Tuesday, March 31, 2009


What do you think of the BBC? There is a whole website devoted to picking holes in its daily output and certainly some of the barbs are true. The BBC news and current affairs output is consistently pro-Palestinian, anti-Israel; pro-Europe, anti-American; pro-left, anti-right; pro-global warming, anti-warming sceptics; pro-Muslim, anti-Christian; pro-Republican, anti-Loyalist; pro-multiculturalism, anti-British; pro-gay/Lesbian/transsexual, anti-conservative life style; pro-EU, anti-UKIP. Recent documents released under the 30-year rule have demonstrated that the BBC played a significant part in the undermining of the Shah of Iran and in hastening the Khomeni revolution. Even when the British electorate so keenly wants to get rid of Gordon Brown and the whole of Nu-Labor, the BBC persists on trying to make the ruling party look good while trying to besmirch the Conservative Party.

However, I have noticed that even Alan Sullivan over at Fresh Bilge, whose conservatism doesn't differ much from my own, often turns to the BBC for news items that are simply not carried by the American media.

There are some things that the BBC does exceedingly well. I might mention period drama such as the recent 'Cranford', 'Bleak House' and 'Little Dorrit'. The output of the Wild-life center at Bristol is also impressive. The photography of documentaries like 'Blue Planet' and 'Alien Empire' presented by David Attenborough is worth getting Blu-ray for. (The effect is spoiled by the specious pro-evolution commentaries). The output of the main television channels is junk, of course, but that is true for most television anyway. Radio programs are better and downloadable as podcasts. I recommend looking at their selection.

This morning my son sent me a link to a series of articles on statistics by Michael Blastland that are worth a second look. They are a remedy for all the hype you read in the newspapers and watch on the news. Take this remarkable fact. Headline figures for GDP are usually wrong. The true state of the economy is not established for three years, when the tax returns are analyzed. In the UK the first figure is almost always too pessimistic whereas in the USA it is mostly over-optimistic. A recession is defined by two three month periods when there is negative growth (or shrinkage) in the economy. Who knows, when the final figures come in we may not even be in a recession.

There is a great deal of hype surrounding the current economic circumstances. Reading Micahel Blandford will probably set your mind at rest over all sorts of stuff you see in the newspapers. Statistics matter, but don't trust anyone other than a statistician making an argument from them. All politicians are liars, they can't help themselves. Journalists prefer a story to the truth. Salesmen want a sale. Businessmen want a profit.

The other thing the BBC does is "The Archers". Giving up "The Archers" is like giving up smoking. You can go for years without them, then just a single puff and you're hooked again.

Monday, March 30, 2009

Three visitors

This morning we had three visitors to our front lawn, the very same lawn that played host to the green woodpecker a few weeks ago. Three Mallards came visiting. The female duck in her dowdy brown and white tweeds simply squatted on the hoar-covered grass while her attendant drakes stood guard duty around her. They marched in step around her like guards in full dress uniform. Their heads covered in bottle green sheen contrasting with their yellow bills, their thin white dog collars separating these green helmets from the russet breastplates. The main body of their uniforms was a pleasant grey – the light grey of a fine-tailored suit – but a black back stripe separated left from right, like the black cross on the back of the donkey that carried our Lord into Jerusalem.

If you have ever been to Athens and seen the National Guard on parade outside the Presidential Palace you will know what I mean when I liken their gait to a formal parade march. No-one would use this walk as a means of transportation. It is a formal march, without the menace of German or Russian goose-steps. Each step is performance that takes months of coaching. The movement is emphasized by the orange webbed galoshes that each of them wears. As they turn you notice that they both have black curly tail feathers, just two or three, protruding at the rear of no possible use, as if to demonstrate that this whole performance is just that. It is just for show.

The dowdy little princess that they are protecting takes no notice. She has her own thoughts and as if she has had enough of sitting on the cold grass. She gets up and waddles off mid performance. They continue their marching, slipping their heads forward in a jerk that precedes every step, even though I am now the only witness, then suddenly both fly off in a rush and flurry like jets launched from an aircraft carrier.

In thirty years of watching that lawn I have never seen Mallards (nor woodpeckers) before. Is it because I have never really watched before, too busy, too distracted? Or is this some special way the Lord is blessing me? Encouraging me that He is really there?

Whatever, I am certainly feeling better. The cramps are largely gone and are no longer so painful. I have put on another couple of pounds and am eating pretty normally.

Chemotherapy should begin this week or next. Things are moving.

Sunday, March 29, 2009

Dream the impossible dream

A Chinese man was given a copy of the Sermon on the Mount. After reading it he exclaimed, "But if everyone lived like this there would be universal peace in the world!"

Even atheists agree that it is the most perfect recipe for peace and harmony. It is perhaps Jesus's greatest claim to fame as a great teacher. He is universally acclaimed as a great philosopher.

But the point of the Sermon on the Mount is not to show us how we ought to live. Indeed it is quite the opposite. It is a sermon that shows us how it is impossible to live.

Expressions like "Love your enemies" and "Turn the other cheek" are hedged around with provisos by Pastors as they are translated into more achievable recipes for living.

But Jesus states quite plainly that He has not come to abolish the Law and the Prophets. Not one iota of the Law will pass away. He says that your righteousness must exceed that of the Pharisees and the teachers of the Law else you have no hope of entering the Kingdom of Heaven.

He then goes on to reinforce the Law, making it even more stringent. When Jesus equates being angry with your brother with murder and looking at a woman with lust in your heart, even if you do nothing about it, with adultery, he is raising the bar to such a level that no-one can clear it. Look, he says, sin in so serious that you had better gouge your eyes out than look at porn and better to cut your hand off than use it to fiddle your expenses.

He is equally hard on divorce or swearing. As for retaliation when you are put upon; you are to accept persecution and make yourself vulnerable for more.

Quite frankly, these are just not humanly achievable standards. And if they were Jesus would just raise the bar even higher. These are standards that are meant to bring us down, be we ever so high. Even what we would regard as our acts of righteousness: giving to the needy, fasting and prayer are tainted with hypocrisy.

What can be done then?

In Matt 7:7 we are told to ask and to seek and to knock. This way we will find the answer, it will be given to us and the door to heaven will be opened. We need to stop relying on ourselves, on our own efforts, on our own righteousness. God has provided the answer in the death of Jesus on the cross and His resurrection from the dead. First we need to humble ourselves and recognise our need for a savior, for unless we feel the need why would we ever ask? Then we need to ask. Then we will receive.

Isn't that all too easy? No, for as Jesus says, Not everyone who says to me, 'Lord, Lord,' will enter the kingdom of Heaven.

Haven't you met those people who will take anything on offer. They would rather spend their afternoons cutting out coupons to pay the grocery bill than work for a living. Those who accept lifts to church just to save the gas in the tank, who sign on for free lunches when they have food enough in their fridge. Often you find people who are just the opposite, people who are too proud to accept charity.

George Bernard Shaw once said something to the tune of "Christianity is a beggar's charter. I'll pay my own debts."

It is true that the default position for a Christian is service, but when we are in need we need to be able to accept charity - the word in the KJV of 1 Cor 13 that is translated 'love' in modern versions. We are never in greater need than in our need of a savior. We should always accept that charisma. He will know us as His own when we do the will of the Father. The strange thing is that once we have put our trust in Jesus his standards don't seem so impossible. Oh, we won't get the pass mark of 100%, but we have this constant forgiveness of our falling short. His ideals seem more achievable because we have the Holy Spirit working within. It is a lifelong plan of approximating ourselves to Jesus with our setbacks met with encouragement rather than disparagement.

Saturday, March 28, 2009

Well enough to work

Today I felt well enough to do some work so I wrote a book review for the New England Journal of Medicine. Here it is.

Chronic Lymphocytic Leukemia. Edited by Susan O’Brien and John G Gribben 301 pp. New York, Informa Healthcare.2008. ISBN-13: 978-1-4200-6895-5

Chronic lymphocytic leukemia (CLL) is a fast changing field. There can be few hematologists who still see it as the boring condition that I was brought up on. A new understanding of the nature of the disease, better delineation of its limits and more effective treatments that have supplanted chlorambucil, the fifty-year old stand-by, have all attracted the interest of serious scientists and high-flying physicians. This volume, largely written by the generation that came after me, presents an effective summary of the state of play in 2008, but, make no mistake, other books on this topic will surely follow since there are many questions as unanswered now as when I first took an interest in the disease some forty years ago.

The normal-cell equivalent that the leukemia derives from is still unknown. Analogies with the mouse have often been misleading and any particular candidate-cell has no more justification for its status than any other, save for the enthusiasm of those who espouse it. The recent understanding that a quarter of patients with CLL have B-cell receptors shaped according to a small number of stereotypes, suggests a common antigenic stimulus, but raises further questions as to how an immune response can be transformed into malignant growth.

If we think back to 1975, when Kanti Rai introduced his staging system, to diagnose CLL you needed a lymphocyte count of 15,000 /microlitre. As immunophenotyping became secure, the threshold reduced to 5000 /microlitre, but this resulted in many people being diagnosed with the condition whose clinical features and outcome were most un-leukemia-like. The latest guidelines from the International Workshop on CLL require in excess of 5000 /microlitre of monoclonal B lymphocytes for the diagnosis – if there are fewer then the diagnosis of monoclonal B lymphocytosis (MBL) is made. Although this largely restores the position of 1975, the figure of 5000 is quite arbitrary and the exact relationship between CLL and MBL is a matter of ongoing research. Furthermore, much of the current understanding of CLL reflects experience with a threshold of 5000 lymphocytes; this will have to be reviewed with the new threshold.

Other unsolved puzzles include why immunity against infectious agents diminishes while immune attacks against self increase and why the disease transforms to an aggressive form sometimes derived from tumor cells but sometimes from apparently uninvolved normal B cells.

In January last year we were informed by a commercial website that the German CLL Study Group CLL8 trial had fulfilled its primary endpoint at the first interim analysis. Although the results of this trial have still to be published in a peer-reviewed journal, it was immediately clear to the cognoscenti that adding rituximab to the combination of fludarabine and cyclophosphamide improved significantly progression-free survival. This result is a vindication for doctors at the MD Anderson Cancer Center in Houston, Texas who have eschewed randomized clinical trials in this area and instead have pursued a series of Phase II studies relying on historical comparisons. It should raise questions for regulators who have insisted on Simon-pure studies before approving new drugs. Most patients and many US physicians have been convinced of the value of the fludarabine, cyclophosphamide and rituximab combination even though until now there has been no formal proof of its superiority. Even now there is no evidence that this combination improves overall survival, but surely this will come as the German study matures.

John Byrd’s remarkable chapter lists 107 agents in early stage trials for the treatment of CLL. Simple arithmetic tells us that patients do not have enough time for conventional trial progression to deliver the best of these to the clinic.

Friday, March 27, 2009

Keep on keeping on

I have seen the consultant surgeon this morning. Not very much new, I'm afraid. My main problems are colicky abdominal pains and diarrhea for which I am taking an anti-spasmodic and codeine phosphate. Th surgeon thinks these symptoms are caused by the mechanical effect of the presence of secondaries in the peritoneum and that the remedy is chemotherapy. I am seeing the medical oncologist this afternoon.

The special stains do not tell us anything new. They were negative for carcinoid, but even that is not helpful since the histology of adenocarcinoid can change to adenocarcinoma when it metastasizes, indeed such patients have a rather better prognosis. Although he thinks that the appendix is the most likely source of the tumor, he cannot be sure. The other option, large bowel, has been searched through very thoroughly on several occasions without finding a primary. The overwhelming majority of appendix tumors start life as carcinoid.

Were it not for the colic I would be very well. I have lost 14 pounds, but the weight loss has reversed and I have put on a couple of pounds since the nadir. My nutrition is important now, and the only restrictions on my diet are to avoid high residue products like peas and beans, sweet corn and cabbage, skins and pith.

I was encouraged when my friend George Stevenson brought me in a paper by Yan et al (Annals of Surgical Oncology 2008; 15:1440-6) which describes adenocarcinoid of the appendix that on peritoneal dissemination lacks the neuroendocrine component and appears as adenocarcinoma. Such patients have an improved survival over those who retain the carcinoid appearance, with a cumulative survival of 70% at 4 years and no further deaths thereafter.

This afternoon I saw the medical oncologist, Tamas Hickish. I will have a baseline CT next week with insertion of a Hickman like, starting chemotherapy at the end of next week of the beginning of the week afterwards.

Yesterday we watched the movie of 'The Kite Runner'. Although perhaps not as complete as the novel, it was a moving story and a rebuke to those who wish for an accommodation with the Taliban. These are appalling people who were quite justifiably deposed by George Bush and his allies. It is a common phenomenon found in the Western Democracies that they fail to complete the task that they embark on. They seem to lose heart when adversities stand in their way. Obama is talking about an exit strategy in Afghanistan. Will he be condemning millions of women to a second class life that includes no education, beheading for being raped, genital mutilation and forced marriage. Will the beard police return?

How this contrasts with the attitude of Christ who does not give up on us. "He who began a good work in you will carry it on to completion until the day of Christ Jesus" (Philippians 1:6).

I continue to receive messages of encouragement. From the Manabats in the Philippines and from Mary and Milena, two former colleagues of mine at the hospital whom I happened to meet in the corridor. Sometimes we despair when we have this diagnosis. When we know so many people are praying we wonder whether God is listening. Then he will send the chance meeting to encourage us and to let us know that he certainly is listening - so keep praying.

Thursday, March 26, 2009

Strutting and fretting

One thing that surprised me about being in hospital was how little the doctors influenced what was going on. When I was in charge of the wards I had the distinct impression that I was running things. Of course, it may be very different in surgery, where surgeons are in essence doing the same thing repeatedly and the whole subject may be protocolized. Standard operating procedures (SOPs) are relatively easy to produce and follow when one case doesn't vary very much from the next. In contrast, hematology patients are very different from each other. About the only leukemia that is at all stereotyped is chronic myeloid leukemia, where an identical molecular lesion produces a very similar clinical condition, but my readers will mostly know how heterogeneous is CLL, and AML or MDS is even more so. Non-Hodgkin's lymphoma breaks down into over 40 separate conditions.

When I was running the hematology lab we majored on SOPs, but then we were doing full blood counts on 750+ samples a day and very few other tests. We even had an SOP for answering the telephone (Good morning, this is the Hematology Lab. How may we help you?). The benefit of SOPs is that relatively unskilled workers can be trained to do complex tasks accurately and reproducibly. The danger of SOPs is inflexibility.

The surgery ward ran efficiently on a cadre of trained nurses and health care assistants (HCAs). There were some things that only nurses could do, like give injections, dole out pills and attach and detach intravenous pumps, but for most of the traditional nursing duties, like making beds, emptying bed-pans and giving bed-baths, the nurses and HCAs were interchangeable. Obviously, the use of HCAs to replace nurses is a cost saving. Many of the HCAs were from Eastern Europe or other foreign countries (though their English was always excellent) but, then, my nurses were also likely to be foreign (Indian, Chinese,) and their training was equally as good as those who were locally trained.

Many of my readers will know the Tom Stoppard play 'Rosencrantz and Guildenstern are dead'. For those who don't the author takes two minor characters from Hamlet and builds a play around them. They spend most of the play discussing the absurdities of life and death, the paradox of freedom and inevitability, of freewill and predestination. Mostly it is a two-hander, but at times the whole Shakespeare play rushes on to the stage and performs their bit of Elizabethan drama before exiting stage left, leaving the two alone, perplexed and totally misconstruing what has just happened.

The consultant ward round is like that. Of course, Hamlet is the main thing and Rozencrantz and Guildenstern mere strolling players in comparison. The great and important decisions are taken by the consultant and his retinue, while we patients are blown about by the forces of destiny.

Everything boxed and coxed, categorized and acted out word perfect without prompting makes for an efficient service where errors of omission do not occur. As long as the out of the ordinary does not come along.

The problem with this inflexibility arose over my drip. The houseman (now called a Foundation year one) has the task of writing up the intravenous fluids for the next 24 hours. At the beginning of March the F1s have only been employed for a couple of weeks and have difficulty in getting their routine work done in the day. In my day you stayed until the work was complete, but today the European Working Time Directive insists that you leave on time. Overstay the 5pm deadline and you get a ticket. Do it twice and you receive a reprimand. Habitual offenders may have to repeat the year.

There is a back up position, though. At night there is an F1 available to cover the whole hospital. Of course, this person does not know the individual patients and apart from catching up on the work left left over from the day she (and these days it is usually a she) has to deal with emergencies as they arise, so it wasn't until 2am that she got around to writing up my fluid chart. By which time the drip had been stopped for two hours and the cannula had clotted. In the old days the nurse in charge of the ward have put up a bag of whatever had gone before rather than let a drip stop, but today a nurse does not have that discretion. She has to obey orders precisely and if nothing is prescribed nothing can be given.

The F1 was very nervous as she tried to resite the cannula, and she failed. She summoned Night Sister and she failed twice. A more senior doctor was called for and she failed three times. Eventually an anesthesiologist was called and she got in first time - but it was the seventh attempt.

The next time I needed a new drip I insisted on an anesthesiologist first time. He turned out to be an old colleague whom I had only met over the telephone. He remembered that I had once done him a favor, and he certainly did one for me.

Wednesday, March 25, 2009

Pain relief.

We expect it to be painful when someone slices your tummy open. I remember seeing a war film once where the soldiers hit the ground when showered with machine gun bullets. After the shooting stopped the sergeant told his men to start moving out, only to be greeted by one of his men asking, "What shall I do with these?" as the camera panned down to his abdomen where he held several coils of intestine in his hand. The very thought makes many people squirm, but it is just what an abdominal operation involves.

Naturally, some form of pain relief is necessary, and the best form is an epidural which stops the messages from nerve to brain, for although it seems as though we feel the pain in our tummy, in reality it is the brain that really does the feeling. Almost all other forms of pain relief involve impairing the function of the brain, sometimes so much that we are rendered unconscious.

It is also true that most forms of pain relief have serious side effects. Morphine and other opiates induce nausea and vomiting, suppress the cough reflex, slow down the bowel causing constipation and in large doses suppress the respiratory center causing one to stop breathing. The non-steroidal anti-inflmmatories can cause mucosal ulceration and depending whether they are cox-1 or cox-2 inhibitors affect the clotting mechanisms, either by leading to bleeding (cox-1) or thrombotic (cox-2). The one drug that is pretty free of side effect is acetaminophen (paracetamol), but overdoses (greater than 15 g or 30 tablets) are fatal, causing liver damage. Standard hospital guidelines allow a safety margin and require anti-poisoning measures after 24 tablets, but strangely the maximum permitted therapeutic dose in hospital in 8 tablets.

Since normally the required dose for pain relief is 2 tablets every 4 hours, this leaves anyone who is kept awake by pain with nowhere to go in the middle of the night. This happened to me. My pain was adequately controlled by paracetamol, but at 4 in the morning I needed another dose. The nurse informed me that I was not allowed any more paracetamol for another hour, but I could have some morphine.

I didn't blame the nurse, she was only obeying her instructions, but I do blame whoever wrote the instructions. It was not a local decision it is a central NHS decision. The maximal allowable dose is just one third of the toxic dose - even when there is a built in safety margin - and did I mention that there is a perfectly adequate antidote for paracetamol?

Had I been at home I could have taken paracetamol with impunity. As it was I suffered for another hour.

Tuesday, March 24, 2009


I'm not sure about waterboarding. They say it is very effective in extracting information and that although it induces a feeling of impending drowning, it leaves no marks and damages no tissue. Watching Jack Bauer on '24' torture traitors with a tazer does not seem immediately preferable. Yet scores of Westerns and cops and robbers movies have shown the 'good' guys beating a confession or information out of a villain.

It is a difficult dilemma. To stand up for human rights is a fine thing, but who would not have looked the other way if a CIA agent had been able to obtain information by torture that would have prevented 9/11? And if you think you would have stopped the torture consider whether you would have done so if your wife or son was one of the intended victims.

The whole question of what rights criminals retain is a difficult one, and even more so in the case of those detained who are presumed innocent until proved guilty or those detained on the basis of evidence that would not be admissible in a court of law.

Strange as it may seem, the law is there to protect the guilty as well as the innocent. Suppose you run over a child in a Malaysian village and kill him. A colleague of mine who served in the RAF during the Malayan crisis of the 1950s was told that on no account under such circumstances should he stop the car and get out; if he did so he would be torn limb from limb by the villagers, because there was no law there. Such a driver might well deserve punishment, but he might be entirely blameless; mob law admits no such nuances.

I don't know whether anyone has considered as a means of torturing, the injection of a drug that induces severe abdominal colic and diarrhea, but I would imagine it to be an effective means of extracting information. The past weekend was truly terrible. I was screaming with agony as the colic hit me. Had someone offered me an injection that would stop it in return for a confession, I would have given up the crown jewels. I would have confessed to anything from treason to pedophilia if they would only make it stop. I would have offered to have an arm or leg amputated rather than continue in such pain.

The real problem with torture is that you can't rely on the answer.

There is such a remedy for colic; it is called mebeverine, and since I have been taking it I am back to normal making a slow recovery from surgery. I have so far lost 15 pounds and am not yet eating properly, but I no longer have wound pain.

Proverbs 3:11-12 says "My son, do not despise the LORD's discipline and do not resent his rebuke, because the LORD disciplines those he loves, as a father the son he delights in.

I'm not sure what lesson the Lord is teaching me, but perhaps it is not to rely on my own wisdom, and not to be too proud the ask for advice. They say of a doctor who treats himself that he has a fool for a patient and a quack for a physician. My wife, who is non-medical, was urging mebeverine (colofac) on me for some hours before I accepted it and I only did that after I had managed to contact my surgeon's colleague (the surgeon was out of town) and he had agreed with my wife's prescription. What a vicious sin pride is.

Sunday, March 22, 2009

Nasogastric tubes

As a medical student I had to insert a gastric tube to measure my own gastric acidity. I remember it as one of miserable days of my life. On that occasion I had to pass it via the mouth and it was only down for three hours. Following my two pint vomit they decided to insert one transnasaly.

At the age of 16 I played at center half for the school second XI. On one occasion I was about to head the ball over my own crossbar to concede a corner from a high cross, when our goalkeeper, Roger Millward, rushed out and in attempting to punch the football, punched me in the nose. When I came too my nose was broken, and this is why inserting a nasogastric tube was very painful, even though the nurse inserting it was Nurse Nightingale and extremely skillful with it.

I have taught generations of students that the word 'retch' is pronounced 'reach' and not 'wretch', but they will not learn. The presence of a tube at the back of the throat stimulated the gag reflex and causes retching. Many surgeons, Dr Fozard included, are not keen on the use of nasogastric tubes post-operatively, but when gastric stasis leads to vomiting, there is very little choice. The usual practice is to spigot the tube and wait until the stomach is clearly emptying before removing the tube as soon as possible. In my case the stasis was prolonged and the tube was down for several days. Eventually Dr Fozard took the decision to pull it up and immediately I felt better.

When I was about 14 I rapidly expanded my vocabulary and began to use long words instead of short ones. I would say 'commence' instead of 'start' or 'begin' and 'velocity' instead of 'speed'. I discovered the word 'recuperate' which for some reason I believed was a posh word for 'to belch'. I remember writing an essay at school in which I used 'recuperate' several times with this meaning. I couldn't understand why the boys in the class were laughing.

After abdominal surgery the first sign of recovery is the downward passage of wind. The nurses come round every morning and discretely ask, "Any wind?"

I see now that as a teenager I got thinks upside down. 'To recuperate' doesn't mean 'to belch', it means 'to fart'.

Saturday, March 21, 2009

How it was in hospital

This is a chance to get off my chest the experience of the past two weeks while it is still fresh in my mind. The first thing I have to say is that I have never known such kindness and care as that I received from the nursing staff at my hospital.

I was admitted to the Royal Bournemouth Hospital early on the morning of my operation. This is the hospital that I worked at for my entire career. When I was first appointed in 1974 it was Victorian Establishment that had just 'growed like Topsy', with major developments in 1911, 1927, 1936, 1968, 1982 and 1986. The building that I originally worked in was demolished in 1993 and the new hospital built on the edge of the city opened in two phases in 1988 and 1992. It is a bright, airy, modern hospital that seems to have seen continual improvement since it opened. I was the first Medical Director of the new hospital.

The colorectal surgery department has an enviable reputation for high quality outcomes and low mortality and morbidity, a tribute to the meticulous planning and forethought of the head of department Dr Basil Fozard (you will see some of his innovations later). Dr Fozard has been at Bournemouth for about 12 years, having completed his training at the Mayo Clinic. I had already been pre-clerked before admission; so on the morning of the operation I knew precisely what awaited me as I sat and read in the day-room. I was able to walk to the operating theater suite. The anesthetist inserted a pink cannula in my wrist and injected a few drops of Hypnoval. He then sat me up to insert an epidural into my back and that's the last thing that I remember until I woke up in recovery. The surgeon came in and told me his findings, but I was still under the Hypnoval and I was in no fit state to fully understand.

My wife and daughter came in to visit me in the evening and here they encountered the first problem. It is now apparently the case that relatives can be given no information by the staff unless the patient has expressedly said that they might. There was therefore no-ne able to impart the news to them when they arrived, and it was I, in my drugged state, who blurted out the diagnosis. It was a terrible shock that they had not been expecting.

The rule has come in as an instruction from above because some patients have complained about their relatives being told. I have always thought that that was an unreasonable attitude to take unless there was some sort of estrangement involved. I have encountered husbands who wished to protect their wives from the news, but I have always countered that view by saying, "You have spent the past x years in the closest relationship it is possible to have, do you really intend to spend whatever time you have left telling lies to each other?"

The best person to break bad news is not the patient, but the doctor in charge, if he or she knows the job. He can speak from a position of knowledge, not only of the pathology, but also of how people react. He has an eye for the physiological reactions that accompany shock and is prepared with acts of comfort from a hand held to a cup of warm sweet tea.

To my mind the new rule is just one more of the vicious consequences of unthinking pandering to PC.

The major consequence of bowel surgery is paralytic ileus. This means the bowel stops its onward contractions (peristalsis) and just hangs about idly loitering. This always happens, especially if the bowel has been much handled (as when searching for a small primary). Post-operative treatment is aimed at making the period of ileus as short as possible. For many years morphine has been the mainstay of control of post-operative pain relief. However, morphine makes you constipated. Indeed, morphine alone can cause a paralytic ileus. Therefore, for Dr Fozard, the policy for pain relief is to use epidural anesthesia.

The problem for me was that the epidural only worked on the left side and the right was still painful. It happens occasionally and when it does the problem is more difficult. There was some Fentayl in the epidural to keep me in a haze, but I needed a PCA pump (patient controlled analgesia) to supplement this. This is a pump that delivers 1 mg of morphine at the press of a button, but then shuts out the patient for 5 minutes befor any more can be delivered. It is very effective, but the most immediate effect of morphine is nausea and vomiting. Generally, we offer an anti-emetic with morphine, but the choice is limited. Metaclopramide is a prokinetic agent that stimulates onward movement - possibly dangerous when the bowel has been resected and then rejoined, and ondansetron is constipating. Cyclizine is effective, but very sedating. As a result I had the morphine neat. This caused me severe spasm of the gullet.

Esophageal spasm produces a pain like angina, but can be relieved in the same way with glyceryl trinitrate, either under the tongue or as a spray. The new young doctor and I worked this out by Googling in the small hours of the morning, so she arranged to get a spray from the CCU. I tried it with instant pain relief. Then I vomited a couple of pints of brown fluid. What had been happening was that the body had contrived its own anti-emetic by constricting the gullet so hard it hurt. As soon as that was released - upchuck.

The response was to put down a naso-gastric tube and tomorrow I will tell you about that.

A great comfort to me throughout the period of hospitalization were the visits of Dr John Falkner Lee. John is a retired general practitioner. He and I were baptized on the same day in 1975 at Lansdowne Baptist Church. He is about 20 years older than I and shortly about to enter hospital to have one of his hip replacements replaced. Please pray for him. We were deacons together, elders together and always very close. For the past several years he has been on the staff of the hospital as Pastoral Visitor. On one of his visits he read to me from Zephaniah chapter 3.

The LORD has taken away your punishment; he has turned back your enemy. The LORD, the King of Israel, is with you; never again will you fear any harm. On that day they will say to Jerusalem, "Do not fear, O Zion; do not let your hands hang limp. The LORD your God is with you, he is mighty to save. He will take great delight in you, he will quiet you with his love, he will rejoice over you with singing."

Notice all those 'wills'; there is no 'might' in God, except that He is ‘might’y to save.

Thursday, March 19, 2009

Home from hospital

I want to thank all those who have sent their good wishes, prayers and kind thoughts over the past couple of weeks.

It has been longer than I expected to fire up my computer again, and I am afraid that the news is not as good as I had hoped. Apparently I have cancer of the appendix that has spread sufficiently for me to need chemotherapy. The disease is not in my liver and the largest lymph nodes were removed

I returned from hospital today and I need some time of convalescence.

The histology came back as well differentiated adenocarcinoma that is CEA positive. There were some goblet cells, however, and it would still be compatible with goblet cell carcinoid, a very rare tumor with only 600 cases in the medical literature. but it will require special stains to distinguish (Chromogranin A). I will also need to know whether the k-ras gene is mutated in order to know whether the new EDGFR receptor monoclonal antibodies will be helpful.

I suppose the most optimistic factors and that I was really very well before the surgery, that the liver is not involved and that the CT in February was almost identical with the one in September.

This all suggests that the disease in very indolent (not another 'good' cancer!).

I have yet to be given a final diagnosis and the prognosis is still uncertain.

I will write later about various aspects of this experience, but I just want to say for now that the most comforting element of the whole episode was to recite to myself, "Thou wilt keep him in perfect peace, whose mind is stayed on thee: because he trusteth in thee" (Isaiah 26:3). Strange how the old King James version comes to me in times of need.

Sunday, March 08, 2009

Waiting for surgery

A Green Woodpecker nodded and nibbled on our front lawn yesterday. For twenty minutes, not twenty feet from our front window, it strutted like a soldier on parade, its vermillion headpiece contrasting with its two-tone green uniform as it stiffly picked off insects that had been drawn above ground by the slightly warmer weather.

It was enough to attract us into the garden for the first clear up of the year. Two days ago we had woken up to blizzards with snow settling on the cars and drive, but Saturday was just about Spring. Now was the time to deadhead the hydrangeas, to cut back last year’s growth from the Sedum and to pull down the dead ivy from our cherry tree.

We gave the lawn a first cut, but first we had to buy a new lawnmower. We needed to be able to start it with an easy pull, and our old Mountfield was a terrible starter that needed strong stomach muscles as you yanked on the draw string. And I won’t be able to do that for a while.

On Tuesday, I go into hospital for abdominal surgery. This has been hanging over me since last September. At that time a CT scan found an enlarged lymph node in my right iliac fossa. Despite many investigations no explanation for it was found. I had hoped that it would just go away, but a recent CT scan shows it to be still there, and the only way of finding out what it means is to cut it out.

The radiologist suspects carcinoid, a rare slow growing tumor that typically secretes serotonin, but all the tests that I had for that were negative. Colonoscopy showed no cancer of the cecum and the biopsies were negative. So we really don’t know what we are going to find. I guess the explanation with the best outcome
is that there has been an old appendix abscess, but there are also more worrying possibilities. It could be a non-secretory carcinoid, or one that secreted another neuroendocrine hormone, like parathormone (I have a slightly raised blood calcium, but so do thousands of other normal people). Or it could be something more distressing.

In Julius Caesar, Shakespeare says, “Cowards die many times before their deaths. The valiant never taste of death but once.” Hemingway had a variation on this in ‘A Farewell to Arms’ “the brave dies perhaps two thousand deaths if he's intelligent. He simply doesn't mention them.” Whichever is true, waiting for an operation is a challenge. The more you know, the more you imagine the worse.

Nevertheless, I face the future with equanimity. The sermon this morning was on 1 Peter 1:8: “Though you have not seen him, you love him; and even though you do not see him now, you believe in him and are filled with an inexpressible and glorious joy,” The worst that could happen is that I will see my Savior sooner. Were that to be the case, it would be very sad for those who love me, but for me, better by far.

Wednesday, March 04, 2009

Darwin's anniversary

This year marks the 200th anniversary of Darwin's birth and the 150th anniversary of the publication of Origin of Species.

Richard Dawkins claimed in 1989 that "it is absolutely safe to say that if you meet somebody who claims not to believe in evolution, that person is ignorant, stupid, or insane (or wicked, but I'd rather not consider that)."

I suppose it all depends on what you mean by evolution. If you mean that various species undergo selection of genetic characteristics by their environment which make them more or less likely to reproduce these characteristics in their progeny - in other words the survival of the fittest, then of course this is true. In fact, it is a tautology. In a struggle for existence, those that are fittest to survive will survive.

If, on the other hand, by evolution you mean that life has begun as a matter of chance because of the happenstance of various chemicals mixing leading to the formation of amino acids, then protein, then nucleic acids, then some form of cellular organization, then more complex cellular forms until finally the prolific array of different species that now inhabits the earth, including all those that have become extinct, then anyone who believes that has never examined the evidence critically.

Evolutionary theories probably began with Thales of Miletus who lived between 640 and 546 BC. Darwin's contribution to the debate derived from his observations of the genetic variation of domestic animals and then his observation of natural variation on his time on the Beagle, especially at the Galapagos Islands. The mechanism that he related demonstrated that small variations are potentially present in every species and that environmental niches are indeed available that suit one variation over another. Given physical separation - either natural or produced by man - then it is possible to produce extreme variations within a species - a Toy Poodle or a Great Dane, for example, though there are limits to that variation and no-one has yet produced a tiger from a tortoise or a rabbit from a greyhound.

Darwin was a man of his time and he had no clear understanding of the mechanism eg this variation. This had to wait for Mendel's genetic experiments with peas, and even that idea had no physical equivalent until Crick and Watson fathomed out the DNA code.

Modern neo-Darwinism postulates a molecular model of random mutations that are selected for by the same 'survival of the fittest' tautology that Darwin hit upon. However, as we know, although mutations occur and are particularly useful for developing the immune response in the lymph node, elsewhere they are usually deleterious and are the chief mechanism of cancer. To suggest that they are the driving force of evolution envisions a highly improbable landscape.

Francis Crick himself (although no creationist) puts the problem clearly in his 1981 book Life Itself, Its Origin and Nature:

To produce this miracle of molecular construction all the cell need to is to string together the amino acids (which make up the polypeptide chain) in the correct order... Here we need only ask, how many possible proteins are there? If a particular amino acid sequence was selected by chance, how rare an event would that be? This is an easy exercise in combinatorials. Suppose the chain is about 200 amino acids long; this is if anything rather less than the average length of proteins of all types. Since we have just 20 possibilities at each place, the number of possibilities is 20 multiplied by itself some two hundred times. This is conveniently written as 20 to the power of 200, that is a one followed by 260 zeros!

The number is quite beyond our everyday comprehension. For comparison, consider the number of fundamental particles (atoms, speaking loosely) in the entire visible universe, not just in our own galaxy with its 100,000,000,000 stars, but in all the billions of galaxies out to the limits of observable space. This number, which estimated to be 10 to the power of 80 is quite paltry by comparison to 10 to the power of 260. Moreover, we have only considered a polypeptide chain of rather modest length. Had we considered longer ones as well, the figure would have been even more immense.

Even a simple bacterial cell comprises not just one protein, but a whole host of proteins that interact together in complex union.

Put simply, there are not enough molecules in the whole universe for even a simple protein to have evolved by chance.

Brick one in the wall of doubt.

Monday, March 02, 2009

Who's in charge?

Bruce Forsyth is Britain's premier TV game-show host. He is renowned for his use of catch phrases. At one time his favorite was, "I'm in charge!"

With financial markets in turmoil and the world in the worst recession since 1929, it makes you wonder whether anyone is in charge. Politicians, try to give the air of being in charge, but it is apparent that they are powerless. Every headline brings a reaction, but they give me the impression of being like England batsmen facing the West Indies pace attack of a former generation. They may be fending off short pitched deliveries and protecting their faces, but they have no plan to build an innings. A few weeks ago Gordon Brown claimed to have saved the world. It's a pity the world did not notice.

The bankers are certainly not in charge. If they were clever they took the money and ran. And they intend to hang on to it. The industrialists are not in charge. Nobody wants to buy their goods and they are laying off workers at an alarming rate. The armed forces are not in charge. Battered and bruised by conflicts for which they have no heart, they just want to come home.

Way back in 539 BC in the land that is modern day Iraq, the rulers were feasting, drinking and revelling, when they were shocked by the sight of a disembodied hand writing on the wall, "You have been weighed in the balance and found wanting." You can read about it in Daniel Chapter 5. It must have been a frightening experience but Belshazzar would have felt safe within the impregnable city of Babylon. How was he to know that Cyrus the Persian possessed sufficient engineering skills to divert the River Euphrates so that he could enter the city along the dry river bed?

Belshazzar that he was in control of events but powerful though he was he was like putty in the hands of history.

Cyrus was a great Persian king (it seems like Iraq and Iran have always been enemies). If you go to the British Museum you can see the Cyrus Cylinder. It was discovered in 1879 by the Assyro-British archaeologist Hormuzd Rassam in the foundations of the Esagila, the main temple of Babylon, where it had been placed as a foundation deposit. The text of the cylinder denounces Nabonidus (father of Belshazzar) as impious and portrays the victorious Cyrus as pleasing to the chief Babylonian god Marduk. It goes on to describe how Cyrus had improved the lives of the citizens of Babylonia, repatriated displaced peoples and restored temples and cult sanctuaries.

Among those people returned to their own country were the Jews who had been taken into exile by Nebuchadnezzar 70 years previously. The liberation of the Jews had been predicted by the Prophet Isaiah in chapter 44 "who says of Cyrus, 'He is my shepherd and will accomplish all that I please; he will say of Jerusalem, "Let it be rebuilt," and of the temple, "Let its foundations be laid." and in 45:13 "I will raise up Cyrus [a] in my righteousness: I will make all his ways straight. He will rebuild my city and set my exiles free, but not for a price or reward, says the LORD Almighty.".

It seems astonishing that so far ahead of time Isaiah should name the liberator, but in Ezra chapter 1 the event is reported <>

The Bible makes it clear that Cyrus was not working on his own. It reassures us that someone is in charge; someone who has control of the future. We used to sing a hymn:

God holds the key of all unknown,
And I am glad:
If other hands should hold the key,
Or if he truseted it to me,
I might be sad.

What if tomorrow's cares were here
Without its rest?
I'd rather he unlocked the day,
And, as the hours swing open, say,
"My will is best."

It seems to us that we face an uncertain future. Our savings are in jeopardy, our jobs are not safe, our pensions losing their value, our homes at risk. Many are worried about our health. Perhaps we face surgery or chemotherapy. WE may be frightened for our loved ones. Sometimes it seems that no sooner has one worry dissipated than another takes its place. Where can we turn for comfort?

Jesus said this, "Consider the lilies of the field, how they grow: they neither toil nor spin; and yet I say to you that even Solomon in all his glory was not arrayed like one of these. Now if God so clothes the grass of the field, which today is, and tomorrow is thrown into the oven, will He not much more clothe you, O you of little faith? Therefore do not worry, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ For after all these things the Gentiles seek. For your heavenly Father knows that you need all these things. But seek first the kingdom of God and His righteousness, and all these things shall be added to you. Therefore do not worry about tomorrow, for tomorrow will worry about its own things. Sufficient for the day is its own trouble."

And St Paul wrote to the Christians in Rome who were suffering far more than we are, "We know that all things work together for good to those who love God, to those who are the called according to His purpose."