lower limb function meant Rosemary was eventually discharged to a nursing home ten miles away, where she’ll live out her days. I’ve seen Charles several times since: beneath the stoicism that characterises so many of his generation, bewilderment and bereavement are being fiercely suppressed. Sixty-four years ago they vowed to be together till death do them part. Neither anticipated such a cruel separation while there was still life left to share.

This article appears in the 22 Aug 2018 issue of the New Statesman, Will Labour split?