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.

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.