I have contributed to a discussion on the importance of the severe communication difficulties experienced in the battle of Arnhem in September 1944. This epic battle ended in the defeat of the British airborne forces, and a tragic failure to punch a route into the north German plain, the route to the industries of the Ruhr, and to Berlin.

The strategic plan, code-named "Market Garden", was famously described as "90% successful". Unfortunately only 100% success meant victory. After huge efforts and heroic fighting the Allies achieved only a 50 mile salient leading nowhere.

There are many books about Market Garden. I have studied its military history, and I have visited the area of the battle.

The film "A Bridge Too Far" is an excellent, if necessarily simplified,  popular recreation of the issues, personalities and conduct of the campaign.

Signal problems were serious at Arnhem, and perhaps avoidable, but they were not a significant element in the defeat. Arnhem failed because the strategic plan was incompetent, close to military nonsense.

Market Garden was a brilliant concept, potentially the decisive battle of the war; but hard to realize, badly planned and inadequately resourced.

Its failure must be considered a tragedy, not just for the soldiers, but for the Allies, the Dutch, the German people and for post-war Europe. Its success would have shortened the war by several months, spared our armies bitter and costly battles, spared the Dutch the terrible winter of 1944, spared the Germans much of the destruction inflicted by the strategic bombers, and ended the war with the allies in Berlin, in a much stronger position to deal with Stalin.

Market Garden was a classic tragedy - triumph leading to complacency leading to disaster.

The Arnhem bridges and ferry were the most important objectives; without them the campaign was pointless. It is astonishing that the lessons from the capture of the Orne bridges on D-Day were not applied: gliders landing commandos before dawn at the bridges, strengthened by air-landing artillery and armour at first light.

The main landings should have been also at first light, on the 'island' between Waal and Neder Rijn, with three landings planned for the first day, The perceived additional risks of landing on polder were insignificant compared to the defensive advantages, the opportunities to facilitate the capture of the Waal bridge at Nijmegan, and to deprive the Germans of their supply and communications route south from Arnhem.

The hills west of Arnhem, behind Heveadorp, should have been a vital objective in the development of the campaign. Artillery there could dominate the battle area. This required the early capture of the Osterbeek railway bridge and the Driel ferry.

Radio communications should not be a problem in such a strategy: distances much reduced, with near line of sight over flat terrain.

Another lesson forgotten from Normandy experience is the extraordinary military competence, tenacity and determination of German soldiers, officers and men. Their rapid recovery and effective reaction to the Market Garden attack was exemplary. It was no fault of theirs that their triumph was a catastrophe for their country.

Market Garden needed Montgomery as commander of all allied forces: its failure must be attributed to Eisenhower's assumption of the supreme command after the Normandy victory. His failure to restrain Patten and to give total logistical priority to Market Garden was strategic folly of historic dimensions. Europe paid the price for a half-century.

Perhaps the biggest lessons from the failure of Market Garden are as follows.
1. War demands total commitment.
2. If the strategy is flawed, individual heroism will not achieve victory.
3. Never under-estimate your enemy - especially if the enemy is German.

A Case of Snakebite

Maybe 20 years ago I was working in a hospital in rural Wales. It was a warm, fine summer Sunday afternoon. I was on call, in my office, writing a letter on my new-fangled personal computer. I was interrupted by an urgent call to casualty.

A woman of 19 had been bitten by a snake. She and her mother were walking on the hills above the town, on a well used footpath, wearing sandals. She had trodden on the snake, which struck her right great toe.

In great distress and increasing pain she had taken maybe 45 minutes to get back to the car, with her mother's help. They came straight to the hospital.

She was sitting up on the trolley, terrified; white, tear-stained face, trembling. Her mother was collapsed in a chair, in severe shock and distress, being comforted by a nurse.

Her lips and tongue were swollen, and she had a noisy wheeze. Her right great toe and the adjacent foot was red and swollen, and very painful. One of the snake's fang marks was on the top of the toe, just behind the nail; the other was underneath, and must have penetrated deeply into the soft ball of the toe. It was a big snake - most adders we see in Britain are around a foot long, so their gape is too small to include an adult great toe.

Adder bite was an easy, instant diagnosis - adders are the only venomous snake species wild in Britain. The puffy lips and asthma were caused by the well-known histamine-releasing properties of adder venom.

Reassurance was urgent. My first words were loud and firm, on these lines.

'You are not going to die. You have been bitten by an adder, but the bite will not kill you. You will have a very painful foot for several days, and you will need hospital treatment. But you will be all right, I promise you.'

I gave her an injection of hydrocortisone, and watched the wheezing and puffiness subside. She had a tablet of pethidine for the pain.

The crisis was over. She relaxed and was much more comfortable. Her mother's panic settled.

Infection of the bite is the big hazard: snakes don't clean their teeth before striking. The bitten area was washed and swabbed with Hibitane, for what that is worth - the bugs have been injected with the venom. She took 2 tablets of oxytetracycline, 500 mg total, to continue 250 mg. four times daily for 5 days.

Fortunately we had a vacant bed in a 4-bedded bay, by the window with views of the mountain, with three other young women.

Her progress was rapid and uneventful, so she was fit for discharge on the third day. As she left my proffered handshake was overtaken by a big hug and a kiss, and she was a strikingly handsome woman, with dark curls and rich brown eyes. Well, even English physicians have human responses; fortunately sister did not see.

Some days later, in the late afternoon, I was walking on the mountain path. On the path ahead I saw  a very large adder - the biggest I have ever seen, heavy bodied, and more than 2 feet long. It was a pale grey variant, with back markings so dark they appeared black. It saw me and crawled off into the heather, leisurely, so I was able to follow it's progress for some time. Snakes are reputed to have second sight, perhaps it knew my history, and was not alarmed.

Snake

Yesterday evening, a Christmas carol service in a small country church, a man's confident voice reading again God's curse on the snake, for tempting Eve:

"Because thou hast done this, thou art cursed above all cattle, and above every beast of the field; upon thy belly thou shalt go, and dust shalt thou eat all the days of thy life.

And I will put enmity between thee and the woman, and between thy seed and her seed ..."

Snakes generate horror and fascination. Many people kill snakes on sight. Yet most snakes are harmless. Venomous snakes can usually be recognised easily; few are aggressive; first strikes are often a warning, with little or no envenoming; fatal snake bite is rare.

But still our reflexes are to hate, fear and kill snakes; there is something atavistic in us, some dark deep phobia from the dawn of man in Africa. The sexual symbolism is obvious: Freud elucidates.

Snakes have a problem with humans, not with God.

I remember with shame how, as a young teenager, I attacked and killed a grass-snake I found in the marshes near my home. I remember how my stick ripped its skin, and how it struggled to escape, torn and back-broken. I remember the instant regret, and the guilt which is still with me.

It happened that a few weeks later our English master introduced my class to DH Lawrence's poetry. In the library later I discovered his poem "Snake". It spoke truth to me, renewed the guilt, made explicit much that I felt but had not yet understood, but finally gave absolution. I read it again and again.

It was an important incident of enlightenment in my adolescence; the poem moves me still.

SNAKE - by DH Lawrence; Taormina, Sicily, 1923.

A snake came to my water-trough

On a hot, hot day, and I in pyjamas for the heat,

To drink there.

In the deep, strange-scented shade of the great dark carob-tree

I came down the steps with my pitcher

And must wait, must stand and wait, for there he was at the trough before

me.

He reached down from a fissure in the earth-wall in the gloom

And trailed his yellow-brown slackness soft-bellied down, over the edge of

the stone trough

And rested his throat upon the stone bottom,

And where the water had dripped from the tap, in a small clearness,

He sipped with his straight mouth,

Softly drank through his straight gums, into his slack long body, 

Silently.

Someone was before me at my water-trough,

And I, like a second comer, waiting.

He lifted his head from his drinking, as cattle do,

And looked at me vaguely, as drinking cattle do,

And flickered his two-forked tongue from his lips, and mused a moment, 

And stooped and drank a little more,

Being earth-brown, earth-golden from the burning bowels of the earth 

On the day of Sicilian July, with Etna smoking.

The voice of my education said to me

He must be killed,

For in Sicily the black, black snakes are innocent, the gold are venomous.

And voices in me said, If you were a man

You would take a stick and break him now, and finish him off.

But must I confess how I liked him,

How glad I was he had come like a guest in quiet, to drink at my water-trough

And depart peaceful, pacified, and thankless,

Into the burning bowels of this earth?

Was it cowardice, that I dared not kill him?

Was it perversity, that I longed to talk to him?

Was it humility, to feel so honoured?

I felt so honoured.

And yet those voices:

If you were not afraid, you would kill him!

And truly I was afraid, I was most afraid, But even so, honoured still more

That he should seek my hospitality

From out the dark door of the secret earth.

He drank enough 

And lifted his head, dreamily, as one who has drunken, 

And flickered his tongue like a forked night on the air, so black, 

Seeming to lick his lips,

And looked around like a god, unseeing, into the air,

And slowly turned his head,

And slowly, very slowly, as if thrice adream,

Proceeded to draw his slow length curving round

And climb again the broken bank of my wall-face.

And as he put his head into that dreadful hole,

And as he slowly drew up, snake-easing his shoulders, and entered farther, 

A sort of horror, a sort of protest against his withdrawing into that horrid black hole,

Deliberately going into the blackness, and slowly drawing himself after,

Overcame me now his back was turned.

I looked round, I put down my pitcher, 

I picked up a clumsy log

And threw it at the water-trough with a clatter.

I think it did not hit him,

But suddenly that part of him that was left behind convulsed in undignified haste.

Writhed like lightning, and was gone 

Into the black hole, the earth-lipped fissure in the wall-front, 

At which, in the intense still noon, I stared with fascination.

And immediately I regretted it.

I thought how paltry, how vulgar, what a mean act!

I despised myself and the voices of my accursed human education.

And I thought of the albatross

And I wished he would come back, my snake.

For he seemed to me again like a king,

Like a king in exile, uncrowned in the underworld,

Now due to be crowned again.

And so, I missed my chance with one of the lords of life.

And I have something to expiate:

A pettiness.

Engineering for Clean air

Climate change is a hot topic. It's the talk of Copenhagen town. The great and green are flying in from all over the world, to declare on this grand-stand their determination to save the planet, preferably at someone else's expense. Copenhagen must also host an army of official and unofficial delegates, and a swarm of private individuals, many using climate change as a lever to promote minority political or social views.

So I was not surprised to read that the carbon footprint of the conference will be in excess of 40 kilotonnes.

Our politicians have accepted the conclusions of one group of climate scientists, notably that human combustion of carbon-based fuels is polluting the atmosphere, and consequent heat trapping is changing earth's climate in ways which are damaging or dangerous. Ice-caps and glaciers are melting, extreme climate events are increasing, human populations are threatened. Action now is imperative.

The problem is that action means nothing short of a revolution in the global economy, with sharp reductions in the living standards of wealthier countries.

A smaller and less influential group of climate scientists dismisses this theory of AGW - Anthropogenic Global Warming. They dispute the data, the analyses, the conclusions, and the warnings. Their position strengthened after recent evidence of dubious practices in the AGW group. Some have suffered personal criticism or vilification for expressing opinions counter to the prevailing dogma: always a danger sign.

Any scientific theory is open to refutation or rebuttal: those responding with outrage thereby admit they lack data or arguments sufficient to convince.

So what is my position in this spectrum of noisy opinions?

The one thing beyond dispute is human pollution of the atmosphere. It needs very special pleading to attribute the increasing atmospheric carbon dioxide concentration to factors other than human combustion. Other pollutants include smokes and dusts, oxides of nitrogen and sulphur, dioxins, and halogenated hydrocarbons, notoriously destructive to the ozone layer.

Of course volcanoes discharge huge quantities of dust and gases, and a warming ocean releases carbon dioxide, but these natural processes do not explain the increase in pollutants in the past century.

The critical question is whether this pollution is causing our planet to heat, and our climate to change. The answer, at present, is a definite maybe.

But that is sufficient for determined action, given the possible consequences of continued pollution. In any case, pollution reduction must improve living conditions for all life on this our only planet.

So, what are the main sources of pollution - and what can we do?

Forest burning is the human activity which causes the most pollution. Brazil, Indonesia, the Phillipines and Malaysia are current offenders, causing smogs sufficient to disrupt transport and damage health over wide areas.

Coal burning for power generation and industrial effluents create the 'Asian Brown Clouds', notably affecting much of China, India and South-East Asia. These signs of human activity are easily visible from space. Remember that Beijing had to take drastic action to improve air quality for the Olympics.

Taken together, forest and coal burning must be the most damaging anthropogenic impact on the atmosphere. The 'greenhouse' effect of released gases is combined with acidifying compounds, while water vapour and particulates increase strongly the capacity of air to absorb and retain heat. The loss of forest exposes soils to warming and dessication, and reduces the fixation of carbon dioxide by photosynthesis.

And much of this pollution is in the zones where solar irradiation is most intense.

It is absurd to clear forest to ranch cattle, to provide cheap meat for hamburgers; it is bad to clear forest to plant oil-palms. It is bad to clear forest.

In my judgement these are the pollution sources which need the most urgent attention.

Let us do our bit. Let us start tomorrow a long-term policy to recreate the Caledonian and Pennine forests.

Hydrocarbon combustion must be the next largest source of pollution. These are cleaner fuels than coal or wood, releasing less sulphur oxides and particulates, and delivering more energy per unit release of carbon dioxide [hydrogen is oxidised as well as carbon when hydrocarbons are burnt]. But the quantities used annually are vast, and the carbon is released from underground reservoirs, previously sealed from the atmosphere.

Shipping is a major oil consumer, using heavier grades of oil, more likely to be sulphurous. Globalisation depends on shipping, so globalisation is an important factor in pollution accounting.

Apologists for air-travel protest that aircraft effluents are a small percentage of total emissions. But aircraft discharge pollutants high in the atmosphere, and especially in the stratosphere. The thin air at altitude means aircraft exhaust gases are slow to dilute, and atmospheric layering means slow circulation of pollutants to low altitudes, where the various processes removing them are found. Watch contrails, and see how long they take to disperse.

Contrail haze absorbs heat, and shades the ground below. I understand that after the 9/11 atrocity all aircraft in the United States were grounded for several days. The consequent clearing of contrail haze caused a measurable increase in air temperature in New York. Much of that temperature increase was caused by the heat otherwise absorbed by contrail fogs and gases, warming the stratosphere.

Strangely, politicians are protective of air travel. Proposals to tax aircraft fuel are resisted; new runways are planned; growth in air travel is promoted.

The planet cannot carry air travel at its present level. The issue must be addressed: the costs of air travel must be increased sharply, and aircraft fleets reduced.

Cement manufacture pollutes as much as aviation. Coal or oil fuels furnaces to drive carbon dioxide from limestone, and pump dust-laden gases from smoke stacks, unless expensive filter plant is installed.

Private automobile use is fiercely criticised by AGW campaigners, and there is no disputing its serious effects in cities. This factor is already much reduced by modern efficient cars: my VW Golf returns more than 60 mpg, as a good example. Battery cars reduce local pollution, but are not efficient if hydrocarbons or coal are burnt to deliver electrical power for charging. The Toyota Prius, so beloved of the greens, is unlikely to return much above 40 mpg. Battery production and disposal has serious environmental impacts too.

A strict and enforced national speed limit of, say, 100 kph or 60 mph would cause a substantial fall in fuel consumption, but I shall be surprised if this is in the manifesto of any major party.

Heavy goods vehicles are heavy polluters, 5 or 6 mpg is a usual figure. Again the message is simple: foster local production. It is absurd to transport to Britain French bottled water, Bavarian dairy products, and Polish coal.

Yet another issue our politicians prefer to avoid. "Get loads off the roads" ought to be a popular electioneering slogan.

An ambitious programme to create fast efficient rail services is needed urgently, especially for freight, and especially in overcrowded Britain. Let this be accompanied by an equally ambitious redevelopment of nuclear and hydro electricity generation, reducing greatly our dependence on imported hydrocarbons for transport, industry, and domestic energy.

Domestic power and heat is the last big item on the list of atmospheric polluters. So much more can easily be done: insulation, low consumption lighting and appliances, solar water heating and electrical generation. So many people prefer to turn up the heating instead of wearing warmer clothes.

I am impressed by the potential of small local hydro-power units in mountainous districts. Quite a small stream with sufficient fall can power an entire village, with surplus sold to the grid. Put the money currently subsidising wind-power into small and large scale hydro-electricity, so much more efficient, so much more reliable.

Last summer I watched the tidal flow through the Ballachulish strait, and wondered how many kilowatts a line of turbines would deliver. In Britain we have so many opportunities for such development.

Wind-farms are my bugbear. Wind-farms are curiously symbolic of New Labour: very expensive, obtrusively visible, contemptuous of landscape, and hopelessly inefficient and unreliable. In the best position a wind turbine may deliver its rated output for one third of the time, and most of those installed achieve less than that. I wonder how long a wind turbine needs to offset the considerable carbon footprints of its manufacture, transport, installation and servicing.

Wind turbines are the triumph of green fantasy over engineering reality.

I have little fear of nuclear power, especially modern fuel-efficient systems. I would insist they be nationally sponsored; not run for profit, but pricing to cover all costs of construction, running, and disposal; and internationally supervised.

Fusion power is within sight. ITER is already in construction, the first demonstration fusion power plant. The cost may reach 10 gigabucks, a third of the cost of the 'troop surge' in Afghanistan.

Why has Britain lost its leading position in this most vital technology?

Efficient large scale energy storage remains an unsolved problem. Hydrogen offers a solution. We should be investing urgently in technologies for hydrogen generation, storage, distribution and use.

Why are we not doing these things? I despair.

Oh dear. This blog-post is banging on a bit. Bear with me while I make three more important points.

The first is that investment in Britain's power supplies and infrastructure should have begun a quarter century ago, when we had North Sea oil wealth. Unfortunately those were the Thatcher years, when that awful, remarkable woman chose to squander money on unemployment and the destruction of our industrial and engineering base, in obedience to economic theory long discredited.

When the New Labour era began TB-GB were deaf to warnings of the growing urgency of new power generating capacity. Now at last a French company mostly owned by the French government will build new nuclear power stations in Britain, for French profit at Britain's risk. It is probable there will be serious power shortages before this new capacity starts up.

I recall the huge bill-boards when I was a teenager in the 50's. "Britain leads the world in nuclear power. British achievements speak for Britain."

Second, every person in Britain consumes, on average, 4 kilowatts total - electricity, heating, car engines etc. New Labour's mass immigration has increased the population, officially by 3 millions, in reality probably 4 millions, maybe 5. That's at least a 12 gigawatt increase in power demand, which supply will struggle to provide. And rapid population growth is expected to continue. Britain's population is already too large: further rapid growth must be detrimental, environmentally, economically and socially.

New Labour has delivered a broken, bankrupt, balkanised Britain, a poor base from which to begin major programmes of reconstruction and change.

Third, I have a growing suspicion that events may overtake our fears of global warming. Evidence is mounting that the sun is entering another 'Maunder Minimum', like that which began some 380 years ago, soon after the discovery of sunspots.

After a period of high solar activity in the late 20th century the last solar cycle was notably quiet, with substantial reductions in sunspot number and other measures of solar activity. We are well past the end of the predicted solar minimum, and so far solar activity has remained low or very low. Sunspots may be rare during the 21st. century.

We know that the last Maunder Minimum was accompanied by global cooling - a little ice age - which lasted some 70 years. We also have reason to believe its onset was abrupt.

The disputed failure of predictions of global temperature to rise this century may prove to be real. Arguments about solar variation driving climate change may shortly be put to the test.

First, Do No Harm

'Primum non nocere' - first, do no harm - is a classic axiom of physicians. Easy to say and remember, correct to the point of truism, it may be hard to observe always in practice.

Prophylactic therapy is especially likely to challenge the axiom. Treatment is prescribed to reduce the risks of future illness, although the person is well at the time. The risks of treatment now are justified if much greater future risks can be mitigated or averted.

Treatment of high blood pressure is a common example. The intention is to reduce the chance of future cerebral haemorrhage [stroke], kidney damage, and heart failure. The general and specific side-effects of therapy are judged less significant than the risks of devastating future disease.

Anti-hypertensives commonly dull the enjoyment of life. Tiredness, lack of energy, low mood, loss of libido and similar symptoms seem to accompany significant lowering of blood pressure, whatever the regimen. I used to teach, half in jest, that telling a patient the blood pressure is high and tablets should be taken indefinitely will change a person in robust health into a complaining neurotic.

And there are also the complications specific to the particular drugs prescribed.

In my experience stopping blood-pressure treatment guarantees a grateful patient.

Anti-coagulant therapy is an especially difficult type of prophylaxis. Abnormal blood clotting may cause serious or fatal embolism: clot which is dislodged from its point of origin, to be carried in the blood-stream until finally it impacts and obstructs an artery; the tissue supplied by that artery loses its blood supply and is damaged or dies - the process of infarction.

Pulmonary embolism is a dreaded complication of surgery to the abdomen, pelvis, hips or legs. Clot forms in pelvic or leg veins, usually with no warning signs. Eventually clot breaks loose, is swept by the blood to the right heart and then into the pulmonary artery. Sometimes the clot is big enough to obstruct the main pulmonary artery, causing sudden death. Smaller clots may obstruct a major branch of the pulmonary artery, causing shock and collapse.

Routine post-operative use of heparin greatly reduces the risk of pulmonary embolism. Modern preparations of heparin make this prophylaxis safe, but the drug must be given by subcutaneous injection.

But heparin use is not without risk.

A 30 year old woman in her first pregnancy gave a family history which was not fully understood. Consequent testing of her blood-clotting system showed a minor abnormality, which in theory might predispose to thrombosis. The doctor prescribed heparin, despite the lack of a history of thrombosis, and her pregnancy.

I was alarmed. I worried about the hazards of heparin in a pregnant woman, especially during labour and delivery. I know that in pregnancy strange things happen to sophisticated blood tests; I doubted the reliability of the abnormal result.

But I was only a relative: I had no clinical responsibility.

In the event she delivered a healthy baby, but had a postpartum haemorrhage estimated at more than 1 litre. She recovered well without transfusion, but she came close to it.

Repeat blood tests gave normal values.

Primum non nocere: and, I might add, leave well alone.

Atrial fibrillation is another condition with a risk of embolism. This disorder of the heart-beat may complicate other heart diseases, and is more common in older patients. The electrical signal triggering the heart-beat fails to stimulate and propagate across the atria - the small chambers which sit above the ventricles. Contraction of the atrial muscle ceases to be co-ordinated and controlled; instead chaotic contractions are triggered by abnormal electrical activities in the atrial muscles.

The atria fail to contract. Blood flow through the atria is slow and abnormal. Clot may form, and then break off into the ventricle, and so into the arterial blood. Clot may then impact in branch arteries anywhere in the body, but obstruction of arteries to brain, intestines, kidney and leg is especially dangerous.

Repeated minor embolism over a long time causes progressive organ damage, notably to brain and kidney.

The risks of embolism are judged sufficient to warrant long-term anticoagulation in atrial fibrillation. Warfarin tablets are the usual prescription. Warfarin has few side-effects, but the dose has to be carefully controlled: too much and the patient bleeds, too little and clots may form. Unfortunately control requires regular hospital visits for a blood test and review, which is a burden for patients, and expensive for the health service, especially if the patient is old, infirm, or disabled.

Effective Warfarin therapy also demands intelligent patient compliance.

Serious bleeding can still occur even in apparently well controlled patients. Accidents happen, unforeseen consequences occur. I will quote two examples from many.

I had an urgent call to theatres. A middle aged man was in surgery for acute appendicitis. The incision was bleeding badly and control was difficult. An urgent blood test suggested he was anti-coagulated. Plasma infusion and other measures resolved the crisis.

We later learned he had been unwell with abdominal pain for several days. A neighbour had given him some tablets which she had been prescribed after an operation. Those tablets were Warfarin.

A woman in her 50's came with thrombophlebitis in the right calf. I prescribed warfarin, as recommended to prevent pulmonary embolism. She attended the clinic and all seemed well. After 5 weeks she came back as an emergency with a severe stroke. Her clotting tests were as expected. She died, and necropsy showed intracerebral haemorrhage.

The coroner recorded a verdict of death by misadventure.

The problem is that it is hard to identify patients who have certainly benefited from prophylactic anticoagulation, but any experienced physician remembers cases where Warfarin has caused crisis or even disaster.

I don't like anti-coagulants, I prescribe them with misgivings, but the prevailing opinion is that the benefits justify the risks, and I must comply.

But always in my mind echoes the advice of an eminent physician, a former mentor: "Warfarin is rat-poison - and that is its proper use".

Primum non nocere. Leave well alone.

The Eleventh Hour of the Eleventh Day of the Eleventh Month

I hate the weasel words of the Whitehall Cenotaph - "The Glorious Dead". 

There's nothing glorious about being dead, especially those slaughtered for nothing in the hell of the trenches.

Rudyard Kipling chose the words, stricken with grief and guilt after the death of his only son.

But he was wrong, no doubt trying to make atonement: understandable, pitiable, but wrong.

Siegfried Sassoon knew from bitter personal experience. He spoke the truth.

On Passing the New Menin Gate

Who will remember, passing through this Gate,

The unheroic Dead who fed the guns?

Who shall absolve the foulness of their fate,—

Those doomed, conscripted, unvictorious ones?

Crudely renewed, the Salient holds its own.

Paid are its dim defenders by this pomp;

Paid, with a pile of peace-complacent stone,

The armies who endured that sullen swamp.

Here was the world’s worst wound. And here with pride

‘Their name liveth for ever,’ the Gateway claims.

Was ever an immolation so belied

As these intolerably nameless names?

Well might the Dead who struggled in the slime

Rise and deride this sepulchre of crime.

John Kipling was killed during the Battle of Loos, in September 1915. Massed infantry were ordered forward in parade-ground formations, towards barbed wire and machine guns. British losses after 3 weeks were 16,000 dead and 25,000 wounded; a short section of the front had been pushed forward 2 miles.

"The Corpse-Field of Loos", the Germans called it, sickened by the slaughter, holding fire as British survivors retreated.

Many of those gunned down were malnourished, poorly educated, conscripted young men from the impoverished slums of London and the big cities. Many wounded suffered hours in the mud before dying.

The loss of young officers was especially grievous: the brightest and the best of their generation, so important in the seed-corn of the future.

"The Glorious Dead."

The story is told that some months later Winston Churchill attended a conference on the Battle of Loos. Afterwards he was asked what he had learned. "Never try such a damn-fool thing again", he growled.

But the generals had learned nothing. They went back to their chateaux and planned the Battle of the Somme.

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.