Arnold Tweed

Arnold Tweed  

Failure to wean was a nightmare for ICU physicians. I do not mean weaning in the usual sense, weaning from attachment to the mother’s breast. Weaning in the medical sense is weaning from dependency on what was intended to be a temporary treatment; opioid analgesics are currently the popular example. In the ICU this usually meant dependency on an artificial ventilator for support of breathing.

Now in some circumstances this is to be expected and accepted. For instance, poliomyelitis or high spinal cord injury with respiratory muscle paralysis may cause respiratory failure that leaves a patient ventilator dependent, perhaps for life. But at the time I worked the ICU the more common and troublesome failures to wean were the results of chronic bronchitis and emphysema caused by cigarette smoking. There were other causes of course, pneumoconiosis from working in the coal or asbestos mines, cystic fibrosis and others. But by far the most common was the ubiquitous cigarette.

Chronic lung disease due to smoking comes in two guises, in the vernacular called “pink puffers” and “blue bloaters.”  Pink puffers (emphysematous) are usually thin, cachectic, barrel-chested individuals who feel short-of-breath and compensate by hyperventilating, ‘puffing’. As a result they usually maintain a better blood oxygen (O₂) levels and consequently are pinker. On the other hand blue-bloaters (chronic bronchitis) have right-heart failure, oedematous swelling (bloating) and are more cyanotic (blue) because they have more red cells but carry less oxygen in their blood. ‘Pink puffers’ are generally more dyspneic but better compensated.

Mrs. N was a pink puffer. She had earned it by a 50 pack/year smoking history (a pack a day for 50 years) and was in an advanced stage of chronic emphysema. This meant that she could no longer consistently maintain adequate blood O₂ levels by puffing, and her blood carbon dioxide levels (CO₂) would then also rise. This was acute on chronic respiratory failure, a respiratory emergency. When she became severely dyspneic she would be brought to the Emergency Department, intubated and placed on artificial ventilation for 2-3 days. In her numerous previous admissions she had improved each time, had been successfully weaned, and had gone home. But her home leaves were becoming shorter and, with each admission, weaning was becoming more difficult.

It was a sunny Monday morning in the spring of 1978 that I arrived on H7 to find Mrs. N again occupying her usual cubicle, sedated and on full ventilator support. I expected a visit from her sons that afternoon. This was part of the challenge of caring for Mrs. N. She was a widow and her two sons were both prominent young specialists in our hospital, one was 3-4 years my senior. Both were extremely careful not to interfere in their mother’s care, but they were very attentive and always were kept very well informed about her treatment. I gathered also that few important decisions were made in that family without her input.

Her ventilator care proceeded as usual but, after about a week, two things were becoming apparent: she was not improving (at least to the extent that she could be weaned) and her sons were becoming uneasy. After considerable soul-searching, I felt it was time for a serious talk.

Failure to wean was a disaster in many ways. It was demoralizing for the ICU staff but even more so for the family and the patient. In our experience, patients with end-stage respiratory disease who could not be weaned, like Mrs. N, never left the ICU. They died in one, or two, or three weeks from pneumonia, sepsis or organ failure. It was an unpleasant, exasperating and emotionally draining experience for all concerned, and especially for the family and patient.

First Bill and Dave and I made small talk — doctor talk (a variation on jock-talk). Then I outlined their mother’s prognosis, as I saw it. It was my considered opinion, expressed perhaps with a little more certainty than my experience warranted, that she would not wean this time and would not leave the ICU alive.

Bill and Dave understood this; they had been warned of this eventuality. They didn’t want their mother to suffer unnecessarily but there was no other treatment available. These were the days before lung transplants. I stressed our shared feeling of helplessness when all that is left is to relieve suffering. We had much in common; as neurologists they were often faced with a similar predicament in which they could diagnose a neurological disease but had no treatment to offer.

I suggested that they have a family conference with their mother. Without seeming to be too grim, I could see only one scenario developing for her. Yes, the ventilator was keeping her alive, but as time progressed her life and theirs would get increasingly intolerable. The treatment we could offer, although the best available at the time, would not reverse her disease. She could, if that was her wish, ask that the endotracheal tube and ventilator be removed. I did not insist that they tell her she would probably die soon after, though I expected she understood. We all agreed it had to be her decision and I was careful not to interfere in their discussion. It was not a long discussion; she had already made her choice.

When we had all agreed I also promised Bill and Dave that a dash of morphine, 1-2 mg intravenously at the right time, would relieve her sensation of dyspnea and make her dying more comfortable. Morphine, though a respiratory depressant and normally never given to patients in respiratory failure, has a wonderful calming effect. We all, staff and family, understood that comfort measures would be maintained — nursing care, supplemental O₂ and intravenous fluids — but we would not re-intubate her or do CPR. It was not necessary to write DNR (do not resuscitate) orders, they were understood implicitly by all of her treatment team.

We, the ICU staff and her family, were pleased with our preparations to make her last hours as normal as possible. We put Mrs. N in a private room down a hallway where her family could have unlimited access. She asked for her own pajamas and housecoat and discarded the hospital garb. Her sons brought flowers and pictures to brighten up her room and make it look like home. When all were gathered I removed the ventilator first, and when she started to breathe spontaneously I removed the endotracheal tube. She resumed gasping respirations and could talk, one or two words at a time, for the first time in several days. My last act was to inject a mg of morphine intravenously, and when she appeared to be comfortable I left, not to spare myself but because my part was finished.

The next morning I came in expecting to find her bed empty and all trace of her gone. To my utter surprise (and admittedly some chagrin) she was semi-conscious and puffing at a rate of 10-12 per minute. Her family had spent most of the night with her and had noted her slight improvement. They were discrete as always – no one questioned my earlier caution that she would not last till morning. The next day, to our further astonishment, she was more responsive and puffing at her usual rate. She looked no better and no worse than when she had been admitted. Since her family had been spending their days and nights in the hospital and we were not treating her actively, I suggested they take her home.

That was the last I saw of Mrs. N. She lived, at home, for about another six months, and later I learned that she had died quietly in her bed. I met Bill and Dave occasionally in the hallways. They were always polite and genial but they never discussed their mother. I am still baffled – was this my most miserable failure or a medical triumph?

It is the duty, the obligation, of a physician to inform patients and family about the possible outcomes of treatment. But what if one is wrong? Was I conveying certainty when no such certainty was warranted? Were my expectations influenced by her smoking habit and my general pessimism about smoking and lung disease?

I was certainly humbled; my attempt at prognostication discredited, my ego bruised, and my enthusiasm for predicting outcomes, especially regarding life and death, decidedly dampened. But, was it the right course after all? Would she have died in the ICU as I predicted and our decision to back off saved her life? Could I justly claim that my treatment was correct, though the outcome was not what I had predicted? My malign and ever vigilant genie just chuckled; he had won again.

But self-justification is not the reason for telling this story. Certainly we are all fallible and judgement is seldom perfect, but this story is not about me. It is about a woman who taught me two important medical lessons. One is that the likelihood that a medical prognosis will prove to be wrong varies directly with the confidence with which it has been pronounced. A life-or-death prognosis pronounced with grave confidence, to many listeners (especially relatives), is almost certain to go the other way. But the more important lesson she taught me was about quality of life. For her, even a few hours of independence were preferable to weeks of futile dependency and distress. Hers was not a theoretical answer to the question: is it better to live long or live well? Her answer was a commitment to what she considered most important and she chose to live well, to salvage a few hours of quality time. It may be a decision with which we will all eventually struggle. I hope we can do it with her courage and equanimity.

Arnold Tweed

We milled about, laughing nervously, carefully selecting our seats, attempting to appear nonchalant. This was to be our first lecture in Theatre F of the Old Basic Science building, demolished last year in the grander scheme of the Rady Faculty of Health Sciences. (Mayes 2017) Even at that time it felt old, smelled old and conjured up images of past grandeur. Later in life I visited the Ether dome at the Massachusetts General Hospital, the site of the first successful demonstration of ether anaesthesia in 1846, and felt the same eerie nostalgia. But that demonstration in 1846, according to the single description that survives, was a sensational and lively experience. We, the newly minted class of ’64, were subdued and there was good reason for our anxiety; our lives were about to change in ways we could hardly imagine. Forty-five first year medical students, 41 men and 4 women, we were gathered for our first lecture in one of the fundamental medical sciences (along with anatomy and biochemistry) that made up the first year curriculum. Not without forewarning though; we had been sagely advised by our older and experienced comrades, those who had survived the first year. Physiology was the core of medicine but they would rather face the Spanish Inquisition than repeat the course. We were to live, breathe and dream physiology for the next year.

The initial impression of our Professor was of a rather austere figure: tall, thin and dressed in a plain black suit. This was belied by his laconic bearing. He sat on a bare wooden table gazing up at his audience, idly smoking a cigarette. Perhaps sat is not quite the right description-he rested his right buttock on the table, left foot on the floor, and his omnipresent cigarette in his left hand. During pauses he flicked through the pages of a notebook with his right hand. Except for a piece of chalk, the notebook was his only prop. It was not his lecture notes; it was the photos and names of the freshman class seated, oozing trepidation, in the rows of seats stretching above him. This was Physiology I, our introduction to medical science, and our lecturer was Professor Joe Doupe. Though we interpreted his gaze as piercing and carefully searching for his targets, it may actually have reflected his difficulty in associating the faces above him with the photos in his book. Joe had severe diabetes, which he treated carelessly, and which probably affected his vision. Perhaps that explained why he generally directed his questions to the front rows.

Joe Doupe was a teacher of the Socratic school. Now Socrates is long dead and the Socratic Method is only known from Plato’s Dialogues, Socrates wrote nothing himself. In The Dialogues Plato describes Socrates’s discussions with his friends in which he leads them, by systematic questioning, to new insights. The Socratic teacher does not lecture, he asks probing questions. The object is to guide the student towards a critical examination and better understanding of his ideas. The Socratic method of enquiry does not presume there is a final answer or an absolute truth; no statement is exempt from further questioning. And no topic is sacred provided that the proposer is willing to expose his beliefs to critical scrutiny. It is the foundation of the scientific tradition, the basis for critical enquiry and for the empiric system of reasoning.

Joe possessed a brilliant, insightful intellect and his questions were penetrating. His lectures were brief and to the point; he used the blackboard only occasionally to highlight crucial points, but his method of critical enquiry was the catalyst for learning. Learning physiology with Joe was a journey of self-discovery. His style became the intellectual foundation of the Medical School and in the process he became a role model for hundreds of medical graduates. His intellectual shadow still dominates the School and, for us, it was a glimpse into the future.

When we graduated from Physiology and finally from Medical School we were convinced that we were the vanguard of a new intellectual revolution. We would complete the Age of Enlightenment begun by Francis Bacon and John Locke in the 18^th century. Our world would be governed by reason and rationality. Science, based on critical enquiry, would show the way and politics, religion, and economics would surely follow. The basic principles were simple: critical enquiry, intellectual honesty, open and questioning minds. The empiric methods of science and reason would lead us to, if not to Utopia, at least to something akin to Plato’s Republic.

That optimism still comforts us but is slowly being chipped away by the realities of politics and the social media. But surely, we have no cause for despair, we can trust our universities to preserve the enlightenment traditions. We can be confident that more than 150 years after Darwin our students will have ingrained the scientific method of thought so firmly that the fuzzy thinking of politics and social media will be irrelevant. Unfortunately that is not so obvious! Critical enquiry and open discussion are not flourishing; it is the new social ideologies that dominate University discussion. Marxist-Leninism is still alive but being challenged by gender diversity, social justice, feminism and animal rights. The ideologies vary from one university to another depending upon what issues the activists, faculty and students, have found immediately compelling. But the reports are numerous enough to conclude this is the new norm, often humorous but too often simply pitiful.

A recent article by Margaret Wente in the Globe and Mail of 20 March, 2017 (Wente 2017) was entitled why campuses are ditching free speech. She reports that student activists at Wilfred Laurier University, supported by faculty advisors, forced cancellation of a talk by a female lawyer who was prominently associated with the successful defence of a recent notorious sexual assault case. The ironic reality is that she had not intended to talk about sexual assault but about the challenges facing women lawyers. Two distinguished psychologists have written an illuminating review titled The Coddling of the American Mind in The Atlantic, Sept, 2015 (Haidt 2015), and state, “In the name of emotional well-being, college students are increasingly demanding protection from words and ideas they don’t like. Here’s why that’s disastrous for education—and mental health.” Free speech, critical enquiry and debate are being subjugated to political and social correctness.

Our age of enlightenment is threatened now, just as it was in the middle Ages, by a style of thinking that emphasizes validation, not questioning, of current beliefs. Social media has made truth irrelevant, an insight beautifully summarized by Sarah Kedzior in another Globe and Mail editorial (Kedzior 2017), “it is not merely the message of the lie that matters, but its shameless delivery, as it implies that both public reaction and truth itself are irrelevant…”  Even those who attempt to defend the role of the university, and therefore the role of the university professor, have bowed to public opinion. In another Globe and Mail opinion piece Éric Montpetit, Professor of political science at the University of Montreal (Montpetit 2017), wrote “In this post-truth period, in which falsities have become alternative facts in some circles, universities have a particular duty to protect their status as institutions that produce valid knowledge.” Unfortunately, the issue that Prof. Montpetit has chosen to defend is another example of the university’s choice of political correctness over freedom of discussion. The issue concerns an article written by Andrew Potter, How a snowstorm exposed Quebec’s real problem: social malaise, for Macleans Magazine (Potter 2017). Admittedly this article is socially controversial and treads on some very sensitive toes. It contravenes a self-image of many Quebecers that they are a socially distinct society, cohesive and self-sufficient. McGill University chose the politically easy path; it forced Potter to resign.

This is a complex world we navigate. We need folk heroes to lend us their identity. We need social values to give us direction. Unfortunately we find some choices much easier than others. Charismatic folk heroes who offer simplistic and absolute solutions are attractive to many. Social values reflect the interests of vocal minorities who are righteous in their beliefs and scathing in their condemnation of detractors. These are compromises that take us backwards, not forwards. Both treat facts as a commodity to be manipulated. The world still needs men and women who question, who never accept a statement without evidence, and who don’t offer easy solutions – we need more like Joe Doupe.

Haidt, G. L. a. J. (2015). The Coddling of the American Mind. The Atlantic. New York.

Kedzior, S. (2017). At long last, a forum where Trump cannot escape the truth. The Globe and Mail. Toronto.

Mayes, A. (2017). “Old Basic Science gives way to planned green space.” from http://news.umanitoba.ca/old-basic-science-gives-way-to-planned-green-space/?utm_source=umalumni&utm_medium=email&utm_content=rfhs&utm_source=Alumni+eNews&utm_campaign=2d2ec9e674-EMAIL_CAMPAIGN_2017_04_18&utm_medium=email&utm_term=0_ca832db3e9-2d2ec9e674-40483443.

Montpetit, E. (2017). Universities: Media pool or knowledge centre\/. The Globe and Mail. Toronto.

Potter, A. (2017). How a snowstorm exposed Quebec’s real problem: social malaise. Macleans Magazine.

Wente, M. (2017). Why campuses are ditching free speach. The Globe and Mail. Toronto.

Arnold Tweed

A tough school for tough kids! That was how you would have described St John’s Cathedral Boys’ School in the 1970’s. It was a denominational school located on the banks of the Red River 5 miles north of Selkirk, Manitoba. Many of its students were boys whose misdirected energy had led them adrift in the public school system. School programs were based on the principle of “muscular Christianity”; the boys’ self-esteem was rebuilt by pushing them to their physical limits of endurance. They were tested with grueling outdoor events: punishing five-hundred mile canoe trips in the summer, thirty mile snowshoe races and dog-sled runs in mid-winter. It was a school that prided itself on building ‘character’ and its successes were notable, as were its failures. The need to achieve was so compelling that even those whose physical abilities were not equal to these extreme challenges would continue until they collapsed.

On 31 January, 1976, 16 year old Edward Milligan could not complete his 25 mile snowshoe race. He collapsed in the snow about 1.5 miles from the finish: wet with sweat, exhausted and hypothermic. When he was delivered to the Emergency Room of the Selkirk General Hospital about 90 minutes later he was clinically dead. The doctor on duty, Dr. Robert Smith, could detect no signs of life: no responses, no breathing, no heartbeat and the body was cold, below 25º C. The ambulance attendants had made roughly the same observations and had performed CPR en route. With that information any sensible doctor would have turned his efforts to consoling the parents. It was Edward’s good fortune that Dr. Smith and Dr. Gerry Bristow who arrived about the same time, were not sensible doctors. Something about this boy, possibly the cold, puzzled and disturbed them. They continued CPR and began to warm Ted’s body. Within about an hour they were rewarded; his heart began to quiver, and with further CPR and defibrillation it started to beat. He had been in documented cardiac arrest for 85 minutes and restoration of heartbeat carried no certainty that his brain had survived. They worried that they had resuscitated a heart but not a person.

I saw him early next morning, after his transfer to the ICU of the Winnipeg General Hospital. Within a few hours he started to breathe spontaneously and by afternoon he was conscious. From that point his recovery was only marred by some minor frostbite. When interviewed several weeks later he was mentally normal and happy to forget this episode.

At that time it was the longest recorded episode of cardiac arrest with complete recovery. This case attracted much attention and some imitators. Winnipeg soon became known as a world center for hypothermic cardiac arrest. Usually it was as simple as getting drunk, walking home and falling asleep in a snowdrift. One young lady who we came to know well, Sally B., was resuscitated three times in two years. In the course of time she lost bits and pieces to frostbite: some fingers, toes and bits of nose and ears, but not her good natured optimism. Each time she recovered she was bright, cheerful and promised faithfully never to drink again. I must assume she kept her promise because she quit coming to us.

This is the stuff of mythology and science fiction, bodies not alive but not quite dead – suspended between life and death, a state known now as ‘suspended animation’. It is undoubtedly the most puzzling and fascinating of the medical mysteries and has inspired both the mundane and the magical. Suspended Animation was the title of a forgettable album released in 1981 by a UK punk rock group who called themselves The Monks (Polydor, Canada, 1981), but is also the material of myth and legend, drama and science fiction, space travel fantasy and a generation of cryo-preservation wishful thinkers. Time has not diminished its mystique and it is currently being seriously studied by NASA and by respected universities.

The earliest written account may be the myth of the handsome shepherd boy, Endymion, and the moon Goddess, Diana. Jupiter recognized her infatuation for the comely youth and bestowed on him perpetual youth and perpetual sleep so that Diana, being immortal of course, could lie with him forever. Shakespeare used suspended animation as a dramatic effect in several plays. The best known is Romeo and Juliet where Juliet takes a potion to induce a stupor resembling death, so realistic a simulation that Romeo takes her for dead and himself commits suicide. In The Winter’s Tale Hermione, wife of Leontes, is suspended for 16 years as an unfinished statue. In fairy tales it is the stories of Sleeping Beauty and Rip van Winkle, and Hollywood has produced several Sci-Fi epics, including “2001, A Space Odyssey” and in 2016, “Passengers,” starring Jennifer Lawrence.

‘Suspended animation’ is the classical term for this state but it is a bit dated and the connotation of animation has changed. We now see animation every day in the visual arts, creating the illusion of movement and action; and to suspend animation is simply to stop the action. A more accurate medical description would be ‘suspended life’ rather than suspended action. But the older term has the authority of tradition and familiarity and I will continue to use it with the specific reference to life, not just action.

It fascinates both the mystical crowd and serious scientific investigators and their interests range from the spiritual to the practical. What transpires in the mind during this period of suspended life? If the individual has a soul is it in the body, leaving the body or outside the body? Are there medical applications? What is the potential for space travel and time travel?

The ‘near-death ’and ‘out-of-body’ experiences have attracted a cult following, but psychic experiences are not our real interest. Accidental cases, as with Ed Milligan, still occur but the medical potential was quickly recognized as a means to facilitate both open heart surgery and complex neurosurgery. Dr. Wilfred G. Bigelow, who was born and raised in Brandon, Manitoba and graduated in Medicine from the University of Toronto, was one of the pioneers of open-heart cardiac surgery. He understood that cardiac surgeons could only effectively repair intra-cardiac defects if they could see what they were doing, and for that they had to have a bloodless operating field and a still heart to work in. The only possible way to stop the heart for long enough to do a complex surgical repair, and have a patient who would recover to talk to you afterwards, was to induce deep hypothermia for the period of cardiac arrest. He pioneered the experimental work but C. Walton Lillehei of Minneapolis is usually given credit for the first successful open heart operation using hypothermia in 1952. Bigelow’s technique permitted operating ‘in the heart’ to repair damaged valves and congenital defects and for this he was awarded the Order of Canada. The citation describes him as, “an internationally acclaimed pioneer of hypothermia in heart surgery.”

In Winnipeg Dr. Dwight Parkinson pioneered a technique to repair arterio-venous malformations deep in the brain (carotid-cavernous sinus fistulae) under deep hypothermia. Patients’ core temperatures were reduced to about 18ºC, the heart was stopped and he had a perfectly bloodless brain for about 45 minutes. Most patients survived intact. But, medical science moves quickly and these early applications are now of only historical interest. Cardio-pulmonary bypass and interventional radiology (stenting, coiling and embolization techniques) have made it unnecessary to stop the circulation and now the only application of hypothermia in cardiac surgery is local cooling of the heart during cardio-pulmonary bypass.

But as quickly as one use fades others appear: space travel, cryopreservation, transplant medicine and more. Hypothermia is not the only way to protect the brain but it is the most effective. The chemical explanation is known as the Arrhenius equation, proposed by Svante Arrhenius in 1889. Simply stated, chemical reaction rates are temperature dependent. The metabolism of the brain follows the same rule. A decrease in body temperature of 10ºC roughly halves metabolic processes in the body, perhaps a bit more in the brain. This is enough to increase the time the brain will tolerate complete ischemia (cardiac arrest) from 5 minutes to about 40 minutes. The chemistry is wonderfully consistent over a wide range of temperature and it is tempting to speculate – for how long can we extend this state by decreasing temperature to say 0ºC or -273ºC.

Unfortunately, it doesn’t work. Temperatures as low as about 12ºC with survival have been recorded, but not lower. Man is not a natural hibernator and human tissue does not survive freezing. But human embryos have been preserved for 13 years and viable DNA has been recovered from the mastodons. Perhaps this is our clue and we should look to our DNA for the secret of immortality. In 1996 a Finn-Dorset sheep named Dolly was the first animal successfully cloned from the DNA of another animal of the same species. Although my body will decay, my DNA could be preserved for long after I have died. But, of course, my clone wouldn’t be me – though phenotypically identical to me, my much younger identical twin, he would be his own person. On second thought, I will spare him that burden, better to start life with a clean slate rather than such handicaps.

However, science does not advance on hesitation. Successful innovation in science is the exploration of fantasy and this is illustrated by a recent headline in a popular British tabloid, the Mirror.  “NASA planning ‘suspended animation’ cryosleep chamber that lets astronauts hibernate whilst travelling to distant worlds.” NASA has been persuaded to invest research money and talent in a project they call “Torpor Inducing Transfer Habitat for Human Stasis to Mars”. The logistics of space travel would be greatly reduced by putting most of the crew in hypothermia induced suspended animation for the journey. This is preliminary research for the Mars mission, about a nine-month return journey. How close are we to seeing this? The Mars mission is targeted for the 2030s and the limiting factor is clearly human endurance, not space technology.

On the medical front the Safar Center for Resuscitation Research at the University of Pittsburgh (named after resuscitation pioneer Peter Safar) continues with ground breaking research. Their projects include hypothermia induced suspended animation for victims of lethal trauma, as well as for neonatal asphyxia and cardiac arrest. The object is to buy time and prevent further injury until definitive treatment is available. Clinical trials have been encouraging. Will this have the same impact as open-heart surgery? Possibly not, but medicine is like the stock market, difficult to predict.

Will suspended animation provide the key to medical and cosmic breakthroughs? Our limitations lie not in our imaginations, but in our physiology. Man’s dreams may extend beyond the heavens and the grave, but evolution has given us a body that is bound to the earth. Our biologic equipment is good for about a century, our brain requires a constant supply of oxygen, and we don’t keep well when deprived of our earthly comforts. Random selection has made us both superior and vulnerable. Perhaps Ted Milligan’s recovery tested the limits of human resilience. But science is optimistic and we refuse to admit limits. Our future on earth may look grim but we still clutch at the hope that suspended animation will enable us to avoid our evolutionary destiny, perhaps even cheat death. It may permit us to escape from this earth to another universe when we have made Earth uninhabitable. Or it may be a way for those left behind to survive the next ice age. On the other hand, these could be just pipe-dreams. The science of suspended animation may have reached its ‘glass wall’. We can see the tantalizing shadows beyond the wall but we are unable to penetrate it. Just as well! If these fantasies were to succeed the survivors would awaken in strange, unfamiliar and probably hostile worlds. Despite my appreciation for science fiction, I prefer to stay firmly planted on earth and enjoy my suspended animation in small doses and familiar surroundings: a glass of single-malt scotch, a wood fire, some Beethoven, and my life’s companion beside me. The evolutionary triumph of the human brain, what makes us truly distinct, is that one’s cosmos can be entirely internal. We don’t have to physically touch the stars in order to experience them.