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The Souvenir

July 9, 2019

By Jean-Honoré Fragonard

This low brow art lover prefers figurative to abstract, uplifting to depressing, sexy to dull, and can’t cope with too much at once. So for my first visit to the Wallace Collection (click here) I went straight to this. A young woman carves her lover’s initial into a tree. His letter lies on the ground and her faithful spaniel looks on. A New Yorker piece (click here) about the film maker Joanna Hogg and her latest film, The Souvenir, had piqued my interest. It’s tiny, much smaller than the more famous Swing in the adjacent room, but I wasn’t disappointed.

Jim Thornton

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Field Flowers

June 10, 2019

By Louise Glück.

James Wood cited this poem in his review of This Life: Secular Faith and Spiritual Freedom by Martin Hägglund (New Yorker, May 20th, click here).

In that book Hägglund, a Swedish philosopher and literary theorist, suggests that even religious people don’t really want to live for eternity; limited time gives life value. He cites CS Lewis’s memoir A Grief Observed about his wife Joy Davidman.  Her deathbed words, “I am at peace with God”, were directed to the chaplain, not Lewis, who wrote, “She smiled, but not at me. Then she turned towards the eternal fountain.” Hägglund argues – he’s also a deconstructionist – that Lewis knew, “There is no CS Lewis for Joy Davidman in heaven and no Joy Davidman for CS Lewis”.  Our short lives are not just the only ones we will have, but the only ones we should want. He may be right.

Unfortunately, according to Wood’s review, Hägglund goes on to argue that this means we should follow all sorts of Marxist and anti-capitalist political nonsense.

Glück’s poem, narrated from the perspective of a flower, doesn’t make the same mistake.

Field Flowers

What are you saying?  That you want
eternal life?  Are your thoughts really
as compelling as all that?  Certainly
you don’t look at us, don’t listen to us,
on your skin
stain of sun, dust
of yellow buttercups: I’m talking
to you, you staring through
bars of high grass shaking
your little rattle – O
the soul!  The soul!  Is it enough
only to look inward?  Contempt
for humanity is one thing, but why
disdain the expansive
field, your gaze rising over the clear heads
of the wild buttercups into what?  Your poor
idea of heaven: absence
of change.  Better than earth?  How
would you know, who are neither
here nor there, standing in our midst?

Louise Glück.

Lahn canoeing – 1

February 28, 2019

Canoeing beside the Camino de Santiago

Wetzlar to Limburg (Click here for Limburg to Lahnstein)

The Lahn valley was once an important wine growing region. In the 17 century vineyards extended as far upstream as Marburg. Today, only two commercial ones remain, Obernhofer Goetheberg and Weinährer Giebelhöll, although abandoned ones are still visible at Dausenau and Nassau, and enthusiasts have recently been replanting at Runkel.

wetzlar to lahnstein camino

The distance boards on the bank measure from the historic border between Prussia and Nassau, a few km downstream of Giessen, but the river is canoeable from Marburg, 37 km above that point.

Click here for another account of the same trip.

WARNING – We made this trip in May 2015, and although I composed this blog the following winter, for some reason I never posted it. Perhaps I wanted to check the mileages or some other detail. Now I’ve forgotten. Please forgive errors.

9.5 km – Camping Wetzlar (click here). Car park and easy launch spot.

wetzlar campsite launch spot     DSC_0304

10.5 km – Railway and Wolfgang-Kuhle-Strasse bridges adjacent to each other.

DSC_0310    DSC_0336

11 km – The beautifully curved E44 bridge.

DSC_0338   DSC_0335

11.4 km – Brukenstrasse bridge. Weir below.  Canoe shoot right. Gentle slope. Easy.

DSC_0313   DSC_0316   DSC_0314

11.8 km – Arno Riedl pontoon footbridge (1985). Sculpture park, Old Town and Cathedral (Dom) left.

DSC_0320    DSC_0326      Wetzlar_Dom

The Cathedral of our Lady, at the start of the Lahn Camino de Santiago, has a statue of St James on the left of the door of the south tower.  The first stage of the camino heads south away from the river before turning west at Kirschenwaldschen to pass through  Nauborn, Laufdorf, and Solms-Oberndorf-Braunfels before rejoining the river at Weilburg. Generally the bank of the river was boggy and difficult going so pilgrims kept to higher ground.

Wetzlar to Weilburg camino

12 km – Old bridge with weir immediately after.  Portage on rollers right. Medieval bridge believed to have been built late 13th century. Defaced by fountains just below and a garish blue puppy dog statue on the bridge.  Don’t miss Restaurante al Camino (click here)

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DSC_0331   DSC_0343        DSC_0346

12.1 km -Road bridge

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12.6 km – Suspension footbridge Muhlegraben

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12.9 km – River Dill enters right

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13.8 km – Railway bridge

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16 km – Weir left. Lock Altenburg right channel.

schleuse altenburg     DSC_0362    DSC_0363

18.7 km – Albshausen left, Oberbiel right. River splits into three channels. Right to weir. Middle to hydro electric power station. Left to lock channel.

19 km – Oberbiel lock

DSC_0366    DSC_0373 DSC_0374

20 km Niederbiel lock.

niederbiel lock

Between here and Selters the river flows well with numerous tiny rapids and riffles.

20.5 km – L3283 bridge

DSC_0376

23.5 km – Lahntours camping right (click here).

24 km – Footbridge and 12.8 km – E44 bridge

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25 km – Brukenstrasse bridge. Leun right.  Some little rapids below.

DSC_0386    DSC_0384

The river leaves the Hessian mountains enters the Rhenish slate massif through which it will pass for the rest of its course.

26 km – Camp right after Leun  http://www.stell-und-zeltplatz-lahnwiese-leun.de/ Bivouac German style; toilet, shower and someone comes round to collect the fees about 6pm.

lahn Leun campsite

28 km -Railway bridge

railway bridge below Leun

29 km – E44 bridge

e44bridge2

30 km – Biskirchen right. Look out for turtles

lahn biskirchen

34 (check) km -Sewage pipe bridge

IMG_2432

35 km Selters left followed by

view from bank at selters

35.9 km – Lohnberg footbridge

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36 km – Lohnburg weir and mill right. Lock left

Lohnburg weir and mill   lohnberg mill   Lohnburg lock

38 km -Ahausen bridge

Ahauser weg bridge    Ahausen bridge

39.5 km -Railway bridge. Weilburg right

railway bridge Weilburg  weilburg lahn

From Weilburg the camino follows the south bank for a mile or so before leaving to run over higher ground to the southwest until rejoining at Vilmar.

weilburg to limburg   weilburg to zeil camino

39.7 km – Weilburg tunnel left.  The distance markers on the bank follow the main river course.  So you save about 2km paddling distance by going through the tunnel.  The tunnel is large and airy and about 200 metres long.  The far end is visible as soon as you enter, albeit partially obscured by the lock gate at the exit. There is no landing stage above the lock so you have to climb directly up a metal ladder to work the gates. Fine for two in an open canoe but would be tricky for a single person in a kayak.

weilburg tunnel entrance   lahn tunnel entrance   lahn tunnel exit

Ignore main channel under 456 road bridge to weir, castle, old Lahn bridge.  Beyond that steel footbridge

Weilburg Oberlahnbrücke   weilburg weir castle and bridge     weilburg steel footbridge

41.5 km – Emerge from Weiburg lock at downstream end of the tunnel

ship and railway tunnel exits below weilburg

Bivouac campsite right bank opposite the tunnel.   There’s said to a plaque on the left bank marking the site of the crash of Zepellin Z II on 24 April 1910 (more here). I couldn’t see it from the river.

42247181  z2_web_a  z2_web_b

44 km – Footbridge (Odersbach right, Kirschofen left) followed by Camping Odersbach right (click here)

IMG_2436   odersbach reception   Camping-Odersbach (4)_large

45.5 km – Kirschofen weirs left (an unusual pair of weirs in series). Keep right for Kirschofen lock

kirschofen weirs

48 km – Camping Graveneck left  http://www.camping-graeveneck.de/ Lovely site adjacent to old railway tower and sidings.

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DSC_0409      DSC_0399   DSC_0403

48.5 km – L3452 bridge

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50.5 km – Furfurt town left. Followed by Furfurt weirs, another double set, left.  Furfurt lock right.

furfurt weirs   DSC_0412   DSC_0415    DSC_0414

Small rapids below Furfurt

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42.7 km -Bridge.  Aumenau right.  Access right.

DSC_0427        aumenau lahn   aumenau from the cycle track

44.6 km – Railway bridge

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47 km – Arfurt right

arfurt church

48.2 km – Camping Runkel right a bivouac site. Don’t confuse with the much larger Campingplatz Runkel near the mouth of the river at Lahnstein.

62.5 km – Unica quarry right, Marble bridge.  Followed by Vilmar left. Marble from the abandoned Unica quarry, now a museum (click here) was once a popular ornamental stone. It was used in the Hermitage in St Petersburg, the Kremlin and the lobby of the Empire State building

DSC_0439   DSC_0440   Villmar marble bridge

62.8 km – Weir. Power station left. Lock right.

DSC_0445    DSC_0449

The camino joins the river at Vilmar, and apart from a couple of short cuts follows the bank more closely now.

Vilmar to Diez

61.2 km – The precipitous limestone cliff left is topped by a stature of King Konrad 1st

DSC_0456     DSC_0461

65 km – Runkel. Slipway right. Wine making in Runkel, which had gone on for many hundreds of years, ended in about 1930. Over the last few years a group of enthusiasts have attempted to revive it. They’ve planted a vineyard  on the slopes directly opposite the campsite, and have produced a few vintages of Runkeler Roten or “Runkel Red”. More here.   To be honest I couldn’t see the vineyard at all in 2016.

Runkel red vineyard   Runkel red label

65.2 km – lock right. Weir left under Runkel bridge. The camino passes through Runkel

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53.5 km – Camping left after the bridge (click here). A popular canoe hire start and finish point.

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53.8 km – Steedener bridge

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55 km – Railway bridge

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59.2 km – L3448 bridge. Dehrn right.  Marina right

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72 km – Burg Dehrn right

IMG_2452     IMG_2453

60.9 km – Kurt-van-der-Burg footbridge 1989. Dietkirchen, dominated by St Lubentius Basilica on the limestone cliff right. Site of a ferry since 11th century.  The small vineyard on the southern slopes below the Basilica, planted in 1998 makes Dietkircher-Lubentius-Ley, a sacramental red wine.

DSC_0496    DSC_0502  DSC_0506

IMG_2454 dietkirchener lubentius ley    DSC_0513

61 km – Emsbach stream joins left. The site of an ancient ford.

62.6 km – Intercity railway bridge followed by N3 motorway bridge, currently being widened.

DSC_0526   DSC_0532

 

64.6 km – Limburg. Cathedral left. Camping right (click here). Alternatively keep left and by the no entry sign, left bank  just above the weir, Limburg canoe club allow camping.  Small site, best to ring ahead.

DSC_0541   DSC_0540   DSC_0545

The camino which has been following the river on high ground to the south descends the hill in a zig zag and then goes straight up to the cathedral.

Keep right for lock channel.  Left another set of two weirs in series. Followed by Limburg bridge

Limburg 2nd weir      DSC_0547   DSC_0549

65 km – Limburg.

limbur to obernhof

For Limburg to Lahnstein click here.

 

Waterbirth videos

February 7, 2019

Propaganda

At work I steer clear of birth underwater. I disapprove, but disapprove even more at obstetricians interfering in normal birth. If asked, I give advice in the normal way but, despite practising obstetrics for almost 40 years, I’ve never witnessed one in real life.

Some enthusiasts think that if people like me did, we might be converted. Recently on Twitter, Milli Hill, a journalist hoping just that, invited a few male obstetricians to watch this waterbirth video (click here).

       

My reply that “birth videos aren’t my thing”, was a clumsy attempt to forestall an argument, but it and a couple of other similarly lukewarm responses seemed to have the opposite effect.

Discussion about water and home birth got conflated, obstetricians were accused of defensiveness, the patriarchy came up, someone shared an emotional blog about a stillbirth at home, and someone else talked of throwing a grenade into the birth debate.

       

Poor Milli was both disturbed at our original refusal to emote, and shocked at the reaction to our refusal. I lay low.

     

But the central issues seemed to be lost in the debate, so as the dust settles, let me try and explain.

Why birth videos in general are “not my thing”

I’ve no issues with home birth, but still don’t watch dry land home birth videos. Hospital dramas and documentaries leave me cold. It’s not a control thing. It’s not the patriarchy. I rejoice when any woman gives birth safely without help. But caring for birthing women is my job. And for every birth attendant that means worry. We’re paid to appear calm and professional on the surface, but we’re also paid to check, anticipate and plan for trouble. I’d go so far as to say that if birth attendants don’t find their job a bit stressful they’re doing it wrong.

I don’t just mean clinical worries about things like cord prolapse and abruption.  Of course we worry about those things. But we should, and usually do, worry about everything else as well.  A good home midwife, calming the partner of a woman in transition as dawn comes up after a long labour, also remembers that the rush hour traffic will make transfer slower if needed. A good obstetrician, encouraging a woman to persevere with an attempt at a vaginal birth after Caesarean, also remembers the twins next door, and that the night registrar has called in sick and the locum is new. Others may view birth videos with pleasure but to me they’re a busman’s holiday.

But why couldn’t I have faked it for Milli? Said: “How lovely!” and moved on. That’s because it was birth underwater.

Why waterbirth videos in particular

I have a visceral dislike of birth underwater. It’s a risky, almost evidence-free experiment with no underlying rationale (click here). Perhaps I’m over-reacting, but it’s one of the few things that makes me crosser than Brexit!

And the video is propaganda. Not just the editing, soft music and beautiful photography, although there’s plenty of that. But the implication that a difficult first birth has been converted to a beautiful second one by being at home, in the pool, with family, friends and first child in attendance.

We aren’t told much about the first birth but it seems reasonable to assume that it had ended via the vaginal route. Second births in such cases are almost invariably easy. Yes the midwives were wonderful, home was a perfectly reasonable place to have the baby, and it was correct to not interfere, but the baby would have come just as easily on dry land, with no risk of water aspiration, intoxication or water-related infection.

I’m sorry Milli

If I’d been quicker witted, I’d have watched the video and made an intelligent comment on the calm, efficient and discreet way the midwives went about their safety-critical duties – monitoring the water temperature, auscultating the fetal heart, checking for bleeding while the mother bonded, and that the clamp was correctly placed before the father cut the cord. See, I did watch it! All that impressed me a lot. I am delighted that such skilful midwives looked after her.

But I have to be honest. I didn’t enjoy it. I don’t think birth underwater is wise. And this sort of video isn’t going to convert me.

Jim Thornton

 

 

My C-Stich prediction

January 31, 2019

No net effect

The C-Stich trial is testing the hypothesis that, among women with cervical insufficiency, monofilament nylon cerclage sutures reduce pregnancy loss compared with braided tapes (click here).  I’m not closely involved and rarely perform cerclage, but Nottingham is a recruiting centre, so I do what I can.

I confess to being rather lukewarm. Surely the bigger methodological issue is “buried v not buried”, and the more fundamental question whether, and in what situations, cerclage does more good than harm. But to their credit the C-Stich investigators are planning to tackle the latter in their next trial C-Stich2.

Meanwhile my not very exciting prediction is here. Although I doubt there will be a difference between the materials, I would not be unduly surprised to be wrong. There may be less infection around the monofilament, but sutures can also come undone, which may be more likely with monofilament. The result could go either way.  I guess that why they’re doing the trial.

The trial is recruiting nicely. The original sample size of 900 participants was increased to 2050 last year because the pooled event rate was turning out lower than expected. That is good research practice. It will at least allow the best suture to be used in C-Stich2, so that if that trial is negative, enthusiasts wont be able to later claim it was because “they used the wrong suture”.

But if one material turns out better than the other, that would emphatically NOT be evidence that cerclage is better than nothing. It’s just as likely that the other is less harmful.

Jim Thornton

For more on AsPredicted.org click here.

My PRISM prediction

January 28, 2019

My first public trial result prediction on AsPredicted.org

PRISM is a randomised trial comparing progesterone or placebo for the treatment of women with a threatened miscarriage. i.e. vaginal bleeding but the scan shows a heart beat, so the fetus is alive. Details here.

In July 2018, the chief investigator Arri Coomarasamy rang up to tell me the result in confidence.

It was a Sunday morning, I was eating my breakfast and tapping out a blog post criticising the way an education trial had been interpreted (click here).  The post sank without trace – one “like” and no comments – but Arri’s call fired me up.

As he swore me to secrecy, I said:

“Not another word Arri. I’m going to predict the result on a date-stamped website, send it to you and call you back. Then you may tell me.”

Click here to read my prediction. Dates are in US format; Month/Day/Year.

Or if you prefer, guess what the arch sceptic, who believes the only thing maintaining interest in progesterone is it’s name (click here), predicted?

The trial publication will appear soon. You can see if Jim was right.

Jim Thornton

For more on AsPredicted.org click here.

My EPPPIC prediction

January 27, 2019

Progestagens won’t work. If they appear to in a subgroup, test in a new trial

Many people are sceptical about progestagens to prevent pre-term birth. Although necessary to maintain pregnancy, no deficiency syndrome has ever been described, early trials were of poor quality, and prospectively registered trials were all, bar one, negative for their predefined primary outcome (click here).

Despite this, enthusiasts have sliced and diced – singles/multiples, progesterone/medroxyprogesterone acetate, short cervix/positive fibronectin, membranes intact/ruptured – and claimed to find subgroups where it works. PubMed has more “systematic” reviews than registered trials. With half a dozen subgroups, selected secondary outcomes, and reviews redone after each new trial, it’s hardly surprising that we keep reading “progestagens work”.

The solution is to collect the original individual patient data (IPD) from the largest  trials, and combine them together in an IPD meta-analysis (IPD-MA). So long as the poor quality trials are excluded, and all patients and all outcomes from the high quality ones included, the scope for selective reporting is limited.

The Evaluating Progestogens for Prevention of Preterm birth International Collaborative (EPPPIC) individual participant data (IPD) meta-analysis started last year. It is funded by the Patient-Centered Outcomes Research Institute (PCORI), an independent non-profit, set up by the US government, which receives a $2 tax from every US health insurance plan. The project is registered here. Website here.

Everything is being done properly. In particular, although they have a steering group which includes many involved triallists, they have excluded people with strong vested interests or who have expressed strong ideas – even me! – from the main study team.  That’s as it should be.  The result should be the last word on this topic. I’ll certainly take it as such. I’ve committed to do so here.

When all the data are in and analysed, if progestagens really reduce something important like perinatal death or brain damage, I’ll stop arguing and start prescribing them.

And if there’s no overall benefit, but progestagens seem to work for one arbitrarily defined subgroup, let’s say women who entered the trials via the finding of a short cervix, I’ll take such a finding seriously and support a further trial to test that new hypothesis.

Jim Thornton

Read about AsPredicted here.

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