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Abstract

Clinical hypnotherapy has been soundly established as an effective treatment for the symptoms associated with cancer and its related therapies, including chronic and acute pain, nausea and vomiting, fatigue, insomnia, anxiety, and mood disturbances. Its use produces strong tendencies toward improvement of patients’ quality of life and of treatment cost. As the etiology and progression of various forms of cancer become better understood, the potential of hypnotherapy for increasing survival rates by improving medication response and even slowing or reversing the progression of the disease increases. Given the lack of risks to patients and the wide potential for benefit, additional research and clinical experimentation into this area are encouraged, and recommendations for this type of hypno-oncological exploration are discussed. An experimental hypnotherapy script which attempts to reverse the course of the disease while addressing multiple symptoms is included as Appendix I.

Introduction

Cancer presents the patient with a wide variety of symptoms and challenges. Many types of cancer cause intractable and chronic pain or other organ-specific symptoms in the areas they affect. Patients frequently experience a variety of nonspecific symptoms as well, such as fatigue, malaise, and insomnia. Hypnosis and self-hypnosis are extremely flexible and highly effective treatments for all types of cancer-related symptoms (Sunnen, 2004), and also aid in the numerous psychological adjustments that are required of cancer patients: “adjustment to the condition itself, to its treatments, and to the poignant intrapsychic, family, and social changes it may induce” (Kubler-Ross, 1969, as cited in Sunnen, 2004, p.15).

One recent study of 20 terminally ill cancer patients allowed each patient to choose the symptom they would most like to address using hypnotherapy. As a result, 19 of those 20 patients reported dramatically improved quality of life, anxiety status, and ability to cope, as well as better sleep and more energy. The symptoms they successfully addressed during the course of the study included pain, fatigue, malaise, irritability, insomnia, nausea and vomiting (NV), anticipatory NV (ANV), food aversions, anxiety, depression, guilt, anger, hostility, frustration, isolation, reduced self-esteem, and helplessness. Additionally, significant cost savings were realized in the form of reduced need for medication and nursing (Peynovska, Fisher, Oliver, & Mathew, 2005).

On top of being proven effective for symptom management (Liossi, 2006), the beauty of hypnosis is that it can be readily adapted to the needs of the patient, can be used to address physiological as well as psychosocial issues, and is extremely well-tolerated. Christina Liossi explains:

“It is safe and does not produce adverse effects or drug interactions. Patients enjoy the hypnotic experience. They obtain relief without destructive or unpleasant effects. There is no reduction of normal function or mental capacity and no development of tolerance to the hypnotic effect. It is a skill that individuals can easily learn, that provides a personal sense of mastery and control over their problems and that counters feelings of helplessness and powerlessness. An additional benefit is that hypnosis can be generalized to many circumstances. The person who learns hypnosis for management of pain or nausea and vomiting may apply their skills to lessen the distress of insomnia and anxiety, to address dysphagia for pills or to enhance their performance in their favourite sport. For a clinician, hypnosis is an opportunity to be inventive, spontaneous and playful and to build a stronger therapeutic relationship with a patient while providing symptom relief” (2006, p. 55).

This paper will briefly review the literature regarding the efficacy of hypnotherapeutic interventions for symptoms management, and will explore issues surrounding the psychotherapeutic treatment of cancer in general. A general understanding of the etiologies and biomechanics of cancer as they are relevant to hypnotherapeutic treatment will be attempted, and this treatment’s implications and potentials for improving survival rates and directly influencing
the course of the disease will be discussed.

Hypnotherapy for the Control of Pain

Hypnotherapy is particularly effective for the control of primary and treatment-related cancer pain, and has achieved the status of an evidence-based treatment for this purpose (Liossi, 2006). Multiple studies have found it to be superior to acupuncture, massage, or CBT in the treatment of pain and anxiety (Peynovska, Fisher, Oliver, & Mathew, 2005). One randomized, controlled study, for example, found hypnosis highly effective for the prevention of post-operative pain in patients receiving bone-marrow transplants, while an intensive cognitive-behavioral skills program was ineffective for this purpose (Liossi, 2006).

A randomized clinical trial to examine the effects of a single 15-minute hypnotherapy session administered to breast cancer patients immediately prior to lumpectomy surgery found that the treatment group experienced significantly less pain intensity, pain unpleasantness, nausea, fatigue, discomfort, and emotional upset. In addition these obvious benefits to the patients, the intervention was found to be extraordinarily cost-effective: patients in the treatment group costed the hospital 9% less (almost $775 less per patient) than those in the control group, owing to their significantly reduced surgery times and significantly reduced need for anesthesia and analgesics during the procedure.

There is evidence that hypnotherapy can be highly effective with pediatric patients, who experience much less pain from the primary effects of cancer than their adult counterparts—owing to the varieties of cancer to which they are most susceptible, such as leukemia—but are subjected to repeated, painful and invasive procedures and usually consider this to be “the most difficult part of their illness” (Liossi, 1999). Children appear to be far less capable of using self-hypnosis to manage procedure-related pain and distress than adult patients, and so it is necessary for the therapist to remain present with them during the procedures (Liossi & Hatira, 2003).

The hypnotic technique for pain relief typically begins with relaxation, which significantly assists in analgesia by reducing anxiety and thereby dampening the perception of unpleasant sensory experience. After a standard hypnotic induction is used, many patients will respond to direct suggestions that their pain will simply “diminish in intensity to the point of becoming unnoticeable” (Sunnen, 2004, p. 16). Another technique for eliminating pain involves first producing “glove anesthesia,” or a deadening of all sensations in one hand. As Sunnen explains, “the hand is ideally suited as a starting point for hypnotic anaesthesia because it is so richly endowed with sensory innervation and occupies such a prominent place in the cortical homunculus. Once the anaesthetic experience is established in the hand, it is a relatively small step to transfer it to other parts of the body.”

The patient’s mental representation of their pain can also be altered such that it occupies a smaller portion of their phenomenological experience, and the pain’s qualitative aspects may be modified so that they no longer correspond with the patient’s conceptions of what substantial pain is like. If the patient experiences the pain as hot and stabbing, for example, the therapist might suggest that it is becoming cool and soft. Some individuals achieve extremely good results from the use of hypnotic imagery, while others are able to dissociate from the experience by imagining that the pain is falling away from their bodies and out of sight (Sunnen, 2004). It is highly beneficial to assess the patient’s cognitive style and hypnotic ability prior to the intervention in order that the techniques used can be matched to the patient’s own inner experience.

Hypnotherapy for the Control of Nausea and Vomiting

Hypnosis has achieved status as an evidence-based treatment for chemotherapy-induced NV (CINV), with numerous controlled studies attesting to its efficacy (Liossi, 2006). A comprehensive meta-analysis of hypnotherapeutic treatment for CINV found it significantly more effective than the standard treatment, and at least as good or better than CBT (Richardson et al., 2007). The researchers also noted that none of the studies they examined had evaluated the hypnotic ability of their participants. For reasons that will be discussed in a later section, it is reasonable to expect that a clinician who assessed and utilized their patients’ individual hypnotic abilities would achieve even more impressive results.

About 30% of patients receiving chemotherapy experience NV not only following the administration of the chemotherapy, but in anticipation of its administration as well. The most widely accepted model for understanding ANV is a classical conditioning model, in which NV becomes a conditioned response to procedures surrounding the administration of the chemotherapy. Anxiety plays a role in this effect not only by increasing sensitivity to environmental stimuli but also by potentiating the learning of conditioned responses (Marchioroa et al., 2000).

Marchioroa et al. (2000) conducted a study of 16 consecutive adult cancer patients affected by chemotherapy-induced ANV, in which they examined common personality factors of participants in order to surmise traits that may predispose patients to ANV. Common factors identified included “a strong need for approval, a tendency to reveal emotions in an exaggerate or unsuitable way, superficiality, inconstancy and difficulty in giving a detailed description of situations or people.” Each patient was subjected to a two-hour progressive muscle relaxation training session preliminary to hypnotic treatment. The treatment itself consisted of a one-hour hypnotic session immediately prior to chemotherapy administration, using an eye-fixation induction followed by suggestions intended to induce organ anesthesia. The hypnotherapy treatment prevented ANV in all 16 patients, and actually produced significant reduction in post-chemotherapy NV as well for 14 of the 16 patients.

Hypnotherapy for the Improvement of Overall Quality of Life

A number of meta-analyses have demonstrated the profound efficacy of hypnosis in improving cancer patients’ quality of life (Walker, 1998). This improvement involves the alleviation of the intense anxiety and depression that are common among patients diagnosed with cancer, as well as control of the physical symptoms that cancer and its medical treatments produce.

In 1999, Walker and his Behavioral Oncology Unit team randomized 96 consecutive breast cancer patients into a control group receiving general support and a treatment group receiving the same type of support along with guided imagery and relaxation training. As chemotherapy progressed, the quality of life and mood of the control group declined significantly, as expected. The mood and quality of life of the treatment group, however, actually improved. By the end of chemotherapy, members of the treatment group were not only suffering lower levels of anxiety and depression that they had been at the time of diagnosis, they were actually less depressed and anxious than the general population in their community.

A 2001 study of 50 terminally ill cancer patients found that patients receiving hypnotherapy in addition to standard medical care and psychotherapy enjoyed significantly better quality of life, in addition to reduced anxiety and depression. Another study even found that just giving patients tapes teaching hypnotic muscle relaxation and light, slow breathing alleviated anxiety attacks in all 35 study participants (Liossi, 2006).

The flexibility of hypnotherapeutic treatments allow them to accommodate the very specific needs of various groups of cancer patients. For example, post-operative breast cancer patients frequently suffer from “hot flushes” that “cause discomfort, insomnia, anxiety, and decreased quality of life.” They can be treated fairly effectively with a hormone replacement therapy, but that treatment increases the risk of breast cancer recurrence. Compelling case evidence indicates that hypnotherapy may be the preferred treatment for this problem (Liossi, 2006).

Some general hypnotherapeutic techniques for improving psychological adjustment include: learning relaxation and self-hypnosis, which help to improve self-efficacy and self-empathy among patients who often feel that they have lost control and that their bodies have turned against them; hypnotic ego strengthening, in which the adaptive functions of the patient’s personality are brought to the foreground for them and utilized in novel ways; hypnotic imagery, which the patient can play an active role in developing so that it suits their unique style; and enhancement of spiritual practice through the connection to favored religious symbols and ideas and deepening of the feeling of spiritual connection (Sunnen, 2004).

Understanding Etiologies

Connections between temperament and cancer growth have been suspected since ancient times, and have been repeatedly reexamined as new medical paradigms have developed (Harris, 2006). British surgeon David Kissen studied the relationship between emotional repression, cigarette smoking, and the development of lung cancer in the early 1960s. He concluded that smokers who exhibited a repressive coping style were five times more likely to develop cancer, and that the level of cigarette smoking necessary to induce cancer in a smoker was furthermore conversely related to their level of emotional repression. (Kissen and Hysenk, 1962, as cited in Harris, 2006, p. 5). These findings were replicated “in a most spectacular way” in a ten-year Yugoslavian study in which smokers who endorsed fewer than 10 or 11 items on a “rationality and anti-emotionality(R/A)” survey demonstrated no incidence of cancer, “suggesting that smoking alone is not sufficient to cause cancer” (Gossarth-Maticek, 1985, as cited in Harris, 2006, p.5). Harris suggests that the requisite emotional factors are the imprints of childhood experiences, and as such are intertwined with physiological as well as personality development. Clinical success in the treatment of maladaptive personality factors over the last few decades (McWilliams, 1994; Sperry, 2003) may therefore have profound implications for the emerging field of primary care psychology.

Harris (2006, p. 6) goes on to cite research implicating the repression of anger (RA) as a major factor in the development of breast cancer, and demonstrating correlations between this type of cancer and childhood disturbances or feelings of emotional disconnection. Researchers are not in agreement about the existence of such connections. While acknowledging that the link between breast cancer and psychosocial factors has been popular among medical theorists since pre-Christian times, Bleiker and van der Ploeg (1999) found the current evidence insufficient to establish any significant relationship in their informal review. A meta-analysis published the same year (McKenna, Zevon, Corn, & Rounds) found moderate correlations between breast cancer and “denial/repression coping (g = .38), separation/loss experiences (g = .29), and stressful life events (g = .25),” (p. 520) but concluded that the associations were too modest to provide confirmation of “the conventional wisdom that personality and stress influence the development of breast cancer” (p. 520). Butow et al (2000) confirmed this assessment in their own meta-analysis, stating that “evidence for a relationship between psychosocial factors and breast cancer is weak,” with the strongest acknowledged predictors of breast cancer being “emotional repression and severe life events” (p. 169). More recent research, however, continues to implicate life stress in breast cancer incidence and recurrence (Palesh et al, 2007). Participants in one recent prospective study who went on to be diagnosed with breast cancer had suffered significantly more severe stress in the 10 years prior to the study, as well as significantly more moderate and severe personal losses. (Ollonen, Lehtonen, & Eskelinen, 2005). Recent studies also continue to find significant correlations between repressive coping styles and breast cancer incidence (Manna et al., 2007) and survival rates (Reynolds et al, 2000).

A 35-year longitudinal study of Harvard students found a dramatic correlation between perceived familial love and caring and the likelihood of diagnosis with serious diseases (including cancer, cardiovascular disease, and asthma) in mid-life (Harris, 2006, p.6). On the other hand, when Dr. Bert Garssen of the Helen Dowling Institute, a Dutch center for psycho-oncology, reviewed the longitudinal, prospective studies available in 2004, he completely discounted these and other findings, stating that “there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies” (p. 315).

Regardless of these wide discrepancies in findings, it is certain that the basic mechanism for an underlying psychosocial involvement in the development of cancer—damage to DNA, resulting in mutated cells—is present (Gidron, Russ, Tissarchondou, & Warner.) In a critical review of 21 human and animal studies, Gidron et al. find direct causal relationships between acute stressors and DNA damage, as well as significant correlations between DNA damage and ongoing psychological factors such as depression and repressive coping. Ernest Lawrence Rossi (2002) has compiled extensive research on the relationships between psychological factors and gene expression, finding not only significant effects from measurable psychosocial conditions but also psychotherapeutic potential for modifying these responses.

As an example, Rossi cites Stanford University researchers (Zhao et al., 2000, as cited in Rossi, 2002, p. 199-201) in their studies of the changing molecular dynamics of prostate cancer as it transitions from the early, controllable stage to the later, terminal stage. Specifically, this transition involves two genetic mutations which modify the affected prostate cells’ aberrant androgen receptors, which had heretofore been the instigators of uncontrolled growth, into pseudo-androgen receptor sites which can be activated by glucocorticoid stress hormones. From the time this mutation occurs, the advancement of the cancer is very clearly susceptible to psychosocial stressors and to psychological mediation.

It is difficult, on one level, to make any inferences at all regarding the etiology of “cancer,” simply because there are as many different types of cancer as there are types of cells in the human body—more than 200—and at least as many methods of action by which cancer might come about. Finish researchers Vauhkonen et al. (2007) summarize the current genetic understanding as such:

Cancer results from multiple genomic changes that affect DNA and its gene expression. The DNA sequences may be gained, lost or amplified, or translocated into different parts of the genome to form a fusion gene with oncogenic properties. The occurrence of specific chromosomal aberrations may be restricted to only one cancer type and it may be considered a primary carcinogenic event. Furthermore, the aberration profiles may be used to cluster tumors with similar origins. A variety of techniques exist for the detection of specific chromosomal and gene expression changes. However, the etiology of these molecular alterations remains unclear (p. 277).

Vauhkonen et al. investigate the roles of certain bacteria and chemical substances which may play key roles in carcinogenesis. Other researchers have established reliable connections between certain viral infections and almost 15% of all human malignancies, with a substantial number of additional viral etiologies suspected (Butel, 2000; Boccardo & Villa, 2007). Furthermore, it is known that viruses “are usually not complete carcinogens, and the known human cancer viruses display different roles in transformation. Many years may pass between initial infection and tumor appearance and most infected individuals do not develop cancer, although immunocompromised individuals are at elevated risk of viral-associated cancers” (Butel, 2000, p. 405).

These causal linkages between infectious disease, immune functioning, and cancer formation provide a clear inroad for the influence of psychological factors; research in the field of psychoneuroimmunology has soundly demonstrated the profound interrelationship between psychosocial and immunological functioning (Coe & Laudenslager, 2007). To add to this, solid evidence of direct immunological involvement in the phenomena of spontaneous regression of human cancer has been reported (Saleh et al., 2005). This finding gains enormous significance when it is considered that spontaneous regressions have been observed in nearly every type of human malignancy (Chodorowski et al., 2007).

Hypnotherapeutic Treatment of Cancer and Improvement of Survival Rates

It is clear that hypnosis and visualization are capable of having a direct effect on human immune functioning, including differential expression of T-cell subsets and disease-specific immunological activation (Gruzelier, 2002; Wood et al, 2003). It is also clear that these types of immune system changes take place when hypnotherapy and guided imagery are used specifically with cancer patients: natural killer cell counts are improved (Hudacek, 2007);  lymphokine activated killer cell activity is increased, total T-cell count (CD2+) is increased as are mature (CD3+) and activated (CD25+) T-cell counts; circulating levels of tumor necrosis factor alpha (TNF-α) are even decreased. Furthermore, these changes reliably occur in direct proportion to the perceived vividness of the patient’s visualizations (Ogston, et al, 1997, as cited in Walker, 2004).

What is not clear is the reason that these hypnotically-induced immunological changes do not appear to have a significant effect on the course of the disease or on clinical outcome (Hudacek, 2007; Walker, 2004; Spiegel & Moore, 1997), despite a small but compelling set of well-documented cases in which this type of treatment has apparently initiated spontaneous remission (Rossi, 2002, p.216; Chong, Smith Chong, & Fraser, 2001). This is particularly confusing when it is taken into account that standard, supportive-expressive group psychotherapy—which seems to be a less targeted treatment—can sometimes significantly impact the survival of cancer patients (Spiegel, Bloom, Kraemer, & Gottheil, 1989; Walker, 2004; Küchler, Bestmann, Rappat, Henne-Bruns, Wood-Dauphinee, 2007). For those cases in which psychotherapy does improve survival, Walker (2004) suggests enhanced treatment compliance, health-promoting lifestyle changes, improved mood-mediated chemotherapy response, improved host defenses, and amelioration of chemotherapy-induced immunosuppression as possible mechanisms. Other times, however, this type of treatment also appears to have no significant affect (Spiegel et al., 2007; Kissane et al., 2007).

The results are simply too strange for the problem to have been well-understood: there has to be a key ingredient which mediates the clinical success or failure of direct psycho-oncological interventions. Researchers at the University of Colorado Cancer Center, noting the proliferation of conflicting results in this area of research, came to essentially the same conclusion. They demonstrated that a highly significant factor in the success or failure of psycho-oncological treatment is the maturity of the individual patients’ styles of ego defense—a factor which is predictive of psychotherapeutic success in general (Beresford, Alfers, Mangum, Clapp, & Martin, 2006).

It could be noted, furthermore, that these findings are indicative of a confounding trend in psycho-oncological research which is likely responsible for many of the inconsistencies in its findings: failure to account for and accommodate psychological variables which are known to impact clinical outcomes. For example, Spiegel et al. (2007) suggest that their failure to replicate their previous findings may be due to differences between subgroups of breast cancer patients that are distinguished by receptivity to estrogen-replacement therapy. However, they did not report on the measurements of widely accepted therapeutic factors related to general group therapy treatment outcomes, such as group cohesiveness (Yalom, 1995), nor on the psychological
makeup of their participants.

As different styles of psychotherapy are indicated for patients operating at different levels of personality organization (McWilliams, 1994), it should go without saying that psychotherapeutic interventions specifically aimed at cancer must also take these variables into account. The fact that they are not being accounted for in the bulk of relevant research could reflect a basic disconnect between the required specificity of the medical model as a treatment metaphor and the contextual requirements and implications of psychological treatment (Wampold, Ahn, & Coleman, 2001), or perhaps some manner of entrenched condescension or apprehension toward psychotherapy as a potential medical treatment. The complexity of patients’ psychotherapeutic requirements, after all, should not be surprising: as pharmacological treatments have grown more complex, they, too, have acquired a greater need to accommodate individual factors in treatment. Depending on the type of cancer, degree of advancement, and other diagnostic features, a cancer patient may be administered any combination of surgery, radiation therapy, and more than 50 chemotherapy medications, and yet we study just a single mode of treatment called “supportive-expressive group psychotherapy”?

Likewise for hypnotherapeutic treatments: although individual differences in hypnotic susceptibility and absorption are clearly predictive of the efficacy of the treatment in up-regulating immunological functioning (Liossi, 2006), studies of hypnotherapy for cancer patients have almost uniformly failed to measure the hypnotic ability of their subjects (Richardson, et al., 2007). This oversight is problematic for three reasons:

1. Hypnotizability is a normally distributed, stable personality trait with at least some genetic basis, which is known to be predictive of clinical success in hypnotherapeutic interventions (Wickramasekera, 2003). Hypnotherapy may therefore not be expected to be an appropriate treatment for individuals who fall in the low-hypnotizable range. Research which fails to identify these individuals will both underestimate the efficacy of hypnotherapy for those who can benefit from it and fail to discern elements of the treatment which may be beneficial to those lacking this trait.
2. Low hypnotic ability may be modified or overcome. A number of techniques, such as biofeedback, have been found to at least temporarily improve hypnotic ability in low-hypnotizable individuals (Wickramasekera, 2002). Additionally, the application of multiple successive hypnotic techniques may be effective in patients who have failed to respond to standard hypnotic techniques (Crasilneck, 1995).
3. Hypnotic ability is not a unitary trait. If overall hypnotic ability is not measured, then the interventions studied cannot be tailored to utilize the specific hypnotic abilities of each patient. Patients who are unskilled at hypnotic visualization but excel at kinesthetic representations, for example, will receive far less benefit from guided imagery-based interventions than they would from hypnotherapy that utilized their individual, measurable hypnotic strengths (Pekala, 2002).

Discussion

Hypno-oncological interventions intended to directly alter the progression of the disease have not been yet been studied in controlled trials. However, the theoretical and biological bases for hypnotherapy’s potential as an effective adjunctive cancer treatment appear to be sound. Such interventions should be tailored to the individual hypnotic abilities of the patient and should be designed to foster the development and use of more mature ego defenses.

Additionally, it seems likely that a degree of biological specificity which has yet to be achieved in this type of hypnotic treatment could have the potential to significantly enhance its efficacy. The types of imagery used in the studies we’ve reviewed, when mentioned, have tended to be combative—as though the cancer cells were isolated intruders. Biologically, however, we know that the occurrence of cancer is far more complex. At least two genetic mutations are required to convert healthy cells into malignant ones, and viral, bacterial, or chemical interference is involved in some or all of these mutations a substantial percentage of the time. (Butel, 2000; Vauhkonen et al., 2007; Boccardo & Villa, 2007) Some cancers seem to result from ongoing viral infections and to reverse their course when the immune system is awakened to the presence of the intruder. Other types of cancers seem to occur systemically, with numerous precancerous lesions preceding the development of a site-specific, diagnosable cancer (Baker & Kramer, 2007). If hypnosis is able to directly influence biological events—which it does seem to be able to do (Rossi, 2002)—it would seem logical that more accurate therapeutic metaphors would yield more accurate treatment.

Hypnotic imagery involving the mobilization of cellular warriors does, in fact, increase the mobilization of natural killer and lymphokine activated killer cells (Gruzelier, 2002; Wood et al, 2003; Hudacek, 2007; Ogston, et al, 1997, as cited in Walker, 2004). That alone is essentially cause for celebration; the implications are staggering. Using hypnosis, we can tell our patient’s bodies what to do, and they will do it. Now all that is needed is to understand exactly what human bodies must do to be free of cancer. Increasing T-cell activity and focusing that activity on the site of the cancer is clearly not sufficient. If research in this area is conducted in such a way as to directly compare the efficacy of different pathogenic models for particular types of cancer, the results may very well have implications for the development of new biological treatments as well. Perhaps the body can tell us what it needs in order to heal.

There is presently no evidence of any downside to open experimentation in this area. Hypnotherapy is already conclusively established as a highly effective treatment for many primary and secondary symptoms of human malignancies—acute and chronic pain, chemotherapy-related nausea and vomiting, food aversions, fatigue, insomnia, anxiety and mood disturbances—and is currently under-utilized (Liossi, 2006). Furthermore, there is no evidence that the addition of far-fetched suggestions into existing empirically-based clinical hypnosis protocols would reduce the effectiveness of existing treatments, significantly increase treatment expense, or present additional risk to the patient.

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Tagged: clinical hypnotherapy, hypnosis, hypnosis and cancer, hypnotherapy

§ One Response to “Hypno-oncology: Hypnosis In The Treatment Of Cancer”

• Susan Wallace says:

  February 1, 2010 at 4:25 pm

  Many thanks for sharing Dr David.

  Kind regards from muddy, wet, cold, on the edge of the world, Ireland!

  Reply