Grown-up medicine

How often do we get up from our beds thinking that we know what the day holds, especially when we have been given some advance clues, only to find that events unroll either beyond or below our expectations? When I woke on Friday 8 October 2010, my head was full of information about R-CHOP chemo, received a few days previously from my haematologist and augmented by subsequent reading online, but in reality I had no idea how the day would feel as I lived it out.

The recommendation is always that chemo patients be accompanied to their treatments by a supportive friend or family member and on this particular day my brother did the honours. The staff on the Haematology Day Unit wanted to see me at 10 in the morning, as the first treatment session generally takes longer than subsequent ones. Shortly after arriving at the Unit, I was introduced to my key worker, one of four nurses on the team, whose first job it would be to brief me on the drugs I was about to receive and the changes that would be necessary or advisable in my lifestyle over the coming weeks and months.

Most of these changes, as far as I could see, would arise from the fact that chemo is nasty poisonous stuff that kills more than just cancer cells and blitzes your immune system, most particularly about seven to ten days into each 21-day treatment cycle, at which point the neutrophils, foot soldiers of the battle against invaders, take major casualties. So it was that I learned with some sadness that I should avoid fruit that needed washing, because of the difficulty in getting it truly clean. It would be advisable to peel such items as apples and pears. No more grapes either (unless I went to the trouble of skinning them); strawberries and raspberries would also be particularly problematic with all those nooks and crannies where microbes could lurk. Seafood was a no-no, while soft or blue cheeses would most definitely be off the menu.

While I was undergoing treatment I should also avoid the attentions of dental hygienists, described by my key worker as “butchers", as their techniques could injure my gums and open the way to infection. I should from now on use a soft-bristled toothbrush, clean my teeth four times a day and use mouthwash (available on prescription) on each occasion. From now on I would be drinking filtered water and alcoholic hand gel would never be far away. As my mouth would be at risk of thrush infections, I would also need to take a daily anti-fungal capsule.

Water filter
After weeks of the stuff, I am not entirely convinced that these produce better tasting water:
to me it seems bitter and rather oily

The briefing would not have been complete without touching on hair loss, which would probably occur about three weeks into treatment. It was part of the nurse's protocol to ask whether I would be interested in a wig. My reaction to this offer surprised me with its vehemence and I admit that I said that I did not want a “dot-dot-dot wig". My response having been registered as a “strong no", the way was clear for treatment to begin and so we moved into the main room of the Unit, where I chose a chair and was surprised to find that, contrary to NHS norms, it was extremely comfortable and supportive.

For the second time in my life I had a cannula inserted in my arm and was attached to a drip. Simple saline solution was administered first to flush through the lines and the first injection I received through the tube was a strong dose of a drug called ondansetron, a state-of-the-art anti-emetic and thus a powerful remedy against nausea and vomiting. I was also given prednisolone tablets to take as part of the R-CHOP regime. Next came a small bag of vincristine, which came packaged within an outer yellow bag warning of the highly toxic nature of the drug: administered outside the vein this particular substance can be fatal and so I was advised to let the nurse know immediately if I felt any pain or discomfort at the injection site.

Seeing the anxious look on my face, the nurse delivered one of the best jokes I have ever heard: “Don't worry; I won't kill you. The paperwork's horrendous". I felt immediately better for the laughter that could not help but follow this invigoratingly honest statement.

Next came doxorubicin, administered from a large syringe into the cannula. This drug, which can have terrible effects upon the heart, is a pale pink colour and so resembles diluted Campari. Appropriately enough it is derived from microbes found in Italian soil in the 1950s. As well as being toxic, it has the added effect of turning one's pee pink for a while.

Last of all came two fat syringes of cyclophosphamide, which would be the main cause of my future hair loss. This was the only one of the cocktail of drugs that caused a nearly immediate side-effect, namely a feeling in the bridge of my nose as if I had inhaled pepper accompanied by lightheadedness. These feelings passed off after about ten minutes, which was a relief as, although mild, they were disconcerting.

After about half an hour I felt ready to be on my way, the whole experience having left me somewhat tired and queasy. I had to take with me a bulging plastic bag full of what were now, to me, freebies: mouthwash; prednisolone to be taken for a further four days; anti-fungal capsules; three days' worth of ondansetron to keep nausea and sickness at bay; another anti-emetic—metoclopramide—to be taken for the rest of the treatment cycle and with the added benefit of mitigating the gastric reflux that could arise from prednisolone; laxative sachets (orange flavour, what else?) to be mixed with water to counteract the constipation that would be a side-effect of the anti-emetics. To guide me through this pharmaceutical maze, my key worker very helpfully prepared a chart showing the various drugs, dosages and frequencies of administration.

As the evening progressed I was conscious of a growing but bearable feeling of nausea. Like any normal person, my deepest apprehension about chemo hovered around how ill it would make me feel and so I was quite glad when the time came for me to take another anti-emetic to keep sickness at bay.

I had difficulty sleeping, not least because of the stimulating effects of prednisolone, and so I sought solace in music and in one of the recordings which my friend had kindly lent me a few days earlier: solo violin music by Bach coupled with some of his vocal motets. The rise and fall of the melodic lines were heart-rending and sublime and tears came. I gave thanks for the beauty of the music and the feeling of peace and rest that duly descended.

Johann Sebastian Bach (1685-1750)
Painted by Elias Gottlob Haussmann in 1746, the all-time mightiest man of Western music is shown holding a modest sample of his vast output.

A "forensic reconstruction" of the head of JS Bach by Caroline Wilkinson,
who worked from the Haussmann portrait and from a metal cast of the great man's skull.
What do you think? This seems a kind face...

Reflection, research and action

Although, as you will have seen from my account of what happened on 5 October, I made up my mind to proceed with a more robust regime of chemotherapy than I had started on, the deeper recesses of my mind still resonated with uncertainty. That is why I found myself awake at 5:30am on Wednesday 6 October, trawling the Internet for information on the possible risks of acute myeloid leukaemia associated with the treatment I was about to receive. Will I never learn? I am not scientifically trained and so, in trying to seek out such information, I was like a blindfolded man in a cave trying to catch tiny shrimp from a pool he had yet to find and using a net with a hole in it. After some time I found myself sufficiently reassured to be able to go back to sleep for a little while, but I would not presume to share what I discovered, as the purpose of this account is to describe a personal journey rather than to issue authoritative pronouncements on science that I am not qualified to make.

Once up and about I decided to gather some moral reinforcements and went to have a chat with my neighbour, who is a Macmillan nurse. As well as giving her the latest medical news, I asked her how to set about getting community-based support. Her advice was to go and see my GP. Amazingly, I was able to secure an appointment that very day with the doctor of my choice and this bolstered the sense of rightness I felt about this course of action (although this thinking is not grounded in logic, I readily concede).

To see this particular doctor is always a pleasure, as his manner is consistently calm even if he is discussing uncomfortable realities. Another bonus is that he has a fantastic collection of colourful turbans. The one he wore on this particular day must have been so dazzling that I have forgotten what precise hue it was. This was in fact the first opportunity I had had to see him since my diagnosis, many of my previous dealings with him having arisen from rather more trifling concerns than those now presenting themselves. He readily understood my need to access additional support in view of the fact that I was about to experience a more demanding chemo regime and he agreed to make the necessary referral to the local hospice where Macmillan services were based.

The trip to the surgery had the added benefit of giving me a walk there and back of around two miles and I was able to stride along at quite a brisk pace. Once home I gave my news to one of my closest friends over the telephone and to other friends by e-mail.

After all this energetic communicating, I felt buoyed up, but still quite emotionally vulnerable. I have often found cooking a very potent displacement activity and so I made a lamb mince curry for the family, later distracting myself still further by ordering from the trusty Amazon a total of four books: single-volume histories of the two world wars, together with “Tommy" by Richard Holmes, a much-respected account of life on the Western Front, and “Overlord" by Max Hastings, a study of the Normandy landings and their aftermath.

The final weapon in my armoury against the onslaught of gloomy thoughts and preoccupations was the return to the television that evening of that modern equivalent of the Victorian freak show known as “The Apprentice", starring the prickly teddy bear of business himself, ennobled since the last series and now therefore known as Lord Sugar. I duly armed myself with a collection of virtual rotten fruit to hurl at the participants as soon as they uttered their inflated pronouncements about their skills and achievements.

Lord Sugar of Nascent Beard (for it is he),
caught in the act of firing someone.

These various tactics to dispel brooding seemed to have worked because on Thursday 7 October I faced the day rather tired but in a calmer frame of mind. This state of equilibrium was however threatened by the cheeky black cat Frida, who, you will recall, belonged to a neighbour but who had shown increasing signs over recent weeks of wanting to adopt us. The crafty feline had identified the bag in which our own cat's food was stored and lacerated it in several places, eventually making a whole large enough to access what were its, no doubt to her, scrummy contents. Such behaviour was beginning to spark a change in our attitude to this otherwise likeable and beautiful creature, as she was showing every sign of being more intelligent than our own pet and therefore as constituting something of a threat to her. We were not yet so annoyed however as to give Frida her final marching orders.

I had lunch at our local cafe with a friend from church who was beginning to support me with visits, conversation and prayer, as well as loans of CDs from his ample collection of classical music. He cautioned me against throwing myself too readily into “the WM Cause", saying that this particular time was one of regrouping and concentrating on my own existing interests, rather than for being pressurised into others' agendas. I valued the kind intent behind this advice, believing in my quieter moments that there would be ample time to be more involved in raising awareness of this rare condition and thus in helping to generate more funds for research. I cannot however ignore the white flame burning deep inside me, believing firmly that I have a responsibility to play my part in the battle against my disease.

In the evening I prayed with my wife and son about the treatment that would begin the next day. The phrase from Scripture that came to mind were “underneath are the everlasting arms", words of assurance given to Moses as he faced various dangers.

Moses, as played by Charlton Heston.
A rather fuller beard than Lord Sugar's, but probably not his own.

Give it the CHOP

Tuesday 5 October 2010 was to be another milestone in my experience and understanding of this disease and its treatment, but in the small hours of the day, as I lay awake listening to iTunes U on my phone, I had no inkling of this. Instead I found myself pondering the distinction (and maybe at the same time the complementarity) between neural events and mental events and wondering whether we would ever fathom the mystery of consciousness, how it is that we experience and interpret being alive.

When however I arose from my bed at a normal time, such pretentiousness was driven from my mind (whatever we mean by such an entity) by the persistent feeling of dizziness hanging over from the previous day. Mind you, I was not so much in a whirl that I was unable to continue my rather disorganised attempts at maintaining physical fitness and so it was that I managed 20 press ups.

My brother arrived in due course to take me to my regular appointment with Dr M, the haematologist. While we waited for the usual blood samples to be taken and for me to be called in to see the doctor once these had been analysed, my brother and I chatted merrily, as we do, about our many matters of mutual interest. Not least among these is the state of the NHS, in which my brother worked for many years as a GP and which he now supports as an independent consultant.

In due course, the phlebotomists and pathologists having done their work on the samples, I was called in to the doctor's office and my brother came too. I had come prepared to ask about this mysterious substance, rituximab, but I found the doctor ready to head off my question at the pass. How could I forget she was the physician-in-charge? She told me that she had, given the rarity of my lymphoma, consulted a leading specialist in the condition, based at University College Hospital (UCH), one of the London teaching hospitals. The expert, who had also offered to see me in due course, had indeed recommended treatment with rituximab, but this needed to be combined with a chemotherapy regime known as CHOP, named, as such regimes are, by the initial letters of their constituent elements. The resulting concoction, to be delivered every 21 days (to allow for recovery of strength) was known as R-CHOP and offered a better remission than the relatively simple pill-based treatment I had so far been receiving.

So I was being offered the baby and the bathwater, but what was in the water? You can find a description of R-CHOP here, including a list of side effects. The most obvious ones that occurred to me at the time, and which Dr M confirmed, would be nausea and possible vomiting and hair loss, although I was assured that anti-emetic drugs were now very effective and would be included in my treatment. Going bald for a while was just something that I would have to accept, although I found myself getting quite emotional at the prospect of it, I think because it would mark me out to all the world (okay, that's an exaggeration) as a cancer patient.

The periwinkle, a pretty little flower that packs a punch.

Vincristine, a highly toxic substance and potentially lethal if administered outside a vein, derives from this plant and is one of the elements of CHOP (Vincristine was originally known as Oncovin, so that is where the "O" comes from: these chemo acronyms are sometimes a bit of a stretch—wait until I introduce you to BEAM!)

I would have to wait for the rituximab. There were two reasons for this: the first was therapeutic; the second was economic, in that The National Institute For Clinical Excellence (NICE) had not so far found it in its steely heart to admit this well-known and effective combination of human and mouse protein into its approved armoury of treatments for Waldenström's Macroglobulinaemia. The doctor would therefore have to apply for special funding, either from the local PCT (itself due for the chop under NHS restructuring plans) or from a special £50 million fund set up by the Government for cancer treatment in London. She was optimistic that funding would be forthcoming, but rituximab would not be added to my treatment regimen until the third or fourth round.

When however the good doctor produced the yellow consent form for me to sign, she placed a white sticker on it on which was set out a list of side effects, the last one of which alarmed me even more than the others: “increased risk of leukaemia". Suffice it to say that I did not feel inclined to sign the form there and then. Dr M explained that the risk was of acute myeloid leukaemia and was in the region of 5%; also, my existing disease would be a complicating factor in any treatment of AML. She emphasised that the treatment regime recommended was most powerful and effective but conceded that the leukaemia possibility was “the sting in the tail".

I needed time to reflect and was, more than ever, grateful for the presence in the room of my medically qualified brother. It was agreed that he and I would go away and reflect, have some lunch and then go back to see the doctor in the afternoon.

As on the day of my diagnosis, my immediate need was to get out in the fresh air and be under the naked light of heaven. So it was that I made my way outside the hospital entrance to the spot where I had felt the clasp of despair after hearing for the first time that I had an incurable cancer. My emotions on this later occasion where a muted version of that panic but threatened to drag me down once more into a bleak darkness. It was at this point that I felt the benefit of my previous experience and knew that I had acquired some resilience over the few brief weeks since my diagnosis.

I first telephoned my wife, who was quite clear on two things: first, that the treatment recommended was a good idea and second, that she would support me through the rigours of the regime. I next rang Father Milligan, the vicar for whom I work, to inform him that I could be about to embark on a course of treatment that would keep me away from the office for some months. This was bad news for him, but he was gracious and compassionate, as always.

Over the course of a simple lunch from the hospital café, my brother watched supportively as I talked myself into accepting the recommendation of, now, two specialists. There was just one question that I needed to put to Dr M before my mind could be finally made up. Back in her consulting room after a little while I asked her whether the risk of leukaemia also attached to my current treatment. When she confirmed that it did, I signed the consent for R-CHOP.

Treatment would begin the following Friday, 8 October but first she needed to record my weight and height as the doses of poison would be tailored to these. She also took me to meet the nurse in charge of the Haematology Day Unit next door. I was struck immediately by the positive atmosphere among the various patients distributed around the two circles of comfy chairs, each one attached to a drip, some receiving transfusions of blood, others doses of clear liquid, yet others resting after treatment. I was to become very familiar with this room—its comforts and trials—over the course of the next four months, but for now I returned home in something of a daze.

As it happens, the delay between blog time and real time has caused the writing of this entry to coincide with my first appointment with Dr M following my final dose of rituximab on 11 February. I am therefore going to fast forward to today and tell you that indications are that treatment has been successful: my haemoglobin now stands at 12.1 (grams per decilitre), whereas at diagnosis last September it was 9.8, so I am markedly less anaemic, with the prospect of further improvement as the depressive effects of chemo on normal cells ebb away. The production of ImG paraprotein (that was silting up my blood vessels) has also markedly declined. More unpleasantly, I will be having a further bone marrow biopsy (BMB) on 28 February to see how much the population of rogue B-lymphocytes that were infesting the hollows in my bones has declined. There will be another CT scan a couple of days after that to assess the reduction in swelling of my lymphatic tissues, notably the spleen.

Dr M wants to see me again towards the end of March. At the beginning of March I will be going, armed with BMB and CT results, to see the expert at UCH, who has something dramatic planned for me later in the year. This will in fact be my second visit to UCH, but the account of my first visit as well as of the highways and byways of R-CHOP and other adventures between October last and today will follow in the normal sequence of blog time.

I am hoping that I will be able to bring the timing of blog and actual events closer together over the course of the next few weeks, but the return to normality and the steady return to my day job may just get in the way a bit. We shall see, but thanks for being with me on the journey thus far.

A scene from Aesop's fable of The Mouse and The Lion, another instance of how a small entity comes to the aid of a larger one. You can find the story here

Rituximab is an assemblage of human and mouse protein that targets a particular marker on WM lymphoma cells and wipes them out. Respect the mighty mouse, then.

Every little helps

Now that my computer has been rescued from the flames in real-time, we can revert to blog time, which at this particular point is running in October 2010.

On Sunday 3 October my wife and I went to morning service at church, where infant baptisms were taking place. It is always a joyful occasion when parents bring their new or nearly-newborn to be introduced to the local church family and invite that family to support and encourage them and their children in their walk of faith. Babies and young children are naturally bearers of hope and on these occasions goodwill, shared joy and laughter predominate, with the parents and godparents in their best outfits and the babies (sometimes with older, cheekier siblings in attendance) all fresh and new. For the clergy officiating there is always the mild peril that one or more of the children will act up, but this particular service passed off without incident.

After the service I sat in the recently built extension to the church, which abuts the eastern wall and which is filled with natural light streaming through the windows in its sloping roof. The extension was not yet fully commissioned, but would in due course house the creche where parents preferring to give their whole attention to divine service can leave their children to play happily (or usually so).

Here I got into conversation with a member of the congregation I have known for quite a few years and who grapples with a serious and long-standing medical condition. On this particular day I was profoundly pleased to see him looking really well and with more energy than usual. He told me, with a broad smile on his face, that he was feeling the benefit of new medications. The change in him was so evident that I was able to rejoice with him and also to take some encouragement for my own situation from the knowledge that medical science does not stand still.

We went home to a delicious lunch of salmon and roasted vegetables. Although I felt tired in the afternoon I managed to do 20 press ups. Would I be able to keep up this good work?

On the following day, Monday 4 October, feeling shaky, I was initially not at all sure that the good work was at all within my grasp. Nevertheless I persisted and managed to perform 20 press ups as well as to hold a front plank position for one and a half minutes.

Plank exercise (basic, front position)
Good for the abdominals and developing core strength, the latter so important for good back health and stability

I followed this up with the assault course otherwise known as “shopping in Tesco". Mindful of good diet and the need for antioxidants I bought some chocolate with an 85% cocoa content.

These various exertions had the desired effect on my motivation and I was able to spend a good part of the day in personal administration. It is a bare statement of fact and no false modesty to say that my financial interests are not extensive. Nevertheless I find that, even with—or perhaps because of—online banking, security card readers, passwords, PINs and the like, basic money management takes an inordinate amount of time.

Supper consisted of a good salad with jacket potato, baked beans, grated cheese and tuna mayonnaise, food whose simplicity always appeals.

The following day I was due to see the haematologist for the next of our now regular appointments. Previously unbeknown to me, my wife had been doing some more reading up of her own and we had both come across the word “rituximab", an intriguing substance which seemed to be having good results in the treatment of various lymphomas, including mine. We agreed that it would be a good idea to ask the doctor whether this agent could have any role in my treatment. It would however turn out that rituximab, far from travelling solo, would bring along some fellow passengers as well as a fair amount of baggage. More will be revealed soon.

George Osborne, now Chancellor of the Exchequer,
In blog time he has just made an important announcement about welfare, but here looks a bit of a plank himself.
Let's hope he has learned a bit more about the whys and wherefores
of welfare since his days in the Bullingdon Club.

Short intermission continues...

Real time will stay aligned to blog time for a while as I let you know what happened today, Monday 7 February 2011.

You will remember from my last entry that my laptop, whose hard drive bears all my notes and most of my pictures for this blog, began behaving oddly a few days ago. In the hope of a remedy for its ills I took the machine to the Apple Store in Kingston today for an appointment with an Apple "genius", the company's title for an employee designated to answer all manner of technical questions.

The Kingston store must be one of the smallest in Apple's growing empire, contrasting with the Covent Garden store, which I visited a few weeks ago and which is the largest in Europe, all cavernous expanses of high-tech-trendy exposed brickwork, glass staircases and truckloads of beautiful machines to try out. Kingston's little Apple by contrast is a single-fronted unit in a shopping mall but nevertheless manages to accommodate a good quantity of enticing hardware, software and accessories, as well as a fair number of staff, all wearing the appointed blue long-sleeved teeshirts bearing the white Apple logo. Some of them wore hats, but there were no geeky beanies in evidence. The genii were clustered behind the Genius Bar at the rear of the store, where I made myself known to a young woman who kept the list of appointments on an iPad and who duly registered my arrival. She later suggested that I take a seat as the genii were working through a busy schedule and consequently running slightly late.

The appointed genius did not keep me waiting too long however and I was duly ushered before him. Diagnosis was swift and certain after he had run a test programme stored on the external hard drive that he had swiftly connected to my machine. The problem was indeed the graphics chip housed on the motherboard, an item produced not by Apple but by a company called (without apparent irony) Nvidia, the fault being a known issue and the subject of some discussion between the two companies. I would of course have been delighted to have been offered a brand new and consequently faster machine (like the couple talking to the next genius along) but my bespectacled genius was able to offer a completely free repair, the only tiny wriggling fly mired in the sticky ointment being that the back-room repairing genii had such a large workload currently that it could be as many as ten days before I would be reunited with my computer, although this would be "unlikely".

The due paperwork having been printed and signed I left and returned to my car, my case now lighter than when I had arrived.

The genius had not been wearing a hat but sported the most a la mode spectacles imaginable, with black lettering taking up the whole depth of the creamy white side arms, a bold statement crediting Georgio as the design house responsible.

STOP PRESS: As I typed that last sentence on my phone, the same phone took a call from the Apple Store telling me that my machine was, beyond wildest expectations of me and genius alike, now repaired and ready for collection. Normal blogging should therefore be resumed sooner rather than later. Not a groundhog day, then.

There will now be a short intermission...

In blog time we have reached early October 2010, meaning that there is now a four-month gap between event and record. Something has however just happened in real time that means I must once again, for a brief moment, bring blog time and real time together.

Yesterday, that is to say Friday 4 February 2010, the previously blameless and perhaps even long-suffering laptop on which I have hitherto composed this blog began to exhibit signs of serious illness. The screen showed patches of a checkerboard-like pattern that began to overtake normal patches. I rebooted the machine, whereupon the screen became wholly infested with the pattern and stalled irretrievably in the early stages of the startup process.

This morning I took the computer the mercifully short distance to the nearest repair shop although, having done some web research (on my phone) the previous evening, I already had a pretty good idea of diagnosis. The problem related to the graphics chip, located on the motherboard, meaning that the said board would most likely need replacing. I did however find a YouTube video of one enterprising young man who had persuaded the motherboard of his similar computer to function again after wrapping it in foil and running a paint-stripping heat gun within inches of its defective circuitry.

Lacking however his daring, tools and, perhaps crucially, his capacious skateboarder's beanie, I felt it best to rely on the skills and experience of the young men in the repair shop, one of whom now stood behind his counter, tellingly wearing a beanie of similar colour and dimensions to that of the eager geek in the video. The prospective repairer, having listened to my sad tale and switched my computer on, confirmed the diagnosis.

Repair, he said, would be possible, but expensive and his general recommendation would not be to go ahead with it. Motherboards were pricey items to replace, even before the addition of labour costs, but, more importantly for assessing whether repair would be worthwhile, any replacement could exhibit the same fault, perhaps even after a very short time (yes, minutes were shockingly mentioned). The fault lay with the chip manufacturers, who had happened, for reasons unknown, produced a particularly suspect piece of kit that had found its way into laptops built around four years ago.

When I mentioned the heat-gun workaround, he said that they no longer carried this out, as it was in turn uneconomic and only met with success in about two out of ten cases.

His advice was to go to the nearest gleaming Apple Store and cast myself on their mercy, since he believed that there may have been legal issues with the chip makers, leading to a product recall.

Upon my return home, my laptop case as heavy on the return as it had been on the outward journey, I made an appointment to take the case its contents and me to the Apple Genius Bar this coming Monday. I will let you know what happens, but the polite young man I spoke to indicated that "options" would be discussed.

Why did I feel relatively untroubled by this irksome and potentially costly business either yesterday or today? On a simple level, I knew that most of my data was safe as I had made a complete backup to a separate hard drive not too long ago, although my most recent notes for this blog will most likely have been lost. This translates to the philosophical consolation offered by the observation that what matters about a computer is not its physical mass, its circuits or any other aspect of its hardware, but what is engraved (if that is the right word) on its hard drive, in other words data. It is these data that embody and give expression to our thoughts, memories, aspirations; the fruits of our work, our play, our time. Provided those are preserved in one or more locations, we have not really lost much when an individual machine dies, however much we may relish the design, ease of use, maybe even the beauty and elegance of the device.

There was a further reason however for my relative peace of mind, which was that yesterday evening I was aware of feeling more my old self for the first time in months. I look forward to sharing the journey to this point with you. Now where did I put my notes?