Remembrance

We approach again the anniversary of the eleventh hour of the eleventh day of the eleventh month; the time we dedicate to remembrance of the numberless casualties of the terrible wars of the twentieth century; in particular the catastrophic European civil wars.

Europe may never recover from the industrialised slaughter of its sons in the Great War, or from the horrific destruction accompanying a second slaughter between 1939 and 1945.

I make no apology for posting again this poem by Wilfred Owen, killed during some senseless attack ordered in the last days of the Great War of 1914-18.

Parable of the Old Man and the Young

So Abram rose, and clave the wood, and went,

And took the fire with him, and a knife.

And as they sojourned both of them together,

Isaac the first-born spake and said, My Father,

Behold the preparations, fire and iron,

But where the lamb for this burnt-offering?

Then Abram bound the youth with belts and straps,

And builded parapets and trenches there,

And stretchèd forth the knife to slay his son.

When lo! an angel called him out of heaven,

Saying, Lay not thy hand upon the lad,

Neither do anything to him. Behold,

A ram caught in a thicket by its horns;

Offer the Ram of Pride instead of him.

But the old man would not so, but slew his son,

And half the seed of Europe, one by one.

This poem was set to music by Benjamin Britten. It is the centre of the War Requiem: music we should recreate every Remembrance day, and which should be played only in live performance.

A Second Chance To Get It Right

This happened in Muscat, in 'Oman.

He was a student in the university. He had just returned from his native village to the campus after a vacation.

He was referred urgently because he had developed jaundice.

He told me he had felt hot and unwell for maybe 10 days. He had diarrhoea, not severe. He had rather vague abdominal discomfort.

He had noticed his eyes were yellow the previous evening; today he was worse.

Unexpectedly he said he had continued to eat, and smoke cigarettes.

There was no significant past history. He had taken no drugs.

Examination showed a well-nourished young man, obviously jaundiced, with a low fever, 38.4 degrees.

The liver was a little enlarged and tender; the spleen could just be felt.

This looked like acute hepatitis, most likely acute hepatitis B. His continued appetite for tobacco was puzzling; aversion to smoking is an important sign in hepatitis. Also I expected him to be more unwell with hepatitis, perhaps with a story of feeling better as the jaundice came out.

Still, everything else fitted.

I arranged some blood tests, and he was admitted to the ward.

Next morning I came to do a ward round, accompanied by a junior doctor and several students.

There was a commotion around a bed at the end of the ward. Several nurses were there, and another was hurrying up the ward carrying several hospital blankets.

It was my 'hepatitis' patient. He was shivering violently, shaking the bed, complaining of feeling cold.

This was a rigor, a sudden severe fever. His body temperature was rising rapidly. He felt cold because the body's thermostat had reset to a value hotter than normal, and had activated the mechanisms to increase heat production.

The clinical thermometer read 40.4 degrees. The penny dropped.

Hepatitis does not cause rigors. Acute malaria does - and malaria can occasionally present with jaundice. After all, the parasites destroy red blood cells, liberating haemoglobin, which is broken done in the spleen to produce the yellow pigment of jaundice, bilirubin.

I took another blood sample to the lab. My colleague quickly made the stained smear, and we looked using the oil-immersion microscope objective.

There they were: tiny parasites of Plasmodium falciparum in 1% of red cells.

Acute falciparum malaria.

An important experience for the students - and indeed, for their teacher.

Back to the ward, to prescribe quinine tablets, 600 mg. 8-hourly for 1 week.

The response was dramatic. His temperature was normal that afternoon; the jaundice disappeared in 2 days. He stayed in hospital until the treatment was finished - he could hardly go back to the student hostel where he had a room, and it was important to complete the treatment as prescribed.

Later I asked about his home village. It was in a wadi I knew well, with extensive palm groves and gardens attesting abundant water. Almost certainly it was a hot-spot for malaria.

"Where have you been recently" is a question to remember while taking a medical history.

A Painful Lesson

This happened 8 years ago. I have changed details where necessary.

I was working in the north of England. We had been on 'take-in' for 24 hours. I met my team of junior doctors at 0745 to do the 'post-take' ward round which ended our duty period, after which the juniors would be free until 0900 the following morning.

Some 2 hours later we had seen and made management decisions for the new admissions, maybe 12 or 14 in number. I thought we had finished.

But there proved to be one more to see, in a side-room, usually used to isolate cases where infection was feared.

Before we went in the registrar warned me the patient was a man who had undergone surgery for 'gender reassignment'. The patient had wanted admission to the female ward, but had to go in the side ward, for obvious reasons.

A warning bell should have sounded in my head, but it didn't.

The name on the bed-notice was 'Barbie' - no surname. The cover of the notes had 'Barbra' written in marker pen across the top.

The patient was heavily built, plump faced, with broad shoulders and big hands. The hair was long, platinum blonde, loose, but carefully combed and clipped. Heavy make-up did not completely conceal a dark beard area. Large filigree gold rings hung from each ear-lobe. There was a whiff of perfume, which did not disguise a smell of tobacco.

Barbra was wearing a white cotton sleeved bed-gown: breast development could be seen. Nearly every finger had a ring; the nails were painted purple, and manicured.

Barbra was taking daily doses of an oestrogen preparation, and several other preparations of vitamins, minerals and tonics.

Barbra was unemployed, living with a male partner in social housing.

The clinical problem was chest pain, and suspicion of angina pectoris. The pain had lasted several hours the previous afternoon, but had resolved after admission. There was a previous history of hospital attendance for similar pains, but no heart or chest disease had been identified.

On this occasion ECG's taken on admission and 16 hours later had shown no abnormality. Blood values on admission had been in the normal ranges; the results of a second set of blood tests were awaited. Chest X-ray was unremarkable.

Examination revealed a normal pulse, blood pressure a little increased, normal heart sounds, and no other significant signs.

The clinical evaluation was that this was unlikely to be heart disease. Barbra could go home that evening, provided there were normal results from the third set of tests and ECG at 24 hours after admission, as the hospital protocol required.

I discussed the findings with Barbra. It is difficult to be totally confident that such chest pain is not angina, so I asked for an appointment for out-patient review in a week's time. The atmosphere was friendly, reassuring and good-humoured, or so I thought.

Barbie failed to attend follow-up.

Instead the hospital received a furious letter of complaint ten days letter. Both sides of a foolscap sheet, written by hand in small neat capital letters. While discussing Barbra's chest pain I had used male personal pronouns - he, not she; his, not hers.

There were complaints of severe emotional distress in consequence, threats of litigation, and of a complaint to the General Medical Council. There was a demand that I should attend counselling for my attitude problem to transsexual people.

I was horrified. This torrent of anger was totally unexpected, and unreasonable.

I spent several days - and nights - worrying. The threats caused little anxiety. but the ferocious personal accusations did. How could an unintended impoliteness cause such fury, especially as it went unremarked at the time?

In the end I sent a bouquet of flowers with a brief note of apology: I heard no more.

I subsequently learned there had been a previous, similar incident. Barbra came before with chest pain, and had made a scene in the ward when a colleague had used the wrong personal pronoun. "I think", said my colleague, "Barbra gets a kick out of aggrievement and outrage. You walked into a trap".  

Maybe: maybe people like Barbra have powerful psychological stresses relieved by an outburst of anger. Victim status brings rewards, too.

But there remains a difficult issue for the physician. Male sex is in the Y chromosome in every cell in a man's body. Genitalia can be amputated and some simulation of female parts created by plastic surgeons; female sex hormones can be taken; womens' dress can be worn, and womens' behaviour emulated: still the genetic reality remains. The white cells in the blood will lack the Barr bodies which identify a blood specimen as female.

Does the male pattern of disease prevalence persist when female hormones are taken for years? Do oestrogens protect men against coronary heart disease, as they do women? I don't know.

What is the chance of cancer in an oestrogen-stimulated male breast? I don't know.

If Barbra came complaining of difficulty passing urine would I be wrong to suspect prostate problems?

I'm glad I'm retired.

British Democracy 1649-2009

Democracy was born in Britain on the 4th. January 1649. On that day the House of Commons enacted itself as the final authority in England, in words which have echoed down the centuries.

Resolved, &c. That the Commons of England, in Parliament assembled, do Declare, That the People are, under God, the Original of all just Power:

And do also Declare, that the Commons of England, in Parliament assembled, being chosen by, and representing the People, have the Supreme Power in this Nation:

And do also Declare, That whatsoever is enacted, or declared for Law, by the Commons, in Parliament assembled, hath the Force of Law; and all the People of this Nation are concluded thereby, although the Consent and Concurrence of King, or House of Peers, be not had thereunto.

The people are the original of all just Power; the Commons, representing and chosen by the people, have Supreme Power. This is the fundamental principle of democracy.

Others enacted the same principle for themselves, notably the Americans. It is the root of all constitutions written at the independence of the countries of the British Empire.

Through the centuries the British people kept faith with this fundamental democratic principle, when necessary fighting devastating wars in its defence.

Today, 4th. November 2009, this principle is formally abandoned. Yesterday the Czech president signed the Constitution of Europe, the Lisbon Treaty, devised and written by the unelected Eurocracy.

The Eurocracy has taken to itself the power to over-rule national governments, including our House of Commons. The new unelected President of Europe will have precedent over our Prime Minister. Britain is to be an off-shore island in a European federation, a German-French hegemony.

All this has come about by stealth, small step by small step. Politicians have lied to their electorates and betrayed solemn undertakings to bring us to this.

Let New Labour be remembered as the government which ended 360 years of sturdy democratic  independence of my country.

Let Gordon Brown be remembered as the unelected Prime Minister who sneakily signed the Lisbon Treaty without the authorisation of the British people.

From now on I shall give financial and electoral support to politicians pledged to repatriate the Supreme Power which a generation of politicians have ceded to the Eurocracy. This will over-ride all other issues. If it means supporting people to whom previously I would not give time of day, so be it.

The Endgame.

Today the High Court in Prague gives its verdict on the legality of the Lisbon Treaty in the context of the constitution of the Czech Republic. It is expected to declare no serious problems.

President Havel will thereby have to end his stand against the ambitions of the Eurocracy. The last obstacle to the Lisbon Treaty has failed; Havel must sign; a Federal Europe will be established in all but name.

Who will get the new top jobs, especially who will be the first president? I suspect we are seeing the endgame of the Blair Retirement Plan.

Slowly we are understanding the final objectives of the european policies of Prime Minister Blair. As always, the good reasons were trumpeted, the real reasons were suppressed or denied.

The good reasons are so familiar: Europe as a world superpower to balance American hegemony; wonderful commercial opportunities in an ever expanding market; Britain at the heart of Europe, a wise, experienced, senior member of this union of high ideals, punching above its weight; Europe as a great force for peace, reconciliation, and human rights. Yesterday we heard it all again from David Miliband.

I will be generous and allow that the Eurocracy probably believes its own rhetoric: the good and the real reasons are complementary, the public and private ambitions co-exist.

The real reasons can only be surmised, but I think the following is more likely to be reality than cynicism.

As the consummation of a political career, an EU appointment is devoutly to be wished.

The Aristeurocracy - the cabal of senior eurocrats - enjoys power with little democratic accountability, a most tempting prospect for those wearied by the tribulations inflicted by an electorate.

They believe the hand of history is on their shoulders - if I may borrow a phrase.

Better to walk with destiny than cope with the problems of little people in a weekly constituency surgery; better to present your case to a sympathetic EU committee than have to argue it forcefully against an opposition in the House of Commons.

And much better not to be subject to proper audit of your expenditure decisions.

No-one mentions money, of course. Only the vulgar raise the issue. Called to public service, our masters are indifferent to the high salaries the Eurocracy awards itself, they reluctantly accept the multitude of expenses and other perks, and the wonderfully generous pensions are no more than their just rewards.

After 5 years even a simple MEP can expect a pension and maybe a million pounds saved, while an EU commissioner can expect a very comfortable future.

We remember that Tony Blair promised that the British rebate was safe in his hands. Mrs. Thatcher had negotiated a substantial relief of Britain's net contributions to the EU. In the event he conceded the rebate in return for a verbal assurance that agricultural subsidies would be reviewed sometime soon, and maybe other unspoken concessions and understandings.  

At the same time he was discussing with other leaders the job description of the President of Europe to be created by the new constitution - which mutated into the Lisbon Treaty after rejection in referenda in France and the Netherlands. It is reported that he showed great interest in the presidency, arguing for detailed changes in the initial description.

Yes, I know I should be ashamed even to think that Mr. Blair may have allowed considerations of personal opportunity to influence him in such dealings: perish the thought!

But there is no doubt about the consequences of the Blair concessions. Over the next 5 years Britain's increasing obligations to the EU will leave little change from 40 billion pounds - and that's just net contributions to the EU budget, our serious trade deficit with Europe will continue. That huge sum will be borrowed. This is the 'elephant in the room' in all discussions of Britain's financial crisis.

The Blair Retirement Plan has had a difficult ride so far. First the delays caused by referenda results. Then the risk of collapse of the Brown government, and a new Tory government promising a referendum in Britain. Mandelson was shipped back to London to buttress Brown until the Lisbon Treaty could finally be ratified. The irish were bought out, and the Czech nuisance may soon be over.

Blair's mate Silvio backs him for President, and Sarkozy is open to persuasion. Others lower in the EU pecking order are variously for, against or indifferent. In the end Blair's ambitions will be decided by Die Bundeskanzlerin, Frau Angela Merkel.

But nothing is for nothing in the EU. Blair's budget concessions were years ago. Is there any other card the British eurocracy could play for Blair?

What if Frau Merkel makes her support conditional on Britain joining the euro? Could Brown be persuaded his conditions are fulfilled, and the time is right to bounce Britain in? He too must be wondering about his future opportunities. He has nothing to lose, a chance to prove he can be decisive, and bid for a place in history. Influential people would praise him as a statesman, and at the least he would deeply embarrass the Tories.

Ridiculous!

The DROLLS 1-3

DROLL: the Doctor's Record Of Lessons from Life.

Wise aphorisms learned in the school of experience. My first three are here.

DROLL 1: The best apples on the tree are always just out of reach.

DROLL 2: The ripest apple is the one that falls as you try carefully to gather its neighbour.

DROLL 3: The better the apple, the more it attracts pests and parasites.

Read, mark and learn from one who knows!

Liver Failure - Last Words [ for now ... ]

There exists no reliable system of artificial liver support, despite a half century of expensive research.

There are kidney machines, heart machines, lung machines; there are well established methods to manage loss of intestines, pancreas, endocrine glands, skin, even reproductive organs.

There is no liver machine, and less radical management of liver failure is reactive. We lack the fundamental understanding of liver function necessary for confident, precise management. We have no medical means to reactivate brain and kidney function in liver failure; only liver recovery or transplant does that.

Livers for transplant are hard to obtain. In liver failure the need is urgent: the patient will die in a few days without the transplant. Perfusion techniques mean a liver taken for transplant can now be kept in reasonable condition for a day or two, buying time to bring liver and patient together, in a prepared theatre, with experienced staff. Even so, the opportunities for transplant in liver failure are few. There is no prospect of a 'liver bank', like a blood bank.

In all surgery the best results are from routine, planned procedures. Liver transplantation is major surgery demanding specialised facilities and meticulous preparation.

Animal livers have not proved useful. They cannot be transplanted. In artificial systems they produce plasma for the animal species of origin, which is likely to have serious differences from human plasma.

Liver failure is an unsolved clinical problem. We may appreciate the magnitude and complexity of the abnormalities in liver failure, but so far there is no full understanding of what happens when the liver goes down. Without that strategic understanding management has to be based on trial and error, experience, even guesswork.

Liver medicine awaits a breakthrough in research into the basic physiology of the liver.

Liver, Brain and Kidney

In my last posting but one I described the clinical features of liver failure. It is interesting that many problems in the management of liver failure are caused by the secondary failure of other organs, especially the brain and kidney. The direct consequences of liver failure - jaundice, blood clotting defects, low blood glucose and low body temperature - are less threatening or are easily treated.

Secondary brain and kidney failure occur together, though one may more severe. If the liver goes down it takes brain and kidney down with it.

Perhaps brain and kidney functions are impaired by the same abnormality, caused by loss of liver function.

If liver function recovers, naturally or after transplant, brain and kidney recover too. The problems are functional, not structural.

I have seen a woman in liver coma for five days recover consciousness in less than twelve hours after a successful liver transplant.

What do brain and kidney have in common? How might liver, brain and kidney interact?

Liver function is central to these questions: kidney failure from other causes does not affect liver or brain function; similarly, coma from other causes does not affect liver or kidney.

High blood flow is a common feature of these three organs. Each takes about a quarter of cardiac output at rest - over a litre per minute in each case. Reduced blood flow may be a factor in the secondary failure of the kidney, but not for the brain.

Brain and kidney also share a dependency on the sodium-potassium pumps in their cell membranes. These produce the chemical and osmotic gradients fundamental to kidney function, and the electrical potentials on which the brain depends.

The conventional wisdom is that liver failure is an intoxication, Substances accumulate in the blood which poison brain and kidney.

Ammonia is the traditional culprit. The problem is that clinical severity does not correlate with blood ammonium values, and washing out ammonium by dialysis does not improve the patient.

The ammonium ion is physically similar to the potassium ion: it is conceivable that ammonium could interfere with sodium-potassium pumps.

There is a long list of other candidate toxins, including methionine and tyrosine or derivatives, diazepam-like substances, and bacterial endotoxins. The same problems apply: poor correlation of biochemical values and clinical state, and failure to improve on dialysis.

These objections weaken if the toxin binds to plasma proteins, or is itself a protein or other macromolecule. But exchange transfusion is no benefit either.

The intoxication hypothesis is strengthened by the undoubted improvement after emptying the colon: patients in stupor or early coma may be aroused by purging or enema. 'Bowel sterilisation' using antibiotics may also be beneficial. Unfortunately these manoeuvres fail if the liver failure is severe.

[A doctor prescribing an enema for a patient in liver coma should do it himself.]

Deficiency is the alternative to intoxication. The liver produces substances essential for brain and kidney function: loss of these essentials causes the secondary organ failures.

Glucose is an obvious example. Reduced blood glucose content will certainly impair and eventually damage the brain, but most patients in liver coma have adequate blood glucose, naturally or by infusion.

The rapid start-up of brain and kidney after transplant does suggest the restoration of something vital for brain and kidney cell function, either a substrate or an activator of a metabolic process.

Poor activity of membrane sodium-potassium pumps can be demonstrated in white blood cells from patients in liver failure. Incubating the cells in normal plasma rapidly restores full activity.

Such depressed pump activity resembles the effect of digoxin on normal cells. Patients in liver failure do not show the ECG changes familiar after digoxin dosage.

But, it is legitimate to ask, why do membrane sodium-potassium pumps have a receptor for digoxin? The same question asked of the brain and morphine led to the discovery of endorphins.

Digoxin and bile acids share the unusual 5-beta steroid nucleus. So far as I know, this type of steroid is produced only by the liver in humans. Bile acids accumulate in the blood if the bile duct is obstructed. They cause intense itching, and may affect the ECG, but brain and kidney functions are maintained.

So this is my hypothesis. The liver produces a regulating activator of the sodium-potassium pumping enzymes in cell membranes, especially in brain and kidney. Perhaps other ion transporting enzymes are similarly regulated. Function of these enzymes is impaired if supply of the liver activator fails, with consequent encephalopathy and nephropathy.

The activator may be a 5-beta steroid molecule, similar to a bile acid. It may be short lived in the body, so constant synthesis is necessary. The activator binds to the digoxin receptor on the enzyme, and increases its activity. Digoxin binds but does not activate, and blocks access of the activator.

Cerebral oedema is a lethal complication of liver coma. It must happen because the pumping of salt and water out of brain cells has collapsed. This is a hint that membrane pumps are failing, but of course other causes must be considered.

And. of course, the putative activator might not be a 5-beta steroid, but some other substance produced by the liver, maybe a peptide, maybe an active vitamin such as adenosyl-cobalamin, or something else entirely.

May be it is another metabolic pathway which is activated, such as ATP production. Ion pumps need ATP.

I have studied liver failure for many years. I have seen theories and treatments come and go. I perceive that there is a fatigue in liver research at present, especially in the mechanisms and management of liver failure. I suspect the subject needs a breakthrough in understanding of liver function, especially its interactions with other organs.

If I had a research facility, my priority would be liver-kidney interactions - much easier to study than the liver-brain axis. Membrane ion pumps would be my first focus.

The Death of Stephen Gately

What can reliably be concluded about the cause of death of Stephen Gately? Sudden death does occur in apparently fit 33 year old men, but the list of diseases which can do this is short.

Conditions which might cause sudden death in a young man without previous diagnosis include:

- aortic coarctation;

- hypertrophic cardiomyopathy;

- aortic valve stenosis;

- coronary thrombosis;

- pulmonary embolism;

- subarachnoid haemorrhage.

All these would be identified with confidence at necropsy.

Some infections can rarely cause acute death - death within hours of onset. Two might be listed:

- meningococcal septicaemia;

- influenzal pneumonia.

These have a notoriety in this respect, but of course other infections might just do it.

A patient would feel ill, and raise alarm, probably even if sedated.

The authorities have reported that Stephen Gately was found in a kneeling position by a sofa, his head on a pillow. He had vomited, but had not inhaled vomit. At necropsy he had pulmonary oedema.

Pulmonary oedema is fluid accumulation in the tissues and alveoli of the lungs. It can be rapidly fatal if untreated. An erect posture relieves the severe breathing difficulties of pulmonary oedema, so his position when found is consistent.

Pulmonary oedema is not the same as fluid obstructing airflow in the trachea and bronchi, as would be found if vomit were inhaled, or in drowning.

The fluid in pulmonary oedema comes from the blood, not from outside.

I can imagine him asleep on the sofa, awakening in severe respiratory distress, weakened and confused by lack of oxygen, and managing to struggle to a kneeling position before final collapse and death.

The problem is that pulmonary oedema is not a complete diagnosis. In Britain a death certificate citing pulmonary oedema alone would be returned by the registrar. Pulmonary oedema is due to a primary condition, most commonly affecting the left ventricle of the heart and causing it to fail.

The first four conditions listed above could do this, but none is mentioned by the authorities. Perhaps more information will be released eventually.

Speculation is always dangerous, especially where there is celebrity and controversy. However I can think of one further cause of sudden death from pulmonary oedema, and that is the drug Ecstacy, MDMA.

Acute heart failure and pulmonary oedema are recognised complications of high doses of MDMA. This cause of death might not be evident at necropsy.

I understand samples are in the toxicology laboratory, so this hypothesis will be tested.

In the meantime we can only reflect again on the fragility of life, especially when acutely challenged, and mourn the death of a man in his prime.

Cirrhosis: Foul and Fatal

Cirrhosis: cirrhosis of the liver. It is an untreatable, lethal disease. Any study of the prognosis of cirrhosis in Britain is likely to find that, from the time of diagnosis, half are dead within one year, and very few will survive five years. Many cancers have similar prognoses.

The incidence of liver cirrhosis is increasing, especially among women. Epidemic alcoholism is the most important cause, but demographic change is increasing the number of cases of imported liver disease, notably chronic hepatitis B and C.

Cirrhosis should be an active subject of public and political concern, but there is lack of understanding about the disease, and a popular tendency to dismiss warnings about alcohol.

Make no mistake. Cirrhosis is deadly, and a foul way to go. The occasional patient can be rescued by liver transplant, but the opportunities for this dramatic intervention are few.

Cirrhosis is a process which destroys normal liver structure and function. Sustained or repeated injury to the liver lights up a chronic inflammation, which progressively damages and destroys liver cells. Fibrous scars develop in the liver substance. The injury also damages the liver's normal regeneration and repair mechanisms, so that abnormal nodules of liver cells begin to replace surviving normal liver tissues.

These nodules fail to link properly into liver blood and bile systems: the nodular cells cannot provide normal liver function.

Eventually the smooth normal liver is replaced by a nodular scarred mass, essentially a fibrous conglomerate of benign liver tumours.

Cirrhosis, once started, tends to progress remorselessly: stopping drinking has little effect.

The blood supply of the liver is unusual. Blood coming from the intestines, spleen and pancreas is intercepted by the liver, for processing before release into the general circulation. The veins from intestines, spleen and the pancreas join to form the portal vein, which then branches into the liver. There is an arterial supply, the hepatic artery, but this is relatively small.

Total blood flow through the liver at rest is about one quarter of cardiac output, approximately equal to blood flow through the brain.

What is the function of the liver? This was a favourite question to students, and few indeed were the occasions when the answer was satisfactory.

The liver is a gland secreting two fluids.

Bile is the first: a liquid secreted through the bile duct into the duodenum. It is the pathway for the excretion of bilirubin, a breakdown product of haemoglobin. Bile also assists digestion, providing the detergent bile acids, phospholipids and cholesterol needed, especially for the absorption of fats.

Blood plasma is the second secretion of the liver, and by far the most important.

Blood is the product of three organs: bone marrow and lymphatics supply the cellular components; the kidney regulates water and mineral balance; the liver synthesises and controls the complex array of organic molecules which make up the plasma - glucose, albumin, blood clotting factors and so on.

The liver is the custodian of the constancy of the internal environment, the condition for free life, independent of the environment.

If the body is an engine, the liver is the carburettor.

Liver function ensures that the blood has a constant composition: the concentrations of plasma components are controlled within strict limits. It synthesises as necessary, stores and releases glucose and other nutrients, and removes wastes and foreign substances.

Liver function maintains the plasma volume, by regulating the synthesis and plasma concentration of albumin.

The liver is the main source of body heat at rest: its intense metabolism produces heat. It is notably hot to the touch, and blood leaving the liver is the hottest in the body, commonly at least one centigrade degree above the body temperature.

The liver has defence functions too - trapping and destroying bacteria and foreign materials in the blood from the intestines.

Liver, kidney and bone marrow function must be closely co-ordinated. These interactions are poorly understood, but their failure in liver disease has important clinical consequences.

The liver has a huge functional reserve: probably 90% of liver function may be lost before clinical problems begin.

The syndrome of liver failure has three main parts.

Jaundice is the first: accumulation of bilirubin in the blood. This is disfiguring, but does little to impair health otherwise.

The second is nephropathy: impaired kidney function. The patient cannot excrete salt and water adequately. Daily urine volume falls, and sodium excretion may be less than a tenth of normal. The normal urinary excess of sodium over potassium is reversed.

Oedema develops, especially of the lower parts - feet, legs, abdomen. There is likely also to be fluid accumulating in the abdomen - ascites.

This retention of water dilutes the plasma: thus the concentration of albumin falls, but the total body albumin pool is normal or even increased.

In some way the liver drives kidney water and salt excretion. The mechanism of this interaction is not clear.

The third is encephalopathy - disturbance of brain function. In the early stages this causes apathy, loss or reversal of diurnal rhythms, loss of social inhibitions, poor spatial discrimination, and other neuro-psychiatric changes. 'Flapping tremor' is a transient, abrupt loss of posture of the out-stretched hands, with instant recovery. It occurs in other metabolic brain diseases.

Stupor leading to coma is the final state of liver failure. Once established, coma is difficult to reverse and the prognosis is poor.

Fetor is common in liver failure - an unpleasant smell to the breath, like bad meat. It is caused by the excretion of methylated sulphur compounds into the inspired air.

Liver failure is one mode of death in cirrhosis. There are at least two more.

Blood flow through a cirrhotic liver is impeded. Pressure increases in the portal vein, and venous pathways bypassing the liver open up. Eventually varicose veins develop, notably in the lower oesophagus, but also in the rectum and round the umbilicus. These are points where the portal and systemic circulations meet.

Oesophageal varices are large, thin-walled veins, carrying a big flow of blood. They rupture easily, causing severe bleeding into the oesophagus, and so massive vomiting of blood. This dangerous catastrophe is difficult to manage. Varices can be blocked by endoscopic injections of sclerosing substances, when they are not bleeding. Occasionally other interventions are possible.

No one who has witnessed a patient dying in a bed-full of blood will ever doubt the dreadful consequences of cirrhosis.

Finally, malignancy may develop in a cirrhotic liver. Usually a sudden deterioration raises suspicion. Sometimes a blood test can confirm the diagnosis, but the diagnosis may be made only at post-mortem. Malignant change is untreatable and likely to be rapidly fatal.

Never risk cirrhosis. Heed warnings about safe drinking; immunise against hepatitis; practise safe sex - hepatitis is transmitted venereally.

Cirrhosis is as lethal as cancer.

Artemis Rampant

The season of fashion shows is here. Haute Couture is strutting its stuff. And bizarre stuff it often is: do some of these apparitions appear anywhere but on the catwalk?

I gaze in disbelief at the pictures in the weekend supplements. Is it because I'm male, or because I'm 70+, or maybe both?

Being male may be a factor. These beanstalk models and their fantasy outfits are not meant to be attractive to men; they are, if anything, anti-sexy, male-repellent.

The models project challenging female self-sufficiency: feminist, not feminine. Their gait and manner is arrogant, unsmiling, unappealing. The clothes neither flatter nor enhance a female figure; on the contrary, they flatten and conceal any curves the model may have. A fashion designer said recently on television that his clothes did not hang well on a woman more than size 12.

The whole appearance is designed to impress and dominate, especially other women.

These are the votaries of Artemis: Aphrodite has no place here.

Catwalk models may be admired role models for anorexics, but I suspect these two groups of underweight woman differ in psychology.

Those models do not show the classic features of anorexia nervosa. Self confidence is the opposite of the 'daddy's little girl' posturing of the truly anorexic; charming, manipulative, devious, untruthful, so badly treated by others. Watch the famous interview by Lady Diana - the adult anorexic personality on display.

Severely affected anorexics starve themselves into extreme body wasting, but the breasts are often surprisingly preserved. No doubt catwalk models starve themselves too, and smoke cigarettes rather than eat, but I suspect they are often naturally tall, skinny women, with poorly developed female body contours.

Anorexia nervosa is a flight from sex and motherhood, a wish to remain juvenile, a phobia of fat, perceived as a symbol of sexual maturity. It is aberrant development of the maternal instinct; turning inward to love of the immature self.

Catwalk models suppress and disguise their normal sexuality.

So who designs these fantasy outfits for for these anti-feminine women? Well, are high proportion are homosexual men.

Draw your own conclusions.

What strange lives these people must lead.

But I suggest there is material for a doctorate thesis in psychology in just one season of these fashion shows.

These Stubborn Islanders

I prize my first edition copy of Chester Wilmot's book 'The Struggle for Europe', published 1952. It is a classic history of the allied invasion of Normandy and the subsequent campaigns which ended with the defeat of Nazi Germany. Wilmot was an Australian who reported for the BBC. He saw the campaign in the west from its beginning: he flew in on D-Day in a glider. He was present at its end, at the surrender of the German High Command on the Lüneberg Heath.

He was killed in 1954, in the first BOAC comet disaster.

He wrote this about the British reaction to defeat in 1940, and Hitler's misjudgement of the British mood - a misjudgement which proved critical for Germany's eventual defeat.

>>

Once the first shock of the disaster in Flanders had passed, the people of Britain, with their strange capacity for seeing victory in defeat, drew encouragement from Dunkirk.

The miraculous escape of 225,000 British troops from what had appeared to be certain destruction or capture came to be regarded as a divine deliverance which gave men and women throughout the land new faith in themselves and their destiny.

This was not the first time that a continental despot had stood on the shores of France and hurled threats across the channel. Time and again in the past 400 years England had fought to prevent the domination of Europe by a single power. Hitler was now faced with the same British stubbornness that had baulked Philip of Spain, Louis XIV, Napoleon and Kaiser Wilhelm II.

When Hitler looked across the Channel from Cap Gris Nez in June, he saw only Britain's present material weakness; he did not appreciate the strength and courage her people drew instinctively from the past.

Ignoring the warning of history, Hitler clung to the hope of another 'Munich', or at least an 'Amiens', but he was extravagantly optimistic in thinking that the traditional Balance-of-Power could be jettisoned by any British statesman in the summer of 1940, not least by the descendent of its most renowned exponent, John Churchill, first Duke of Marlborough."

<<

I understand that on Cap Gris Nez that day, a general reminded Hitler of the words of one of Napoleon's marshals, as they stood on the same spot under similar circumstances:

"There are bitter weeds in England".

We now know now that Hitler's first taste of the bitterness of defeat was delivered by Hurricanes and Spitfires: each carrying eight machine guns, and powered by the Rolls Royce Merlin engine.

In the light of this recent history, how should we Britons today respond to the unfolding conspiracy to entrap us in a European super-state, under German-French hegemony? Do we consent to most of our policies being decided by unelected Eurocrats? Is our elected Westminster parliament still to be the 'sole power under God' in this United Kingdom? Do we submit to a future as second-class offshore islanders?

Do we, at last, abandon our Balance-of-Power strategy?

When they say Tony Blair is the best man to be our new, unelected, President, are we expected to applaud? Will they tell us if the new President will have precedent over our Prime Minister - and what is the status of the Queen in all this?

When Edward Heath took Britain into the Common Market [as then it was called], assurances came from all sides that this was not the first step towards our assimilation in a United States of Europe: it was a commercial union, not a political movement. On this assurance I voted 'yes' in the subsequent referendum. How badly we were deceived became apparent as the years passed, and successive governments signed up to increasingly political European treaties.

It is reported that now 70% of the time of parliament is spent passing rules and regulations from Brussels into British law.

It is true that European integration has made war in Europe unthinkable, and that is a huge advance. I believe that for a thousand years until my generation no Frenchman had lived to 70 without seeing his country invaded by Germany.

This most welcome development was already achieved in the Common Market: nothing is added by the ensuing drive for political integration.

I shall never agree the Lisbon Treaty is valid until it has been approved by a free vote of the British people. I believe this opinion is consistent with traditional British values and strategies.

The promised referendum is the bitter weed in England which the Eurocracy has conspired to kill.

Fascism in the 21st. Century

'Fascist' - it has become a term of abuse, intended to induce guilt, a contemptuous dismissal of opinions which the speaker doesn't like, but can't rebut convincingly.

What is the correct use of this word?

Fascisti was the name of Mussolini's political party in Italy, 1922-1943. The Latin fasces means a bundle, and was used for the axe bundled in rods which was the symbol of a Roman magistrate. Fascism came to be the group name for similar political movements and governments in other European countries in the 20's and 30's; in Germany, Spain, Croatia and Romania. There was a British Fascist Party in the 1930's, but it never achieved mass support.

Italy had been a single state only for a half-century when the fascist movement began: the bound bundle of rods had a significance we easily overlook.

Paranoid nationalism is a key feature of fascism. The nation is threatened or unjustly treated by enemies within and without. Militarism is one response. I remember seeing a faded slogan painted on a house wall in Italy:

Il Credo Del Fascismo E L'Eroismo.

Another response is oppression of those perceived to be hostile, or secretly plotting against the nation.

Judeophobia is intrinsic to fascism.

Fascist patriotism demands submission to the state as embodied in the fascist party and its leader. Democracy is a danger and a distraction: the party, by definition, knows best, and will be violent towards any that demur.

Fascist parties typically include paramilitaries: brownshirts, blackshirts and so on: street brawlers marching, drinking, singing, and fighting opponents. In Germany they became official private armies - the SA and SS.

Idolatry of The leader is perhaps the distinctive feature of fascism: Der Führer, Il Duce, El Caudillo. A leader endowed with mystical wisdom and power, who will lead the Nation to salvation. Remember those grainy films of huge crowds, enraptured to hysteria by the sight and words of the Führer? We may gaze in disbelief now, but it happened.

Fascist economic policies are socialist; a command economy, driven in part by preparations for war. "Far right" is an absurd name for fascist parties.

But fierce anti-communism is universal in fascism, despite the close similarities between the two. Stalin, Mao, Kim Il Sung: these were fascist leaders in most respects, except title.

In Ireland Sinn Fein - 'ourselves alone' - is arguably fascist, except it never had a great leader. But it had dangerous paramilitaries, and its founder was notoriously judeophobe.

I perceive very little native fascism in Europe today. There are nationalist parties of varying popularity, but none has the intensity, paranoia and idolatry of fascism.

Yet the evil that Fascists did lives after them. The shame and guilt of the fascist era corrodes the self-confidence of modern Europeans, inhibiting action if any echo of fascism is perceived.

Fascism enjoyed mass support for a time: from this memory comes the suspicion of democracy so prominent in the godfathers of the European Union.

Today the shadow of fascism taints even the benign nationalism needed to counter the unelected Eurocracy in its quest for Napoleonic powers.

Real Fascism today is mostly religious.

Islam, for example, is a hierocracy with strong fascist features: paranoia, warrier-worship, submission, crudely socialist economics, judeophobia, and idolatry of leaders who claim to be agents of the Greatest Leader of all. It also has paramilitaries; young men [and some women] persuaded that suicidal violence is the sure way into God's great Playboy Mansion in the sky.

In the 1930's and 40's many muslims made common cause with European fascists.

So it is bizarre to see muslims demonstrating and brawling under the banner of "Unite Against Fascism". It is equally bizarre to see communists making common cause with them.

The great struggle of the 21st. century is between those who pray to God the Father, and those who prostrate to God the Führer.

Magna est Veritas

I suppose, in these days, few have heard of Coventry Patmore, and fewer still value his poetry. His Victorian style is unfashionable. Mannered archaic usage and lapses into sentimentality were popular in his time, but date him now.

At his best he achieves greatness, recognised by four entries in the New Oxford Book of English Verse.

Here is one I shall never forget. Of course 'reality' is my reading of 'truth', and likely to differ from catholic Patmore's.

It captures the sense of futility to which 70-year olds are prone.

Magna est Veritas

Here, in this little bay,

Full of tumultuous life and great repose,

Where, twice a day,

The purposeless, glad ocean comes and goes,

Under high cliffs, and far from the huge town,

I sit me down.

For want of me the world's course will not fail;

When all its work is done, the lie shall rot;

The truth is great, and shall prevail,

When none cares whether it prevail or not.

Pandemic Economopathy

This is my analysis of the world's economic illness.

1. The diagnosis is global trade imbalances, and their consequences.

Globalisation has crashed. Elementary economic principles were ignored, because it was profitable and fashionable to do so.

2. Open borders, free trade, and similar economic nostrums can be sustained if and only if flows of goods and money are in balance over time. Similar standards of living, and of state welfare provision, energy prices, social structures and cultures - these are essential for such a balance among the nations in a free trade area. This forces industries and commerce to compete by increasing factors such as design, quality and efficiency, not by a race to the bottom in employment and other costs.

All these factors are present in the United States of America, still the world's largest and most successful free trade area. They are absent in a globalised economy; they are absent in the European Union, in which the strains of the global economy are replicated.

This principle of balance was simply ignored, if not denied.

3. Exchange rates between the currencies of a free trade zone must float freely, to offer a self-correcting mechanism against trade imbalances.

This principle was openly or covertly evaded by China and other important trading partners. The Euro inhibited self-correction in Europe.

4. The consequence of this economic folly is to divide the industrialised world into producer and consumer blocks, especially the USA and Britain as consumers, and China, Russia and petroleum exporters as producers.

Producer countries build up huge reserves of consumer currencies: industries in consumer countries wither and die; poverty eroding prosperity.

In some producer countries individuals now control wealth sufficient to perturb global markets in finance and goods: one man can move the world of finance to his advantage.

Producers' seek profitable investments for their new wealth; consumers' money must be recycled so trading can continue. These are the roots of the present crisis.

5. The producers' accumulated dollars, pounds and other currencies were deposited in American, British and European banks; the banks in turn had to generate returns for the tsunami of money flowing into the system. Housing and other assets were easy and popular choices.

Abundant money and cheap borrowing set the stage for a property boom, which moved towards frenzy as rising property prices fed back into demand.

6. In Britain and the USA banks were released from government regulation. Bankers are prudent, wise, honest and good; they can surely be trusted to govern themselves. So they argued; politicians listened and were convinced.

Our trust was betrayed. Abundant deposits, cheap to borrow, profitable to lend on - in these conditions bankers encouraged reckless short term behaviour, paid themselves fortunes, and devised clever 'instruments' to conceal the insecurity of many loans. Deliberate, criminal fraud was disguised, rewarded, celebrated. 'Toxic' debt was diffused into sound investments, poisoning trust in all.

Elementary rules of sound banking were declared obsolete. Bankers gambled with other peoples' money; the City of London is now a vast casino.

It needed a simple rise in interest rates to expose the rot in the system. The consequences of global banking collapse appalled governments, so unprecedented public wealth and credit has been committed to shore up the system. The long-term consequences of this panicky response cannot be evaluated with confidence. We can expect unemployment, taxation and inflation unto the second generation.

The Gods of the Copy-book Headings were mocked; they are back, jealous and vengeful.

Reckless bankers were a symptom, not the cause, of the global economic sickness.

7. New money was not being created; the process was inflationary only to asset values. Central bankers were not moved to raise interest rates - in Britain a new inflation index ensured house prices were removed from inflation evaluation. Most people felt more prosperous; politicians claimed credit for achieving non-inflationary growth, at last; bankers made easy fortunes, paid taxes, and spent their lavish bonuses.

Inflating asset values gave security for another boom in consumer borrowing. These loans supported continued purchasing from the producer nations, increasing their currency surpluses further, feeding even more purchasing power back into Western banks.

A system of obvious instability and unsustainability.

8. Why was this dangerous cycle not recognised and stabilised? Were world leaders and bankers stupid, short-sighted, or deceived by their own rhetoric? The few who spoke out were scorned. The dangers were obvious to people in my circle: how come those paid handsomely to manage these things failed so dismally?

As always, money talked. We'd never had it so good, why heed those crying 'woe'? Surely this time the world has changed, the old cautions and rules no longer apply. Prosperity is here to stay: the value of your house can only increase, release this new equity and enjoy your good fortune. Go with the flow.

And learned commentators agreed.

Pone merum et talus. Pereat qui crastina curat.

[Set down the wine and the dice. May he perish who cares for tomorrow.]

The motto of the New Labour years.

9. What can be done? Never get into this position is sound advice, but far too late. There is no salvation in trying to recreate the failed globalised system. The prevailing economic dogmas must be rethought, modified, in some respects reversed. Britain needs an election now; we need a government with an electoral mandate to think clearly and act rationally in the national long-term interest; free, for a while, of the shackles of electoral calculation.

Fags, Face, Figure, Future

[I wrote this in a previous blog, but it's a message I want to shout at street corners, so it bears repeating.]

Why do women smoke, in particular, why do young women addict themselves to tobacco? The epidemic of tobacco addiction is our biggest threat to womens' health, with alcohol excess a close second.

An answer often given is that men smoke for good reasons, and women for bad. Men smoke in a foolish attempt to prove themselves tough, mature, macho. Women smoke to be like their friends, to appear liberated and sophisticated, and to satisfy hunger without gaining weight. Few seem to appreciate how potent tobacco addiction is, how difficult it is to give up. My impression is that the heroin habit is easier to kick. Tobacco really should be a class A++ drug.

What are the big interests of young women? Look at the many glossy magazines for them. Five topics dominate the covers: beauty, health, clothes, relationships, sex. Does nobody tell women how badly tobacco damages at least two of these - beauty and health - and threatens two more - relationships and sex?

If a teenager starts regular smoking, the habit is visibly affecting her face and health within a few weeks. Cyanide and other toxins in tobacco smoke inhibit the synthesis of skin proteins, notably elastin, but also collagen and keratin.
Her facial skin loses its healthy bloom, her hair loses gloss and weight.

She doesn't eat well, she will lose weight: she begins to look drawn and haggard.
After months of smoking defective elastin and collagen production makes the skin prone to wrinkle, and precocious wrinkling becomes more prominent as years pass. Tars and pigments from smoke slowly accumulate in the skin, giving a sallow colour.
The loss of supporting fibre-proteins affects her figure too: her breasts sag, her buttocks droop. She loses the subcutaneous fat which gives women their curves.

Carbon monoxide displaces oxygen from haemoglobin, and the body increases haemoglobin production to compensate. Her lips and cheeks show a hint of purple, and her performance in sports is impaired.
And, of course, she smells like an old ash-tray.

Young women who smoke wear more make-up than women who don't [I think that is common observation]. They are aware of their facial deterioration, and try to cover it.

It should be written on every cigarette packet: FAGS F*** YOUR FACE *.

As for tobacco and womens' health, consider the expected life-story of a female tobacco addict; smoking, say, 20 per day.

Age 15 - she thinks she's cool and mature. She thinks she can handle it.
Age 25 - she is severely addicted. She show all the signs I have described. In pregnancy she is at increased risk of toxaemia; her babies will be born, on average, 1 week early and 1 pound underweight.
Age 35 - she is a fag-hag: wrinkled, sallow, thin, slovenly. On average her children miss twice as much schooling as the children of non-smokers, mostly because of recurrent respiratory infections. She is likely to be chronically short of money.
Age 45 - she has chronic bronchitis: cough, phlegm, frequent infections, short of breath on mild exercise. She is at risk of stroke, coronary thrombosis, cancer.
Age 55 - respiratory cripple ....

Why do they do it? I despair.

[* NB F*** is code for FOUL: what else could I mean?]

Heroes at the Hot Gates

ΘΕΡΜΟΠΥΛΕΣ THERMOPYLES

So says the sign on the new GR1 motorway north from Athens to Thessaloniki. Looking south from the motorway the stranger passing by sees the white stone wall of the monument, and, to the right, steam rising from the hot springs which give the place its name. Behind the monument the small conical wooded hill of Kolonos is hard to discern against the background of the steep forests, crags and gullies of the northern face of Mount Kallidromos.

To the north of the motorway maybe two kilometres of flat marshy land end at the shore of the Malian Gulf.

The scene was different in August 480 BCE - 2,489 years ago. The land surface was sea-bed, maybe 20 metres below the present level, the shore was then at the foot of the mountain slopes. There was only a narrow passage through between mountain and sea, hence the 'gates' in the place-name.

Rivers depositing silt in the head of the Malian Gulf produced this change of geography during the intervening millennia.

The hot springs are still prominent to the west of Kolonos. The largest is the source of a small river of water almost too hot for the hand, stinking of hydrogen sulphide.

Look at Thermopyles on Google Earth and you will see the white deposits from the thermal springs and streams.

There is a small spa establishment by the hot water; let us hope it is not developed for profit, now there is motorway access.

This passage between mountain and sea was the site of the most famous battle, when King Leonidas and his 300 Spartan hoplites led another 4,000 or so troops from the districts east and south of Thermopyles. It was a desperate attempt to delay the remorseless advances of The Great King of Persia, Xerxes, into Greece. Xerxes' army included forces from the vast Persian empire, extending from Anatolia to the Punjab, and south to Egypt and Ethiopia. It is hard to be sure of numbers, but Xerxes commanded well over a million soldiers, carrying a great diversity of arms and armour. A large number of camp-followers came too - women. servants, slaves, traders.

Through Thermopyles the invaders could pass only a few abreast, in small numbers. They had to wade the hot smelly river to confront a phalanx of grim, determined, ruthlessly trained Spartans, backed by the other Greek soldiers; less determined, less disciplined.

It was the heroic mind-set in open, stubborn defiance of overwhelming odds, that mind-set which has been the stuff off fame, legend, and epic since the dawn of man.

It may be stated thus: fame is the only sure immortality; therefore act so that your deeds will be remembered with honour and admiration, even though you go down to defeat.

So, the last words of Beowulf, the lay of a great hero, are lof-geornost - most hungry for fame.

We find it well declared in Macauley's Horatius:

Then out spake brave Horatius,

The Captain of the Gate:

"To every man upon this earth

Death cometh soon or late.

And how can man die better

Than facing fearful odds

For the ashes of his fathers,

And the temples of his gods".

And in Tolkien, at the great battle of Pelennor Fields:

"Stern now was Eomer's mood, and his mind clear again. He let blow the horns to rally all men to his banner that could come thither; for he thought to make a great shield-wall at the last, and stand, and fight there on foot till all fell, and do deeds of song on the fields of Pelennor, though no man should be left in the West to remember the last King of the Mark."

And, most recently:

"Let us therefore brace ourselves to our duty, and so bear ourselves that, if the British Commonwealth and its Empire lasts for a thousand years, men will still say, 'This was their finest hour'."

So too Leonidas and his Spartans, bracing themselves to the duty they lived to fulfil, knowing the odds against them were overwhelming, and believing they should go well-groomed to the Gods:

" 'The King with half the east at heel is come from lands of morning,

His fighters drink the rivers up, their shafts benight the air,

And he that fights will fall for nought, for home there's no returning.'

The Spartans on the sea-wet rock sat down and combed their hair."

At the hill of Kolonos the Spartans made their last stand on the third day of the battle. The summit of Kolonos bears a modern slab of reddish stone from Sparta, inscribed with the lines written by Simonides, perhaps the most famous of all epitaphs [it isn't easy to read].

Ὦ ξεῖν’, ἀγγέλλειν Λακεδαιμονίοις ὅτι τῇδε

κείμεθα, τοῖς κείνων ῥήμασι πειθόμενοι.

O ksein', angellein Lakedaimoniois hoti tude

keimetha tois keinon rhumasi peithomenoi.

[Writing u for upsilon, long ee, in the Welsh fashion.]

O stranger, report to the Lakedaimonians that here

we lie, as they commanded our obedience.

Leonidas and his 300 achieved the fame they sought. After 2-1/2 millennia they are remembered as heroes.

Xerxes' lasting shame is his order to decapitate and dishonour Leonidas' body, setting up the head on a pole.

The Greek who betrayed Leonidas by showing the Persians a path through the mountain to Leonidas' rear has great and permanent dishonour: his name - Ephialtes - is the modern Greek word for nightmare.

The least said the better about the monument erected by American Greeks at Thermopyles: a vainglorious monster, which Leonidas' would view with contempt.

Autopoiesis

This is a first attempt to write down ideas which interest and excite me. This is a brief, preliminary, incomplete and inadequate outline. Obviously these theories demand careful elaboration, precise exposition, critical evaluation, and discussion. A lengthy task, but a start must be made.

1. It is evident that the complexity of our planet earth has increased since its origin, maybe 4.5 billion years ago. A biosphere has evolved from an initial assembly of elements and simple compounds. At least one member of the biosphere is now conscious, with the facility of intelligent information processing.

2. There is no evidence that earth's evolution requires an external designer or controller: all processes on the earth are intrinsic and spontaneous. Therefore the potential of self-assembly - autopoiesis - must be included in our studies of the properties of matter.

The mechanisms of autopoiesis are poorly understood. Our knowledge is best for the biosphere, but insights into pre-biotic evolution are beginning.

Autopoiesis: the theory of natural self-assembly: The Autopoietic Earth: Gaia Autopoietika.

3. Gravity is the great creative force, causing the aggregation of materials and energy release necessary for autopoiesis.

4. Why stop with earth? Physics and chemistry do not vary across the kosmos. Our sun is one of millions of similar stars in our galaxy alone, and there are millions of galaxies: the probability that earth is the only planet suitable for life is vanishingly small. What we perceive here may be a very small sample, but there is no reason to believe it is atypical or unique.

The Kepler spacecraft will be a test of this evaluation.

There is a high probability that life is abundant in the kosmos: conscious, intelligent life must be out there, and may well be common. We can but hope that eventually a means of communication across vast distances will be found; perhaps then we shall find a kosmos full of voices.

5. The increase in complexity from kosmic primordia to stars and planets extends autopoiesis back almost to the singularity which we believe was in the beginning.

An Autopoietic Kosmos - Kosmos Autopoietikos: the grandest of unifying theories.

6. In broadest outline, autopoiesis proceeds:

- from hydrogen gas to generations of stars, and synthesis of all other elements;

- from early, simple stars to later, complex star-systems, with planets of elements and compounds;

- from simple to complex planetary chemistry;

- from complex molecules to simple life;

- from simple to complex life, increasingly homeostatic [independent of the environment];

- in homeostasis increasingly complex neural structures, permitting functions of increasing sophistication; finally consciousness and intelligence.

7. From the theory of autopoiesis we may predict as follows - safe in the knowledge that no practical test is likely.

Given enough hydrogen, enough space, and enough time; first life and then conscious intelligence will develop by natural, intrinsic mechanisms.

8. Autopoiesis - to what end? A question we cannot answer. That the kosmos has meaning and purpose must be assumed, for now. That is the only item of faith I can accept in my kataphusin philosophy. It is the first axiom for any evidence-based theology.

Pied Reality

'Pied Beauty' by Gerard Manley Hopkins is number 727 in the New Oxford Book of English Verse. It is a hymn to all things pied - pied meaning coloured alternately in large areas, as the Texas Paint horse is red and white.
The Pied Piper, for example, is so-called because:
"His queer long coat from heel to head,
Was half of yellow and half of red".

'Pied Beauty' is a fine example of the 'sprung rhythm' of that counter, original, spare, strange poet. Also distinctive of Hopkins, it is a flawed masterpiece.

Glory be to God for dappled things –
For skies of couple-colour as a brinded cow;
For rose-moles all in stipple upon trout that swim;
Fresh-firecoal chestnut-falls; finches' wings;
Landscape plotted and pieced – fold, fallow, and plough;
And all trades, their gear and tackle and trim.

All things counter, original, spare, strange;
Whatever is fickle, freckled (who knows how?)
With swift, slow; sweet, sour; adazzle, dim;
He fathers-forth whose beauty is past change:
Praise Him.

I much admire Hopkins' poem, but I doubt couple-colours always glorify a creator, as he thought.

Consider the Pied Corvids.
I have a visceral loathing of magpies. It runs in the family: my father taught it me; my cousin has it even worse than I do.

Pica pica, the European magpie. Handsome birds, pied black and white, with a long tail. In Shakespeare they are simply pies, the mag came later.
Pica is the Latin name, probably sharing a derivation with the Greek κισσα or κιττα.
So my loathing might be dismissed as kissaphobia, but I would protest. A phobia is an irrational fear or dislike; my aversion to magpies has rational roots.

Magpies raid the nests of other birds: they are egg-thieves. That's bad enough, but pecking the eyes of nestlings is the habit which condemns them. No-one can forgive magpies after seeing a blood-stained robin's nest of cold, dead, eyeless nestlings; or worse, bleeding, squirming nestlings, still alive.
"Cruel", my father would say; "Cruel, that's what they are; they peck but don't eat; they are wicked".

Regrettably, magpies are now multiplying in suburban gardens, including mine, scavenging waste or taking food put out for other birds. This is very bad news for the song-birds and the other welcome visitors to our gardens.
It's time to get a magpie trap - a simple wire cage with a trap-door. Put in a mirror, because magpies are attracted to their own reflection. Then remember the nestlings, put on leather gloves [they are vicious peckers], kill instantly by a sharp twist and pull to the neck; show them what mercy is.

Theses thoughts come after my visit to Wisley Gardens yesterday. My reverie in the Pinetum was disturbed by the devilish chuckles of a pair of magpies, strutting amid a mass of dwarf Cyclamen, in glorious flower under the trees. It was as if a cloud had darkened the sun.
Et in Arcadia ego.

Pica is the medical term for depraved appetite - eating dirt, or stones, or other items. It is said to be named for the magpie's omnivory. I recall a young pregnant woman who caused alarm by sucking pieces of coal [she came to no harm]. Then there was the elderly man referred from the psychiatric hospital because he had lost weight. He had a large hard mass in the abdomen. At endoscopy the stomach was full of stones. They had to be removed surgically.
A colleague had an endoscopic picture from another patient. Among the coins, bits of twig, a key and other things was a fresh packet of Rizla cigarette papers.
That's pica, but I digress. I have another example.

Orcinus orca, the killer whale, is another black and white pied predator with a vicious, cruel nature. Two video sequences from the BBC Natural History Unit come to mind.
The first follows a pod of Orcas hunting the calf of a Grey Whale, off the coast of California. Relentlessly they harass mother and calf, trying to separate them. Eventually the exhausted, bitten calf can swim no more. The pod go into a feeding frenzy, tearing out the tongue of the calf, leaving the rest of the carcass to sink into the depths.
The second is the stuff of nightmare. Sea-lion cubs are playing in the surf. Suddenly a huge black and white shape surges up the beach, seizes a cub, then shuffles back into deeper water. Out in the bay, the cub becomes a toy, still alive. The Orca uses its tail to bat the cub high in the air. When it falls back its tormenter hunts it down and repeats the game. Eventually, I suppose, the cub is eaten, a release from this horrifying ordeal. Extraordinary behaviour; unpardonable cruelty.

Those who argue that altruism proves the existence of God must also justify cruelty: the ugliest of vices, in man and nature.

The Razor's Edge and Rhazes

After writing yesterday about two realisations of Christianity, I remembered the following passages from 'The Razor's Edge', by Somerset Maugham, a writer I admire greatly.

First he tells this story.

" Do you remember how Jesus was led into the wilderness and fasted forty days? Then, when he was a-hungered, the devil came to him and said: If thou be the son of God, command these stones be made bread. But Jesus resisted the temptation.
Then the devil set him on a pinnacle of the temple and said to him: If thou be the son of God, cast thyself down. For angels had charge of him and would bear him up. But again Jesus resisted.
Then the devil took him into a high mountain and showed him the kingdoms of the world and said that he would give them to him if he would fall down and worship him. But Jesus said: Get thee hence, Satan.

That's the end of the story according to the good simple Matthew. But it wasn't.

The devil was sly and he came to Jesus once more and said: If thou wilt accept shame and disgrace, scourging, a crown of thorns and death on the cross, thou shalt save the human race, for greater love hath no man than this, that a man lay down his life for his friends. Jesus fell.
The devil laughed till his sides ached, for he knew the evil men would commit in the name of their redeemer."

Then, a few paragraphs later, he reflects.

"I diverted myself idly with the idea that had sprung so unexpectedly into my mind. I played with it.
I couldn't but surmise that the devil, looking at the cruel wars that Christianity has occasioned, the persecutions, the tortures that Christian has inflicted on Christian, the unkindness, the hypocrisy, the intolerance, must consider the balance sheet with complacency.
And when he remembers that it has laid upon mankind the bitter burden of the sense of sin that has darkened the beauty of the starry night and cast a baleful shadow on the passing pleasures of a world to be enjoyed, he must chuckle as he murmurs: Give the devil his due."

I remembered too the supreme wisdom attributed to Rhazes - Muhammad ibn Zakaria Al-Razi - that great tenth century physician in Baghdad.

Human reason and experience alone give reliable knowledge;
The way of philosophy is open to all abuses;
Claims of divine revelation are false;
Religions are dangerous.

Maugham surely expands Rhazes' fourth point.

Greeks and Scots

My new grand-daughter boasts mixed ancestry. Her father's mother is Scottish; her father's father is English; her mother's parents are Greek. The English part I know: consider the Scottish and Greek.

Scotland and Greece are both mountainous, with numerous islands and sea inlets - lochs and kolpoi. Scotland is the extreme north-west of Europe [excluding Iceland]; Greece is the extreme south-east. Both have a history of isolated communities quarrelling - Scottish clans in their glens, Greeks in city-states.
Both have suffered conflict with neighbours.
Climatically they have little in common. Scotland is exposed to the north atlantic, with complex weather formations bringing wind and rain in abundance. Greece enjoys a more settled Mediterranean climate, with intrusions of cold from central Asia.
Unexpectedly, oats are an important crop in both countries.

Geographically similar maybe, but in religion the two countries are close to the opposing ends of the spectrum of Christianity; and religion is the most powerful determinant of culture.

Greek Orthodoxy is close to the original Christianity, as it developed in the first centuries after Christ. The New Testament is written in Greek; the early development of Christian theology was conducted in Greek; and many Christian rituals and festivals have Greek origins.
Orthodoxy is Christianity as institution. Its churches, its hierarchy and its liturgy exist and continue in their own right, a glimpse of paradise on earth, serving the people as the church decrees. It preserves traditions going back nearly two millennia; venerating saints and ikons, vestments and incense; fostering poetry, music, art.
It's a religion of reassurance and release. Sins are forgiven, doubts passed over: attend, commit, and the priests will make all well.
Zeus may have been knocked from Olympos, but Athena, Demeter and Aphrodite are still influential.
Bread, wine and oil are its most important symbols. It is extensive and inclusive.
[Divisions in Orthodoxy are more national than doctrinal.]

Dostoevsky's Grand Inquisitor defends the church as institution: it offers the magic, mystery and authority which simple believers crave. This argument may prevail even in the land of Hippocrates, Socrates, Aristotle, and Euclid.

Scotland is the birthplace of Presbyterianism. Calvin taught Knox, and Knox blew his trumpet in Scotland.
Presbyterianism is Christianity as community of the faithful. The individual's faith is founded on scripture, to which there is free and open access; no priest intervenes between believer, bible and God. There is no hierarchy: the church is governed by 'elders', some of whom are necessarily professional ministers. Ministers conduct services of worship, teach, and advise. Like physicians, they have no authority.
Presbyterianism is an austere, personal religion, striving to realise the teachings of Jesus; intellectual, suspicious of dogma, stressing the symbolism of ritual, denying magic. Its churches are undecorated.
It is a religion of duty and admonition. Sin and guilt burden us all; each must work out a personal salvation, correct in every detail. That is difficult, many will fail.
It's a tough religion, intense like the whisky of its homeland. It has an exclusive tendency, manifest by its many schisms. Perm the adjectives free, reformed, united and presbyterian before church; you'll probably find it exists or has existed.
Presbyterians and Orthodox share a profound aversion to Roman Catholicism.

The Presbyterians stress freedom in faith, and personal responsibility.
The Grand Inquisitor concedes Jesus offers these, but argues they place a burden on humanity which most cannot bear. He didn't know the Scots.

I favour opinions which are kataphusin, according to natural reality. I have little respect for opinions katabiblion, according to scripture. Still, after 70 the issues raised by religion become more pressing, so my interest in Christianity increases.
Were I to embrace religion, my head tells me I should become presbyterian; but I admit a deeper attraction to Orthodoxy. I am in awe of its ancient heritage, the subtleties and euphony of its language, the glories of its buildings and liturgies. Beauty is seductive, and inspiring.
After all, such a move into religion would be to admit that life is too short for pure kataphusin. Life's biggest questions demand some sort of answer; so dump the doubts, only believe, accept mystery and authority - maybe even the magic. Enjoy the securities and comforts of Faith.

As the Old Dominie said:
"Alone at nights, I read my Bible more and Euclid less".

Arithmetic on the Frontier

They call it asymmetric war: limited high-tech. versus abundant low-tech. Afghanistan was always the prime example. How can a militia of mostly illiterate peasants defeat a Western combat group heavily armed with the latest equipment?

It's easier than you might expect. Never confront the enemy: he wants to bring you to battle, where his advantage is overwhelming. Harass constantly, killing at every opportunity: casualty reports in the Western media are a powerful weapon. Hide among your own women and children, wear civilian clothes: civilian casualties spread shame and guilt, enrage your allies in the enemy country, and rich will be their reward from Allah.

Live in a mountainous country; he cannot match your local knowledge.

Persist, allow no conclusion, let his much greater costs wear him down, over as many years as may prove necessary.

The Brits. have forgotten Kipling's 'Arithmetic of the Frontier'. Let them learn again bitter lessons in the toughest of schools.

Here's one simple tactic for your Jihad, potentially very profitable in several ways.

Ammonium nitrate, NH4.NO3, is a common agricultural fertilizer, produced industrially in thousands of tons annually.

NH4 is nitrogen carrying hydrogen: NO3 is nitrogen carrying oxygen. Ammonium nitrate is set for intra-molecular combustion:

NH4.NO3 ---> N2 + 2H2O + O

The products are nitrogen gas, water and atomic oxygen. Nitrogen and water are stable, low energy compounds: this reaction is exothermic, releasing the energy used in manufacture. It also converts solid ammonium nitrate to nitrogen and water gases: a huge volume expansion. 1 kilogram of solid has the potential to deliver more than 768 litres of hot gas in a fraction of a second.

But there is also oxygen, in an activated form. Mix in something combustible and finely divided to react and remove the oxygen - flour, say - and you will release a lot more energy - and carbon dioxide gas.

If possible, contain the mix in a metal drum, to hold the mass together long enough for the reaction to near completion. It's not high explosive, but there's still a lot of bang for your Afghani buck.

Add a simple detonator, maybe a small quantity of high explosive, and you have a cheap, crude but effective bomb. You can make up in weight what you lack in punch.

Bury a 50-100 Kg bomb in a dirt road; pack it round with stones to carry the blast; sweep sand over it. Run the detonator wires to a concealed view-point, and you have an ambush.

Total cost is a few ounces of crude opium.

The Taliban know this. They also know the human, political, and monetary value of their targets.

Consider their latest successful ambush, the cost to us, the profit to them.

Three of our finest soldiers killed, a fourth gravely injured, probably mutilated and disabled for life. Families devastated, widows and orphans to be supported.

Our media publicise our losses, stressing the suffering, questioning why are we there, degrading public morale and will to continue the campaign. The politicians have to respond.

Each soldier represents an investment of many thousands of pounds in training and deployment. Each injured and disabled soldier will cost millions in evacuation, treatment, rehabilitation, and support.

Deploying the Jackal patrol vehicle and associated kit will leave little change from half a million. It carries weapons, notably a heavy machine gun. Capture that, and your next target is a Chinook helicopter. There is more valuable loot in the wreck - guns, grenades, and radios; not to mention 'prestige' loot - helmets, uniforms, boots, classy sunglasses, ipods.

To what purpose are these losses? To make a safe world for the Karzai clan? To create a free, democratic Afghanistan, prospering by honest toil, not by heroin? To secure full human rights for women, homosexuals, and other victim groups?

Get real.

The odds are still on the cheaper man.

Our Prime Minister says there is a chain of terror from Afghanistan to the streets of Britain. So would we be squandering lives, wealth and honour in Afghanistan if there were no mosques, mullahs, muftis and muslims here?

That question is now 'crime-think'. NewLabourSpeak forbids such talk. I had better shut up.

Into Extra Time

I have recently passed milestone 70 on life's mountain track. My allotted threescore years and ten have flown by; I am now into extra time.

If my 21st. birthday was the end of the beginning, my 70th. can only be the beginning of the end. I have come this far with no serious illness, but the reality is that my good fortune cannot last for ever. That's no cause for lament, but it does bring home the importance of making the most of every day. 'Carpe diem' increases in importance as life expectancy declines.
Unfortunately the andropause saps vitality: it is a new and unwelcome experience to tire so easily.

In many respects I have had a privileged life of unprecedented opportunity, interest and security. I was a child during the Second World War; I was an early teenager during the Korean War: I was never conscripted, unlike my father and my grand-father.
I had a village childhood in Kent - an industrial village with cement and paper factories providing steady employment, but marshes, open farmland and the North Downs within easy walking distance. Natural history obsessed me from an early age, and I had every opportunity to explore my interest.
I had free education. I passed the 11+, which gave me a place at a truly excellent Grammar School in Maidstone. From there I achieved a university place, and so qualified in medicine. All this cost my parents nothing: even at university I had a maintenance grant.
I have never had to fear the economic consequences of illness. The National Health Service is there in case of need; social security would ensure no financial catastrophe in the event of disability.

All these benefits I owe to the Labour Government headed by Clement Attlee in the late 1940's. This has to be the most effective government Britain ever had. British society was transformed for the better; much of its achievements survive, indeed are now regarded as part of the natural order.

So it was my greatest good fortune to be born in England in 1939. It has taken me many years fully to appreciate how privileged my life has been, but I acknowledge it now, forcefully.

Alas I am now retired, and rusting gently. Heeding the advice of a former senior colleague and mentor, I retired completely from medical practice when the time came, and that has proved to be the right decision. I was something of a dinosaur in my last years in practice; an old fashioned, committed, whole-time NHS consultant, impatient of protocols, policies, and directives; I suspect I was a difficult colleague.
I grew painfully aware that I had become a misfit in the Brave NewLabour NHS. No doubt some were glad to see me go - but not too many, I hope.

So, what might the future hold? Well, there's still a lot of things I want to do before I die.
I have never seen a whale, or an erupting volcano; I have never learned to ride a horse; I would like to read and understand at least a few pages of Homer in the original Greek; I want to understand much more of relativity and quantum theory; I want to follow the trail of Lewis and Short from St. Louis to Portland. And the list goes on.
Time to spend the kids' inheritance, and realise a few dreams while the opportunity is here.
Then there are things which must remain dreams. I wish I could play Bach's Toccata and Fugue in F on a baroque organ; how wonderful to sing 'Nessun dorma' in front of a full orchestra; how awesome to pilot a Boeing 747 from London to San Francisco.

My family is my pride - my beloved wife, my three fine sons, and the three remarkable women who married them. My joy - and life's richest reward - is my three little grand-daughters. I tell myself that doting on grand-children is what grand-fathers are for: we're not much good for anything else.

I have few worries, and few fears, with one important exception.
Dementia I fear above all; to lose one's mind, to lose control, to become dependent, to die mentally while the body lives on. Euthenasia is the only realistic prescription for dementia; current therapy can slow its progress, but that only prolongs the misery. Dementing disease causes brain damage which is irreversible, so there is little hope of recovery even though the pathogenic processes may be stopped.
Resources should not be wasted on the management of dementia. And that is the principle I wish will apply in the event of my developing that dreadful condition.

But it isn't good to end on a grim note, so I request my readers to raise a glass and toast England and all its physicians, as I move into extra time as gracefully as I may.

Farewell a While

Kataphusin presents his compliments to his readers, to announce he will be in retreat for a while, maybe a couple of months.