Sunday 27 April 2008

20-a.Nuqueib Part 1.

On the occasion of the 60th anniversary of Israel's independence, I submitted the following article to SHEMA, the newsletter of Judith's synagogue.
It has just been published - slightly shortened:

46 years ago in Israel: The Nuqeib Action

Despite many months of protests through the United Nations, Israeli boats that were fishing legally on the Sea of Galilee were repeatedly shelled from a Syrian army position at Nuqeib, just north of kibbutz Ein Gev. Syrian Nuqeib lies on the eastern shore of the lake, exactly opposite Tiberias on the western shore - see the map.

In March 1962 the Israel government finally decided to attack and demolish the Syrian position. The task was given to the Golani infantry brigade, in which I served at the time as the brigade medical officer. So I was put in charge of the casualty clearing station for the action.

My recruitment for compulsory military service had been postponed until after I had graduated from medical school in Jerusalem. After a short course of military medicine, I was posted as medical officer to the Barak battalion of the Golani Brigade. My work consisted mainly of inspecting the camp's hygiene and sanitation and dealing with the soldiers' routine medical complaints. After a year, I was promoted to become the brigade's medical officer, with the temporary rank of captain. Now I was able to attend also the medical rounds at the nearby hospital once a week. But just as I was due to present a case at the next meeting, I was told to cancel my visit - without revealing the planned action at Nuqeib, of course.

On Friday 16th March 1962 all the combat units reached kibbutz Ein Gev under cover of darkness. I was met by my cousin Reuven, a veteran of the kibbutz, who was in charge of local security. He suggested that I set up my clearing station in one of their underground shelters. But I decided on a location with easy access from the battle area and for medical evacuation, in an open yard just inside the kibbutz gate. Now an enclosure for ostriches stands on that spot. We erected the tent for receiving casualties and by the light of the incandescent kerosene lantern we prepared our medical equipment, assembled some intravenous drip sets - and waited.

When the attack on Nuqeib started, the Syrian artillery on the Golan ridge above began an intensive shelling of the area. Some of the shells exploded in the kibbutz yard, quite near to our tent. Several times, shell fragments tore through the tent canvass but fortunately nobody was injured and n equipment was damaged.

Before long, casualties from the battlefield began to arrive. Ignoring the continuously exploding shells around us, we examined and treated the injured, completed their documentation and arranged their ambulance transport around the lake to Poriya hospital above Tiberias. Several soldiers were dead on arrival at my tent. I cannot now recall the numbers - but later I ascertained that all 30 casualties who had arrived alive at my clearing tent had also reached the hospital alive.

One of the dressers in my team had forgotten his steel helmet in camp, whereas I found it most cumbersome to perform my work while wearing my steel helmet. So I gave it to him. During the fighting, one of my battalion medical officers actually did sustain a penetrating head injury - despite wearing his steel helmet. Luckily he later made a full recovery.

After some hours, the stream of the casualties ceased and I assumed that the fighting was over. But the field telephone wires to the command post had been cut by the shells, despite being repaired twice. Dawn was breaking, but the Syrian shelling was still going on. Thanks to my previous visits to Ein Gev, I was the only person in my tent who knew where the shelter with the command post was located. So I retrieved my helmet and ran there to ask for instructions. I was told to dismantle my tent and withdraw to the force's assembly area in the Yavne'el Valley, across Lake Tiberias.

When we got there, I lay down in one of the ambulances and promptly fell asleep. As a result, I missed the visits by David Ben Gurion the prime minister and by the chief of staff Zvi Tzur. In the afternoon we returned to our camps and I was given home leave. The next morning two Army reporters arrived at our flat in Jerusalem. They said that I had been recommended for mention in dispatches by the chief of the general staff and they required photos. For the following few weeks, whenever a door was slammed loudly, it made me start and I ducked instinctively.

During the next independence day celebrations, I attended President Yitzhak Ben Zvi's customary reception to honour soldiers who had been mentioned in despatches. As usual, this was not followed by any sort of party.

(continued in next blog)


Saturday 26 April 2008

20-b.Nuqeib - Part 2

NUQEIB (continued)

Some months later I was demobilized. I moved to London for postgraduate medical training. The specialty of rheumatology was not well developed in Israel at that time. Ten years later the Israel embassy unexpectedly phoned us one day. We were told that according to an Act passed in the Knesset in 1973, I was entitled to receive the Israel Medal of Courage. My wife Judith and I were invited to the embassy. An official made a speech, and handed me a certificate and the medal in its olive wood case - see photo.

This medal is awarded 'for an act of gallantry, at the risk of life, during fulfillment of combat duty'. So far, during the sixty years of Israel's existence, it has been received by only 220 soldiers. In my case, I had not experienced any fear during that night's shelling and I did not regard myself as being particularly brave. Had I taken part in this action as a combat officer, instead of as a doctor, my conduct might not have been regarded as all that outstanding. I have never worn the medal, nor have I told any of our friends about it.

To my knowledge, I only derived benefit from this honour on one occasion, when I applied for a medical post at Bethnal Green hospital. During the interview one of the consultants seemed particularly interested in my award. I was appointed to that post, and later I discovered that Dr Ian Gilliland was a staunch supporter of Israel. He had previously been a volunteer on Yigael Yadin's excavations at Masada.

- - -

Post Script

Since the ceremonial award of the medal all these years ago, I have not been contacted again by the Israel Embassy. They were obviously aware of my whereabouts; but I was never invited to the Independence Day celebrations, or notified of any other events there. I suspect that in their chauvinistic arrogance they regarded me as a 'Yored', an emigrant from Israel and therefore a renegade - practically a traitor.

Recently, when I decided to write my memoir for the synagogue magazine, I could not remember the number of casualties that had passed through our tent. I thought that perhaps Dr Eliyahu Gillon, who had been at the time the Commander of the Army Medical Corps and my professional superior, might be able to obtain access to the relevant archive. I managed to ascertain his address from a mutual acquaintance: he was retired but still doing research at Tel Hashomer hospital. I wrote him a friendly letter asking for his help. I never received a reply. Many Israelis are well known for their reluctance to write letters.

So I was prepared to skip the casualty figure, but I contacted the Public Relations Section of the Israel Embassy in London. I wished to ensure that my description was no longer classified; and incidentally, could they possibly obtain the casualty data that I was seeking. They replied promptly and assured me, that they did not 'censor' such texts as my memoir. As to the number of casualties - that would be very difficult or impossible to ascertain at this time.

Like Baldrick (of television notoriety), this gave me the idea for a cunning plan:
One of my relatives in Ein Gev is a qualified midwife, who had worked for many years at Poriya Hospital. Perhaps she would be able to obtain the information from the records of her hospital's casualty department? I knew that all the injured had been evacuated to Poriya during that one night, of 16 - 17 March 1962. Within a fortnight she e-mailed me the answer that she had received from the archive: there had been thirty casualties, including two shell-shocked. So now I could write my paper. And Frank Godson, the editor of the synagogue magazine, agreed to publish it.

Thursday 24 April 2008

19.Ethics of medical information

During my medical career, the handling of medical information has undergone major changes. Hippocrates had said, that patients should not be given any information: the physician knew best, and the patient must trust him [invariably male, of course]. In the 1950s, patients were still regarded as idiots who should not know anything. In particular, they must not be told if they had cancer.

Our brilliant professor of paediatrics (Manchester trained) had vomited blood - it was due to a gastric carcinoma. He had surgery - and was told that it was 'an ulcer'. He was a very thin and cynical man - just the sort of person to develop a duodenal ulcer. That is what his all colleague told him - he should wait for recovery from the operation. While he
slowly 'recovered', he developed jaundice - from hepatic secondaries, or perhaps cancer obstructing his bile duct. The surgeon knew that it was hopeless. So he was told that it was due to viral hepatitis, from one of the blood transfusions. Bad luck - hepatitis B was not considered as ominous as it is now. He slowly deteriorated and died - apparently unaware of the diagnosis. But perhaps he did know it was cancer, and just behaved to avoid the unpleasant and futile conversation on his hopeless situation.

But things were beginning to change. The chest surgeon, professor Melvitski, preached telling patients the truth.
Incidentally, he was the first to perform a closed mitral valvotomy in Jerusalem, by inserting his finger with a blade strapped to it, through a purse-string ligature
prepared beforehand in the left atrium, and then pulling it shut. He told us candidly how anxious he was when performing this operation. His method saved the lives of many cardiac patients with mitral stenosis - those were the days of much rheumatic fever - progressing to heart disease. He later died in a crashed El Al plane sabotaged on its way back to Israel. Years earlier, he had saved the septic leg of my brother Michael after a road accident - that was before antibiotics.

In his lecture, Melvitski described to us a man, whose diagnosis of cancer was kept secret from him for some months, by telling him various lies to explain his deterioration. Finally he realized that he was actually dying, and he confronted his doctor. They had to admit the truth. "What a pity", the poor man said. "For years, I had been writing an important book to record my life's work. It needed the final chapter, and a short revision. But you promised me recovery, so I waited. Now it is too late." This did impress us.

But it was emotionally hard to tell patents, and it was contrary to tradition. I was looking after a good friend of my parents, a dental nurse, whose breast cancer had spread, despite having even her adrenals removed - those were desperate times. She fractured her femoral neck through a secondary deposit and it was pinned. On my next visit to her bed, she said, "Now starts my struggle with death." To my regret, instead of talking it over honestly with her, perhaps reassuring her that we could deal with her pain and distress, I just denied that the fracture was anything but an accident. The term 'palliative care' did not exist then.

I wished to tell patients the truth. But I had heard of cases, where this news destroyed the person - sometimes leading to suicide. In rheumatology, I found cancer two or 3 times per year, in a person sent for advice on 'aches and pains'. These patient often came with their spouse, who often guessed a sinister cause when the GP hadn't. When I suspected cancer, I created the opportunity to discuss the possibility of informing the patient, by sending the patient for 'another blood test', etc. and getting the nurse to fetch the spouse for a quick chat.

At the next appointment, I had the results of the investigations, and the couple had had a chance to discuss the possibilities. Invariably, they wanted the truth - but see below - about Mrs S.

The same secrecy, the keeping of information from the patient, applied also to medication. Names were not revealed on the containers - just 'the tablets' or 'the mixture', and how to take it. Often, it was just a placebo, a sham substance: vitamin B complex was the commonest standard.
But if a person consulted a different doctor, or attended the casualty department, all the information that they could give was the colour and shape of the pills. The 'monthly index of medical specialties' included at the end several pages of actual-size pictures classified by shape, colour and size. This usually facilitated identification.
By regulation, the pharmacist was not allowed to write the name of the medication on the container either, unless the prescription included the instruction 'proper name'. But for years, n
ow, names are routinely put on the containers. A good U-turn.

As a final year student, I was observing a gynaecologist in his out-patient clinic. He reassured the anxious woman that after his full assessment and investigations he could reassure her, that there was no disease present. (When I myself said so, I always had nightmares, that the patient would go out and drop dead... Fortunately, this never happened!) Then, for reassurance, the
gynecologist began to write a prescription that would 'make her feel better'. You've guessed it: "Vit. B. Complex i b.d. 14 days"
But this was in Jerusalem - where people are more outspoken. "Doctor, why do I need medication,
if there is nothing wrong with me?" Dr Saltzberger (he later operated successfully on Judith - he is dead now) nodded, agreed, and tore up the prescription. I resolved never to forget this - and I haven't.

From this episode, and from my frustrating experiences in casualty, attempting to identify 'them little white pills', especially when dealing with drug overdoses, I quickly resolved always to write
'proper name' on my prescriptions - and never to use placebos. I would not accept a 'placebo treatment' from my plumber, or from my car mechanic. It is eminently dishonest. It is only sustained by paternalistic physicians who act like god, or as a quick short-cut, instead of a lengthy explanation and reassurance.

Physiotherapy is also used sometimes as a placebo, even when there is absolutely no scientific or experimental evidence for its effectiveness. Patients will often get better while having
physiotherapy - not because of it! I have very occasionally sent a patient for physiotherapy for another purpose: to find out some other problems that were possibly aggravating their complaint. Patients were less inhibited by the therapist - and sometimes the information was very useful to me in helping the patient.

I had written a short article about my opinion, on the lack of scientific proof for the effectiveness of physiotherapy. It was published in 'Therapy', I think, and resulted in a flood of indignant letters to the editor. They all protested bitterly, that I had claimed that physiotherapy was 'useless' - whereas I had only complained about the absence of research. There was no point in arguing.

But in my hospital work, I had made a point of being on friendly terms with the therapists. I took my mid-clinic coffee break in the therapists' staff room, which gave us an excellent opportunity for informal discussions about patients and their problems - mine and others'. Incidentally, the array of unwashed mugs that were left strewn around by the all-female staff was astounding. After I found my own mug on several occasions used and dirty, I took it back with me to my office.

The history of Mrs S is different.

Over coffee, one of the physios in the staff room showed me a request from a local GP. Mrs S was in her late 70s. She had 'widespread arthritis' - could she have physiotherapy please. The physio felt that at this age, the request was unrealistic: could she [or I] refuse the GP's request?
A letter from Mrs S was attached. In the hope and expectation of receiving treatment, she asked to be offered afternoon appointments, because in the morning she was very immobile. That gave me the diagnosis: Mrs S probably had Polymyalgia, and not age-related Osteoarthritis. So I posted her a request for the blood test for an ESR [red cell sedimentation rate] - which is diagnostic - and an early appointment after the result was back.
The ESR was very high. QED. I saw Mrs S, explained my suspicion, and sent her home with a supply of Prednisolone tablets.
A week later she returned, quite convinced that I was god. Her 'arthritis' had melted away and she felt like a totally new woman. Experience with many local GPs had taught me to keep managing this condition myself. Most GPs are not very experienced in Rheumatology. And they attend the weekly lunchtime meetings for the food and to 'sign on'.
Over the following months, as we gradually and carefully tailed off the steroids,
we became good friends. Finally she was 'cured', and off steroids. Each Christmas she sent me a card.

Then, a few years later, she wrote to ask me, whether I could resume her care. She felt very bad and she did not know why. Her medical notes gave the answer: she was under the care of one of my favourite surgical colleagues, who had found malignant melanoma - and it was spreading. This was outside my field, and I reassured Mrs S that she was in excellent hands, and that I could not just take over her care.
Her notes identified her next of kin. So I wrote to the daughter to explain, that perhaps at the age of over 80, Mrs S should actually know her diagnosis, because her uncertainty was her worst problem. The reply came by return: on no account was her mother to be told that she had cancer!

It was only some 15 years later that I first read in the BMJ about the primary responsibility of a doctor to their patient - and not to the relatives. Throughout my career, and at the time of Mrs S's illness, I mistakenly thought that the daughter's views were paramount. As she was now not under my care for the melanoma, it was not up to me anyway. But I could have tried to convince my surgical colleague to tell the truth to Mrs S.

As she deteriorated, she was admitted for terminal care. I went to see her on the surgical ward - her mind was still clear. As she saw me approaching, she slipped on her wig... and again asked me to take over her care: why was she not getting better? She could no longer eat or drink - but I was told by the nurse that they were about to set up an intravenous infusion.
I phoned her daughter: Her mother was dying. But nurses, especially Catholics, want to preserve and extend life. She must come and tell the staff explicitly, that they should not prolong her mother's suffering. Later I heard, that this had in fact been heeded by her.

In reply to my letter of condolence - Mrs S had become a good friend - the daughter wrote, how proud she was, that her mother had not known that she had cancer.
I reckon that it was the daughter, who had been unable to face the diagnosis.

Tuesday 22 April 2008

18.Patrick Horne + 21.04.08

Yesterday I was told that Pat had died from a massive heart attack. He was on vacation in Cuba. The following day, his ashes had been returned to Toronto.
In his last email, just before he left for Cuba, he had complained of being tired, and I thought that he was depressed. But his passing was shattering news to me. I have lost a very close friend - albeit a pen friend. We have corresponded at least twice a week, often more, for several years now. We met only once - when he visited Britain to research his work on Armand Ruffer.

It all started when Pat contacted me to praise the paper
published in the JRSM [by Loebl and Nunn], on walking aids in Egypt and Palestine. It rapidly transpired that he had published an item in the BMJ's Minerva section, on Aspergillosis during life found in the lung of a mummy: the fungus histology is different in vivo. I told him that I remembered the item, and the amusing correspondence that followed. The BMJ always added a note requiring the subject's signed consent if pictures were to be shown. One of the correspondents wondered, how the mummy could give permission; and another suggested, that perhaps it could be obtained from the mummy's mummy.
For my talks on ancient medicine, he promptly sent me better slides of that case.

Pat was affiliated to his university, and so he had far better free access to literature on the web. Coupled with his uncanny knack of finding relevant items, his diligence and generosity, and his acquaintance with other experts, his supply of data was enormously helpful to me on numerous occasions. I shall continue to give him credit in my talks for two exciting small snippets: why the Biblical Ricinus plant [kikayon] that shaded Jonah, is usually illustrated wrongly as a gourd; and the post-Biblical exact Midrashic source for the medieval illustration of Noah, planting a vine accompanied by four animals,
and getting drunk.

We were planning to submit for publication - possibly for 'Minerva' -
another short item of a portrait showing unreported Xanthomata - I had spotted it in an art gallery and Pat had given me much help to define the diagnosis.

With great enthusiasm, he kept 'feeding' me with numerous other papers, which on first reading sometimes appeared irrelevant, but turned out to be valuable - or even farcical, such as the rubbish article
from Beer Sheba about king David's diagnosis of osteoporosis. He told me that he enjoyed reading my papers and the texts of my talks. He was a rapid reader, and usually replied with some obscure picture that I had missed.

And then there were the jokes, including excellent Jewish and Catholic specimens. Pat had a very good sense of humour, and good sources. He probably died before he received my last string of rather good jokes. Ah well, there is no email in the Hereafter... and no
Hereafter, either.

I shall miss him very much.

Monday 21 April 2008

17.Seattle 10th to 16th April

An impressive number of personalities visited Seattle last weekend.
First and foremost, myself and Judith. At our reception at the airport Sam and Josie greeted us with a short speech. 'Welcome', they said, 'your plane was early'.
After we exchanged hugs and kisses (which none of the other VIPs got), and evaded the reporters and photographers
(which none of the other VIPs did), we were driven past the crowds to the Roskin's official residence.
The Dalai Lama and Archbishop Desmond Tutu were also in town.

We saw Miriam and Aaron several times. A bright, lively and well-behaved boy. He thanked us both immediately when he received his 'Thomas' engine. Possibly Miriam had prepared him? I'm not sure, and I forgot to ask... Miriam gave us a delicious meal and showed us her re-modeled garage that will become Aaron's play-room.

For the first time I heard that several people were reading my blog. So I'm not 'a voice calling in the wilderness' - which is a Christian distortion of the OT verse! Nobody has ever sent me an email comment...

We attended an excellent illustrated talk on Bernini by Rebecca Albiani at the Frye Art Museum. During questions she confirmed, that the identity of Bernini's model for St Theresa in the 'ecstasy' sculpture is not known. It is relevant to my talk on medical aspects of art.

Sam took me to 3 of professor Bridgman's classes on Tucidides at the University. Very interesting - he mentioned the six days war
as an example of a just war in response to a real threat. I'll probably get Michael Walzer's book on just and unjust wars.

Sam also took me to a lecture in his Forestry course. Our visit had caused him to decide to miss a weekend field trip, which
was apparently very successful. We had urged him to go - Josie would have coped.
The slide talk was on the aftermath of the Mount St Helen's eruption. Surprisingly, plants and animals survived and regenerated - the ash is, of course, very fertile. I learnt two irrelevant facts: that 'snags' are dead tree trunks that have remained erect - not just lesions in nylon stockings; and that decapitating a conifer permanently stops its upward growth.
But the lecture consisted of qualitative observations, with beautiful slides. We were given no quantitative data, and I'm not sure of the practical conclusions: although such events are rare, can one influence the recovery of a damaged area? And when wood is precious, can these 'snags' be utilized?

Another highlight was a visit to the exhibition 'Roman art from the Louvre' at the Seattle Art Museum. Not only was the material superb, but the explanations were excellent, both the audio set and the labels - far superior to the quality at the British Museum and the Wellcome. From the early emperors to citizens, and slaves, from architecture to military life, leisure and religion - I learnt a lot. But then it's just over 50 years since we visited the Louvre - it's on our list.
They display one Fayoum-style mummy portrait. Curiously, they say it is painted in tempera, whereas I understood that they were
painted in encaustic wax - and the vivid colours would seem to support this. There are no email addresses in the catalogue, and I presume that they are right.

We visited Charles and Jonis Davis and some of their family in their newly and brilliantly remodeled house. A very enjoyable evening.

Sam took us to the Wednesday morning weekly get-together at the nearby cafe. A pleasant and interesting bunch of men - they do not exclude women but presumably somebody has to do the housework. Tom Luce was there - his wife was just about to have surgery to the base of her thumb.
My hearing aids amplify all - so the conversation was not entirely easy. I'd have to think carefully whether to go again.

In any case, the long flights and considerable jet-lag are a very considerable deterrent to going again all the way to Seattle. My earlier return home was a redeeming feature. The last 4 days have more or less restored me to UK time, so that I can start to prepare my next [and last] slide talk - that was the main reason for my return.
Missing the Seder [Passover ceremony] was an added bonus. For years, I have refused to recite the intolerant vindictive prayer, asking God to 'pour his wrath on those who do not recognize him'. I have gradual become more agnostic, and I skipped the ceremony completely last year. It was held in one of the rooms at the hotel in Petra, organized by the few Jewish participants in the ancient water conference. Judith enjoyed it.

The Seder commemorates a fiction, that is based on Biblical history which was only invented and added during the Jewish exile in Babylon. The Egyptians did not keep slaves - apart from prisoners of war. And at the time of the Exodus, Sinai and Canaan were under firm Egyptian control - with a string of military forts along the
Israelites' alleged route. So the Israelites could not have 'escaped'. Not even a tiny fraction of 600,000 men, plus families, could have survived 40 years of wandering in the wilderness, etc, etc.
It follows, that the events at mount Sinai are also fictitious, and there is really no prohibition against adultery, or the other commandments. Politicians who lie, and steal, and send their citizens to die in [illegal] wars, and fornicate - they know all this already.

Sam's and Josie's hospitality was faultless. I had a most pleasant 6 days there, and my current freedom is another bonus, especially playing the radio at full volume.

But all good things have to come to an end - except sausages, which come to 2 ends.

Wednesday 9 April 2008

16.Casting Pearls...

In a fortnight my U3A course on Art of the Bible comes to its involuntary end. And I'm not giving a [different] course next year.
Judith hates her inability to talk to me, whenever I concentrate on the preparations - which takes many hours every fortnight. I can't interrupt my thread of thoughts easily, or sorting the slides, and she can't save things to remember
later, however trivial they might be. That's Old Age...

Although the 'students' are attentive and appreciative, they prefer a totally passive role. Not one of them took notes, or read up my recommended passages. I suspect that not all of them even have a Bible with a modern translation at home.

I set them a task of making a list of recurring elements in the story of Joseph - with a book prize for the best entry. Not one of them bothered - they knew that in the end I would give them the answer: dreams, clothes, recognition, the goat, etc. That's my meaning of 'casting pearls'.

Attendance was erratic. These are elderly people. Visits to doctors and hospitals, booked holidays, other occasional clashing U3A activities, and having to attend unexpected funerals, all took their toll. One or two kept getting muddled about the dates - fortnightly seemed to confuse them.

I did not keep a register of attendance - they came when they could. But if you are a member, it's free: so probably 'it can't be worth much'...
It was a mistake to hold it at the synagogue. Compared to doing it at home, it added almost two hours for travel and setting up / dismantling each fortnight. And a concentrated course over a single weekend would have ensured much better continuity. Maybe in 2010...

A lot of the material this time was freshly prepared. My greatest satisfaction was the search for new images, and the discovery of new facts - Pat Horne was a rich source of weird and valuable knowledge. I suspect that I shall not wish to stop this work - whether or not it ever gets transmitted. And my commitment saved me from having to attend one funeral. A silver lining?

I was going to teach about Herod next. But with Ehud Netzer's work progressing at Herodion, and two recent books, waiting another year may be a good thing.
Meanwhile, Tax Return time is looming...