We are exposed daily to any number of virus infections; we frequently deal with a variety of nasty bacteria with only the most cursory attention to hygiene; and in general we consider ourselves immune to all the diseases of the world and even of the flesh and the devil. Year by year we see the full gamut of nature's ways of terminating our existence on this mortal coil, and gloss over statistics without any thought that they apply to us as well as to our patients.
So when I fell foul of the statistics and developed my own carcinoma I was more surprised than fearful. Increasing difficulty in swallowing led to oesophagoscopy and barium swallow. Biopsies confirmed a squamous cell carcinoma in quite the most awkward position right at the very top of the oesophagus. CAT and U/S scans showed no evidence of secondaries, so as I was otherwise perfectly fit and well, I was referred to one of the Big Hospitals in London for surgery.
My goode wyfe and I attended the out-patient consultation together. We were, initially, not a little taken aback to learn that with a tumour in this position, excision would be impossible without laryngectomy and a permanent tracheostomy as well, but the sense of shock rapidly abated when we had a long talk to a patient who had used an 'artificial larynx' buzzer gadget for many years.
The necessary surgical team - upper GI surgeon as well as Head and Neck surgeon - could not be assembled from the golf links and the trout river for a fortnight, so we snatched a short holiday, during which I seized the opportunity of recording several hours of readings, to save my voice for posterity and for the as yet non-existent grandchildren...
The afternoon before the operation, we sat for hours in our favourite Chinese restaurant in Gerard Street, working our way through steamed sea-bass with spring onion and ginger sauce, Singapore noodles and two bottles of wine. And we parted with the briefest goodbye in the City so that I could go off to the hospital ward and she could return home. We both felt that loss of my voice was going to be something very close to bereavement, as if part of me would be gone for ever. But we were both surprised how quickly we got over this reaction.
I remember thinking, on the way to the operating theatre the next morning, that I had at no time felt any sense of fear. Not even any worry at all about the outcome. I looked upon the whole affair with at least some degree of scientific detachment, interest, and just plain curiosity as to how things were going to turn out. I suppose confidence in the surgical team played a large part in this, but I really didn't have a care in the world whilst the anaesthetist wielded his potions.
When I eventually awoke the next day in the Intensive Care Unit, I was convinced that I could still breathe through my nose quite normally, and summoned pen and paper to ask what had happened about the proposed laryngectomy. I soon discovered that not only had I lost the oesophagus and larynx, but also much of the pharynx as well as the thyroid and parathyroid glands which had become involved in the spread of the tumour through the fascial planes of the neck.
Thus the early days of recovery were punctuated by difficulties in controlling calcium levels, with several quite extraordinarily unpleasant episodes of tetany. Muscle spasm where two large incisions are involved is not nice: pain leads to overbreathing which creates even more havoc with the biochemistry...
I believe the little procession that accompanied me up to the ward saw me with no less than twelve assorted tubes, drips and drains. Apart from the endotracheal tube in the tracheostomy, there was a urinary catheter, a Ryle's tube and a jejunostomy tube. Two long arterial lines, and two central venous lines were left in situ for the first 48 hours, whilst drips and intravenous drugs went into two ordinary Venflon inputs. There was a long mediastinal drain on suction, and a shorter drain to the neck wound as well. I can recall the moment of arrival on the ward when my family, assembled in the waiting room greeted the passing procession with "That's him..." Not to be confused with the series of tonsillectomies and varieties of sinus surgery that day.
In the following days I gradually lost more and more of the tubes, until, oh luxury! I was allowed to drink a glass of Lemon Barley Water on the tenth post-operative day. The quite sensuous feeling of liquid passing the lips was just wonderful: almost worth the ten days of abstinence. I started eating with a celebratory smoked salmon sandwich soon afterwards, and began the long slow process of adapting to having the stomach anastomosed just about at the level of the root of the tongue with little in the way of any remaining musculature in the throat to prevent reflux. I rapidly learnt not to bend down to reach for my slippers...
I found I felt the same cavalier attitude to recovery as I had previously for illness in general: I was impatient, and then frustrated until each little hurdle was overcome. After a few days I could stand, with help, but could only take one or two steps. Gradually though, I rediscovered the art of walking, and eventually determined I would walk to the end of the ward and back. The experience was so emotional I broke down and wept when I reached my bedside. But the days passed and strength returned and I was finally discharged after nearly three weeks, surprising everyone except the Dietician by finding I had gained nearly half a stone since I arrived, and was quite unable to do up my trousers.
Who can tell what the future holds. You already know I don't believe in statistics. Yet I still hope to confound them in years to come...
And perhaps I can offer hints, encouragement and good wishes to others in similar predicaments in future articles in this series, particularly for those who find themselves without a larynx, oesophagus or both... Life is always interesting.
Dr Alan G. Gray