Book Review: The Butchering Art by Lindsey Fitzharris

The Butchering Art

Author: Lindsey Fitzharris

Publisher: Farrar, Straus and Giroux

Date of Publication: October 17, 2017

Pages: 304

"New opinions are always suspected, and usually opposed,

without any other reason but because they are not already common."

- John Locke

     The Butchering Art is a totally captivating work of creative non-fiction, made even more remarkable by the fact that it represents the first book written by author Lindsey Fitzharris.  The author received a PhD. in the History of Science, Medicine and Technology from Oxford University in 2009.   Honors awarded to The Butchering Art include: Winner of the PEN/E.O. Wilson Prize for Literary Science Writing, Top 10 Science Books of Fall 2017 by Publisher's Weekly and a Best History Book of 2017 by "The Guardian."  In addition to this novel, the author has written for “The Guardian”, “The Lancet” and “New Scientist.”  She has a huge social media presence including a fascinating blog: "The Chirurgeon's Apprentice".  You can also follow her on Facebook at https://www.facebook.com/DrLindseyFitzharris/ but be prepared for some graphic posts!  She also has many multi-media projects in progress including a British Television Series: "Medicine's Dark Secrets". 

     The Butchering Art is first and foremost a biography of Joseph Lister.  Lister was born on April 5,1827 in Wetsham, Essex, England to devout Quaker parents.   His father, Joseph Jackson Lister was a great devotee of the microscope and developed the "achromatic lens" which reduced distortions.  Young Lister was very interested in his father's microscope and became proficient in its use.  He announced he wanted to be a surgeon, at that time a profession held in low regard.  He attended the University College of London, beginning in 1844.  Lister was noted to be hardworking and diligent, despite the poor reputation of medical students of the day (who were described as “lawless, exuberant, and addicted to nocturnal activities” in one journal).  Lister brought a microscope with him although the use of that instrument in medical studies was more accepted in Paris than in London.  The author describes the conditions in the medical school in the 1840s.  First, there was no protective gear in the “dissecting rooms” or anatomy labs.  Students routinely went directly from their cadavers to their living patients without so much as washing their hands.  Also, there were two schools of thought in the field of infectious disease: Contagionists, who believed in an "agent of disease" vs. Anti-contagionists, or miasmatists, who believed that diseases were transmitted through the air via poisonous vapors.  Only four types of infections were recognized: eryspielas, hospital gangrene, pyemia and septicemia.  Post-operative infections were routine and mortality rates were very high.

     The author spends one chapter discussing the rapid urbanization and increased population density in London.  These conditions set the stage for more injuries and illnesses.  Lister was frustrated at the high mortality associated with surgery and was intent on finding the cause of infection and used his microscope to investigate.  He felt that something in the wound itself had to be at fault, not just the air around the patient.  Lister: "I examined microscopically the slough from one of the sores, and I made a sketch of some bodies of pretty uniform size which I imagined might be the materies morbi (morbid substances).  The idea that it was probably of parasitic nature was at that early period already present in my mind."

      Lister completed his surgical training and sat for examinations by the Royal College of Surgeons.  It was recommended that he tour European medical schools to learn more about recent advances.  His first stop on this tour was the University of Edinburgh to study with James Syme, renowned professor of surgery.  Syme had achieved quite a bit of notoriety for his economy of technique and time which he tried to achieve with nearly every form of operation he undertook.  Syme took special interest in Lister, who decided to stay in Scotland instead of pursuing appointments in London or resuming travels to Europe.  Lister was elected to membership in The Royal College of Surgeons of Scotland and advanced on staff of Dr. Syme.  Also, during this time he courted and married Syme's oldest daughter.  Lister then began a series of experiments on frogs to study effects of inflammation on wound healing.  He discovered that "a certain amount of inflammation as caused by direct irritation is essential to primary union.  Inflammation of a wound did not necessarily presage sepsis."  These are concepts which are central to wound healing physiology today.

     Lister applied for the position of Regius Professor of Clinical Surgery at the University of Glasgow and was recommended by Dr. Syme: "Lister has a strict regard for accuracy, extremely correct powers of observation and a remarkably sound judgment united to uncommon manual dexterity and a practical turn of mind."  While in Glasgow, Lister grew increasingly frustrated by his inability to prevent and manage septic conditions in his patients.  His case notes catalogue the questions plaguing him:  "11 P.M.  Query.  How does the poisonous matter get from the wound into the veins?  Is it that the clot in the orifices of the cut veins suppurates, or is poisonous matter absorbed by minute veins and carried into the venous trunks?"  He became an advocate of cleanliness in the hospital, even though his method for antisepsis was still to come.  At the same time as Lister was studying inflammation and infection, there were many surgeons in Europe interested in the high maternal post-partum mortality from "puerperal fever."  Alexander Gordon in Scotland wrote in 1789 that puerperal fever was secondary to contamination by the medical staff.  This idea was summarily rejected.  Oliver Wendell Holmes in America revived Gordon's ideas fifty years later and Ignaz Semmelweis in Vienna spoke of "cadaverous particles" which could be transmitted through medical students from the anatomy labs to the obstetrical wards.  He instituted a chlorine hand wash when leaving the anatomy lab and reduced incidence of puerperal fever.  In the 1840's it was proven that cholera was caused by contaminated sewage and not "miasma" or bad air and changed the view of how diseases spread.  In France, chemist Louis Pasteur showed that bacteria ruined fermentation in wine.  Finally, Lister applied this knowledge to the septic wound and proposed the application of antiseptic agents (first potassium permanganate and then carbolic acid) which greatly reduced the infection rate in surgically treated compound fractures.  Lister published his findings in “The Lancet” with a five-installment article which began on March 16, 1867.

     Lister's concepts and method were not immediately accepted.  There was conflict with James Y. Simpson, a noted gynecologist and the discoverer of Chloroform anesthetic.  First Dr. Simpson wrote a letter to “The Lancet” claiming Lister was only repeating studies already performed in Europe and secondly that his own method of preventing infection, acupressure, was more effective.  Lister repeatedly defended antisepsis, pointing to the strict scientific method with which he had reached his conclusions.  Lister's method was also rejected by another distinguished London surgeon, James Padgett, who did note, however, that he might not have been applying the method correctly.

     

     In 1869 Dr. Syme passed away and Lister returned to Edinburgh to take his place.  There was still a debate regarding the efficacy of Lister's method.  Improved mortality rates were attributed to better ventilation, improved diet and improvements in nursing rather than antiseptic technique.  However, Lister's students became believers and marveled at Lister's continued experimentation and constant adjustments to his antiseptic technique.  His students, who came to be known as "Listerians", realized the value of experimentation in medicine and that observational acuity and accuracy could lead to improvements in surgery.  Lister's method gained traction with surgeons in Europe, particularly Richard von Volkmann in Germany and gradually gained acceptance in Britain.  Lister then went on to develop the atomizer, a device to spray carbolic acid into the air to reduce bacteria.

     In 1871 Lister was called to care for Queen Victoria who was suffering with a large axillary abscess.  He used his carbolic acid atomizer on the Queen and then drained the infection.  When he noted further drainage on the first post-operative day, he improvised a new treatment.  He soaked some rubber tubing in carbolic acid and placed it into the wound.  The Queen recovered and this was the first use of a surgical drain!

      In 1876 Lister was invited to speak in America where his methods were greeted with much skepticism.  His presentation in Philadelphia was criticized by Samuel Gross: "Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called treatment of Professor Lister."  Listerism gradually gained acceptance in America and Massachusetts General became the first hospital in America to make institutional use of carbolic acid as a surgical antiseptic.  Lister's method became universally accepted during his lifetime.  He died in 1912 as a hero of medicine and science.

     Interestingly, the change which occurred in surgery through Lister's efforts have been immortalized in the art of Thomas Eakins.  Dr. Gross, who had espoused the contrarian view to Listerism in Philadelphia, commissioned a painting by Eakins entitled "The Gross Clinic":

                                                        

      

 In this painting, Dr. Gross is operating on the femur of a young man with osteomyelitis.  There are unsterilized instruments displayed and one of the surgical assistants is seen probing the wound with his bare and bloody fingers.  Twenty years later Eakins painted "The Agnew Clinic":

                                       

                                             

In contrast, this painting shows the embodiment of antisepsis and hygiene.  It is a cleaner and brighter surgical theater with the surgeons wearing stark white coats rather than street clothes.             

     The Butchering Art is a meticulously researched scientific exercise and yet it reads like a novel.  It is one of those rare books which educates and at the same time entertains.  It is a biography of Joseph Lister, a history of medicine as it struggles to enter the modern age, a historical monograph describing London, Edinburgh and Glasgow in the mid 1800's and a socio-economic treatise describing urbanization, poverty and social injustice in the Victorian era.  It is a long book, but I recommend it highly.  Dr. Fitzharris' next book will be a similar treatment of Sir Harold Gillies and the development of the specialty of reconstructive plastic surgery.

       

                                                       
   


                                          

Book Review: Musicophilia: Tales of Music and the Brain by Oliver Sacks

Musicophilia: Tales of Music and the Brain

Author: Oliver Sacks

Publisher: Knopf Doubleday Publishing Group

Date of Publication: September 23, 2008

Pages: 425

     Oliver Sacks died this past August at the age of 80.  He was a professor of Neurology at New York University and is best known for his essays and books related to many of the fascinating clinical problems he observed during his long career.  His 1973 book Awakenings, an auto-biographical look at post-encephalitic patients becoming "unlocked" after doses of L-Dopa, was developed into an Oscar-nominated movie starring Robin Williams and Robert De Niro.  Musicophilia was originally released in 2007.  In this intriguing book Oliver Sacks explores music as part of disease processes and, further, as part of treatments for other disorders.  

     The book opens with a case study of an orthopedic surgeon struck by lightning who became obsessed with piano music and learning to play the piano.  This physician "once an easy-going, genial family man, almost indifferent to music - was inspired, even possessed, by music, and scarcely had time for anything else."  He eventually loses his family and job because of his obsession.

     Many more case studies follow, including patients with musical seizures, musical savants, stroke and dementia patients.  The sections on patients with profound neurological deficits who maintain their ability to play and appreciate music are fascinating.  The author tells all of these stories with grace and style, managing to entertain as well as educate the reader.  Much of the current understanding of complex neurologic syndromes comes from modern functional brain imaging.  These techniques have been used to map the brain and define which areas of the brain are responsible for musical ability, learning and appreciation.  This data is included in the discussions of the disorders.

    Sacks deftly explains the rationale for music therapy, explaining how the astute therapist can manipulate functioning areas of the brain.  Music therapy can be used in motor disorders such as Parkinson's disease to reduce uncontrollable movement and can also be used in dementia patients to calm and ease the distress which many of them suffer.  The author states:

"As music seems to resist or survive the distortion of dreams or of Parkinsonism, or the losses of amnesia or Alzheimer's, so it may resist the distortions of psychosis and be able to penetrate the deepest states of melancholia or madness, sometimes when nothing else can."

     I can truthfully say that I remember very little neuro-anatomy or physiology from medical school.  Also, much has changed in the decades since I last was exposed to any of this.  This book helps explain many very complex medical issues and engenders a true appreciation of the complexity of neurologic and psychiatric conditions.  The role which music can play in the pathophysiology of disease as well as in the treatment plan for many disorders was a revelation to me.  Musicophilia is packed with compelling information and was a joy to read.

Book Review: Pieces of Light by Charles Fernyhough

Pieces of Light

Author: Charles Fernyhough

Publisher: HarperCollins 

Date of Publication: January 7, 2014

Pages: 320

"Memory has its own special kind of truth.  It selects, eliminates, alters, exaggerates, minimizes, glorifies and vilifies also, but in the end it creates its own reality, its heterogeneous but usually coherent version of events;  and no sane human being ever trusts someone else's version more than his own."
- Salman Rushdie

     Developmental psychologist Charles Fernyhough begins the final chapter of Pieces of Light by saying: "I set out to write about some science, and I ended up by telling a lot of stories."  Indeed he did.  In a little over 200 pages this author has concisely summarized current  memory research.  He enlivens the anatomic and statistical facts with colorful anecdotes and stories which help the reader comprehend what all of this research means on a practical level.  In the process, the author encourages us to think differently about memory and : "Thinking differently about memory requires us to think differently about some of the 'truths' that are closest to the core of our selves."

     In his introduction, Fernyhough states "We need our memories, and we find ways of hanging on to them.  According to the conventional 'possession' view of memory, we do that by filing them away in a kind of internal library, ready to be retrieved as soon as they are needed."   He then goes on to say that "The view that I want to explore in this book is that memory is more like a habit, a process of constructing something from its parts, in similar but subtly changing ways each time, whenever the occasion arises."  It is this reconstructive view of memory that he explores throughout the book.

     In successive chapters the author explores how reconstructed memories are very susceptible to distortion by information provided after the event and by bias.  He distinguishes between semantic memory (memory for facts) and episodic memory (memory for events) and how memories from our own lives involve an integration of these two types of memory.

     He also writes about the evocation of memory by certain stimuli.  In particular, he talks about how certain sensory stimulation can evoke very strong memories (or "involuntary memories").  The classic example of this in literature is Proust's memories of his grandmother which were brought about by the smell and taste of Madeleine cakes in his book In Search of Lost Time.  

     This concept of memories as reconstructions has many critical implications.  The legal system is taking this into account.  More and more, the courts are discounting the reliability of eyewitness testimony in favor of more verifiable evidence.  Memory manipulation is a great concern, especially in the arena of child abuse.  There is great interest in this concept of memory reconstruction in the treatment of memory disorders including amnesia, dementia and post-traumatic stress syndrome.  The chapter on PTSD is particularly interesting, especially since this is a relatively new diagnosis (first included in the Diagnostic and Statistical Manual of Mental Disorders in the 1980s).  The successful use of therapy to refocus the memory of  PTSD patients is fascinating.  

     This book is reminiscent of Malcolm Gladwell's books in that both authors use data and facts which then are augmented by "real world" narratives.  Fernyhough goes further, however, using many personal anecdotes and family stories.  The chapter which describes his interviews with his 90 year old grandmother are touching as well as enlightening.  I also really enjoyed the segments in which Fernyhough uses literature (Proust, of course, as well as many more contemporary authors) to show how different views of memory are portrayed.  Fernyhough also has the advantage over Gladwell in the fact that he is a scientist and a practitioner in the field rather a reporting journalist.  This author obviously had a thorough command of the information and has a real talent for explaining it on a level that the non-psychologist and non-neuroanatomist can comprehend.  

     This is a very enjoyable study of modern memory research which deserves a wide audience.

Book Review: The Great Influenza by John M. Barry

The Great Influenza

By John M. Barry

(Blogger Note: This review was previously published in "LAMLight," the physician newsletter of the Lynchburg Academy of Medicine.)

  

The 1918 influenza pandemic which began in Kansas and killed an estimated 100 million people world-wide in a 24 day period is examined in great detail in The Great Influenza by John M. Barry.  Although this is an extensively researched book with a tremendous amount of medical and scientific information it is never boring.  This is a story which could have been as sleep-inducing as an M-1 Histology lecture but has the pace of a Grisham novel and the suspense of any best-selling mystery.  In the Prologue Mr. Barry describes his book as “a story of science, of discovery, of how one thinks, and of how one changes the way one thinks.”  The lessons learned in the early 1900s are very appropriate to be reviewed a century later. 

The story is divided into ten sections.  The first “The Warriors” is an overview of American medicine as it existed in the late 1800s and how it was revolutionized mainly by William Henry Welch and the Johns Hopkins Medical School and research laboratories.  Dr. Welch almost single handedly changed American medicine from a field not far removed from the practices of Hippocrates to a rigorous, science based investigative discipline.  Welch, along with William Halsted at Hopkins and Simon Flexner of the Rockefeller Institute brought American medicine into the modern age and enabled the medical response to the 1918 Influenza epidemic.

The following sections “set the stage”.  Section two (“The Swarm”) is a very succinct course on virology, directed to the layman and appreciated by this reviewer who is very deficient in his knowledge of infectious disease.  “The Tinderbox” explains the social and geopolitical factors which contributed to the situation which became the perfect storm for a pandemic.  The U.S entrance into the Great War precipitated a number of amazing circumstances.  For those appalled by the the George W. Bush administration's Patriot Act and its potential for restriction of personal freedoms, Woodrow Wilson’s Sedition Act looks like downright fascism.  The Sedition Act was responsible for the imprisonment of anyone who spoke or published words questioning the federal government.  This Act was eventually upheld as constitutional by none other than Chief Justice Oliver Wendell Holmes.  This law essentially put a lid on any accurate reporting of the flu epidemic.  The facts were thought to be detrimental to public morale and the war effort.   The conscription of most men between 18 and 45 years of age created crowded conditions in training camps, again creating a situation ripe for rapid dissemination of infectious disease.  Physicians were secretly “graded” by local medical societies and the best physicians and almost all nurses were rapidly conscripted into the army and sent over seas, leaving the medical care of the citizenry to older physicians, trained prior to the era of scientific method and regarded as “inferior”.  The Rockefeller Institute was transformed into “Army Auxiliary Laboratory Number One” and entire medical school faculties were sent as units to Europe.

The ensuing sections of the book documents the incredible spread of the disease and the terrible ferocity with which it struck, especially in younger patients.  At one point at Camp Pike in Arkansas, for instance, 13,000 out of 60,000 soldiers were simultaneously sick with influenza.  The death rate among young adults approached 40% and often people woke up feeling fine, had an acute onset of symptoms and were dead within twelve hours.

The modern laboratories established by Welch at Hopkins, Victor Vaughan at Michigan, Charles Eliot at Harvard and William Pepper at Penn as well as Oswald Avery at the Rockefeller Institute, William Park and Anna Williams (virus experts) at the New York City Department of Public Health and Paul Lewis in Philadelphia were all in a race to identify the pathogen responsible for this pandemic and, if possible, develop a vaccine to treat and prevent the disease.  The desperation caused by the presence of death all around them, including within the ranks of their own laboratory workers produced a frenetic research response.  The work produced in 1918 is still evident today.  Pfeiffer discovered the “Influenza Bacillus” (what we call H. Influenza today) which was the bacteria responsible for the rapid demise of the younger patient population.  Avery developed the “chocolate agar” growth medium to expedite growth and identification of H. Influenza, which clarified the role of this pathogen in the pandemic.  Many of the deaths were in fact due to secondary overwhelming bacterial pneumonias and what we recognize today as acute respiratory distress syndrome. 

The concluding sections of the book deal with the aftermath of the pandemic.  The repercussions were felt in every segment of society and in every geographic location.  An interesting historical footnote is that Woodrow Wilson succumbed to influenza during the negotiations at the end of World War I.  After two week convalescence, Wilson backed off of all of his previous demands, conceded to the French and stripped Germany of territory, its army, and crippled its economy.  The author hypothesizes that Wilson was suffering from post-influenza psychosis or mental disturbance and quotes Lloyd George as saying “Wilson suffered a nervous and spiritual breakdown in the middle of the Conference (the Paris Peace Commission).”   Barry concludes: “Historians with virtual unanimity agree that the harshness toward Germany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler.”

The flurry of research activity during and following the pandemic led to the discovery by Avery that the substance that transformed a pneumococcus from one without a capsule to a more virulent one with a capsule was DNA.  A report from Avery, MacLeod and McCarty titled “Studies on the Chemical Nature of the Substance Inducing Transformation of Pnuemococcal Types.  Induction of Transformation by a Desoxyribonucleic Acid Fraction Isolated from Pneumococcus Type III” was published in the February 1944 Journal of Experimental Medicine.  This report demonstrated that DNA carried genetic information, that genes lay within DNA.  This report was the direct result of Avery’s years of research into the cause of the 1918 influenza pandemic.  This information inspired many scientists, including James Watson and Francis Crick to determine the structure of DNA.  Watson wrote in The Double Helix:  "Avery gave us the first text of a new language; or rather he showed us where to look for it.  I resolved to search for this text.”  Barry observes: “In fact, what Avery accomplished was a classic of basic science.  He started his search looking for a cure for pneumonia and ended up opening the field of Molecular Biology.”

The author concludes by warning that although medical science has made incredible strides, the stage could be set for another pandemic.  Overcrowding in urban areas, poor hygiene and sanitary conditions in third world countries (as well as American inner cities) and the “shrinking of the planet” by international travel all contribute to a situation where a virulent new virus, should it occur, could spread rapidly.  The severity of a pandemic similar to “The Great Influenza” would easily and quickly overwhelm the world’s medical system.  The World Health Organization has guidelines in place to accurately assess risk of new diseases and promptly respond to that risk.  These lessons learned from the 1918 experience are largely responsible for the quick identification and limitation of SARS (Severe Acute Respiratory Syndrome, a disease which spread from animals to man in the spring of 2003).  Barry warns, however, that “Every expert on influenza agrees that the ability of the influenza virus to re-assort genes means that another pandemic not only can happen, it almost certainly will happen.”

The Great Influenza by John M. Barry is an excellent book and a tremendous compilation of data and information on this timely subject.  

Hyperbaric Oxygen Therapy and Peripheral Arterial Disease

The Role of Hyperbaric Oxygen Therapy in Patients with Peripheral Arterial Disease

Tom Carrico, M.D., F.A.C.S.

Medical Director, CENTRA Center for Wound Care and Hyperbaric Medicine

                Hyperbaric oxygen therapy (HBO) has been available in our community since April, 2003.  Our chambers are located within the CENTRA Center for Wound Care and Hyperbaric Medicine on the second floor of Virginia Baptist Hospital.  Our Center is fully accredited by the Undersea and Hyperbaric Medical Society’s Facility Accreditation Program.  We are one of six accredited programs in the Commonwealth of Virginia and the only one west of Richmond.  This therapy has been successfully utilized for a variety of conditions including diabetic foot and lower extremity ulcers, problem healing in irradiated fields and osteomyelitis (as well as other less frequent indications).  So what is the role of HBO in patients with peripheral arterial disease?

 What is Hyperbaric oxygen therapy and how does it work?   

            

                  HBO is the breathing of pure oxygen at increased atmospheric pressure.  We utilize “monoplace” chambers, in which the entire patient is sealed in an acrylic tube (or “chamber”).  We replace the ambient air within the chamber with 100% oxygen and increase the pressure to 2.0 – 2.4 atmospheres.  In comparison, this pressure would be about the same as a scuba dive to about 50 feet of water.  In this environment, hemoglobin molecules are saturated with oxygen and even more oxygen is dissolved into the plasma of the blood.  This allows the delivery of super-oxygenated blood (about 15 times the amount of oxygen delivered to the tissues if the patient were breathing room air at 1 atmosphere of pressure) to the capillary beds.  This has many beneficial effects on wound healing.  These include improved fibroblast function and collagen deposition, more efficient leukocyte function, an increase in the amounts of growth factors in the wound bed, and a synergistic bactericidal effect with some antibiotics.  Oxygen in concentrations achieved in the HBO chamber actually diffuses into bone and also has a bactericidal effect in patients with osteomyelitis.  The most important effect in our diabetic patients and in the patients with wounds in irradiated tissues is angiogenesis which is most likely mediated by stem cell recruitment from bone marrow.  A new capillary bed can be achieved in diabetics with small vessel disease and in patients with localized tissue ischemia from radiation therapy.

 What role does HBO play in acute arterial ischemia?   

              A patient can develop acute arterial ischemia through trauma (crush injury or direct arterial trauma) or from emboli.  After the acute arterial injury or blockage is corrected a compartment syndrome can develop.  HBO can play a role in these patients post-revascularization by reducing edema and increasing the oxygenation of injured tissues.  Often fasciotomy can be avoided and tissue salvaged before frank necrosis can occur.  This usually involves a short course of hyperbaric therapy, sometimes on a twice daily schedule, until edema resolves and all tissue is viable.

What role does HBO play in peripheral arterial disease and tissue loss (ulcer)? 

              Patients often present to the Wound Care Center with lower extremity ulceration and non-palpable pulses.  If the rest of the history and physical exam indicates significant peripheral arterial disease, then non-invasive testing is ordered.  This may include a test we perform in the Center, a trans-cutaneous oxygen measurement (or “TCOM”) as well as the standard lower extremity arterial Doppler study (LEAS).  We would also consider performing a TCOM in a diabetic patient with palpable pulses to see if they have significant small vessel disease secondary to their diabetes.  If the patient has very low tissue oxygenation at the distal leg or foot level or critical limb ischemia is determined on LEAS study then revascularization (either surgical bypass or endovascular revascularization) would be needed before we would anticipate that these ulcers would heal.  Hyperbaric oxygen therapy is NOT going to be beneficial in the patient with critical limb ischemia which cannot be corrected.  Once a patient with an arterial ulcer has been successfully revascularized, then HBO would be indicated to help speed healing when there is also deep tissue involvement, osteomyelitis or persistent small vessel disease after the inflow has been corrected.

      

        In summary, Hyperbaric Oxygen Therapy is a useful adjunctive treatment in patients with acute arterial ischemia, patients with arterial ulcer and deep tissue involvement after successful revascularization and in diabetic patients with good inflow but significant small vessel distal disease. 

      

        Referrals for wound care and consideration for hyperbaric oxygen therapy or trans-cutaneous oxygen testing can be obtained by calling our Center at 434-200-1800.

Center for Wound Care and Hyperbaric Medicine Staff - Virginia Baptist Hospital, Lynchburg, Virginia

Book Review: Thirty Rooms to Hide In - Insanity, Addiction and Rock 'n' Roll in the Shadow of the Mayo Clinic by Luke Longstreet Sullivan

Thirty Rooms to Hide In – Insanity, Addiction, and Rock ‘n’ Roll in the Shadow of the Mayo Clinic

Luke Longstreet Sullivan

This remarkable book is a comic/tragic memoir written by a young man who grew up with an alcoholic father.  This is certainly a field that’s been plowed many times before, but this story is different in several respects.  First of all, the alcoholic in question was a renowned orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota.  Secondly, the story evolves in a time not so long ago when addiction was poorly understood, alcoholism was seen as a character flaw (“lack of self-control”) and the devastating effects of one person’s addiction on others in the household were grossly underestimated.  Luke Sullivan cobbled together this amazing narrative using contemporary diaries written by several of his brothers as well as his mother and by bound correspondence between his mother Myra and her retired father .

This is really the story of Myra Longstreet and her husband Charles Roger Sullivan.  They met while undergraduates at a small Ohio college in the late 1940s.  Their courtship was interrupted by Myra’s contracting tuberculosis and their marriage was interrupted early on by Roger’s commitment to the United States Navy.  Roger became an orthopedic surgeon and, after completing training at the Mayo Clinic, had the honor of being offered a position on the Clinic faculty.

The marriage produced six children – all boys, Luke being the fifth in line.  A good bit of the book deals with the hilarious antics of a household with six precocious and seemingly uncontrollable boys.  What one didn’t think of the others did.  There were frequent knock-down, drag-out fights, pranks which backfired and stunts which defy belief.  The “thirty rooms to hide in” refers to The Millstone, a spacious home on a large tract of land which the Sullivan’s purchased after Roger Sullivan began working on the faculty at Mayo.  The structure was built in the1930s and has a very unique architecture, including a turret where Myra kept a large library.  There were also spooky places, including an attic with peculiar crevices and a dark and dank basement which was converted by the Sullivans into a bomb shelter during the early 1960s.  The boys all had delusions of super powers and frequently used them to climb the high gabled tile roof of The Millstone or to climb down the sides of the structure like Spider Man. 

Underlying all of this seemingly charming veneer, Luke Sullivan tells the story of the deterioration of his father.  Roger developed the propensity to “rage” when he came home from the Clinic, consuming more and more liquor as time goes on.  He directed his rage mainly towards Myra, hurling verbal abuse that is incomprehensible.  He railed on for hours at a time about her deficiencies as a mother and wife and resented her close relationship with her father who lived in Florida and with whom she exchanged weekly letters.  Roger had a difficult relationship with his own parents.  His father was a Methodist minister and his mother (who the Sullivan children refer to as “The Rock” because of her stone-cold demeanor) was a domineering, fault-finding shrew.  Roger also verbally and physically abused his sons, once beating the head of one of the younger boys against the refrigerator because he couldn’t remember the days of the week for a quiz at school.  The resulting dents in the refrigerator remained a silent but constant reminder of how bad Roger’s temper was and how dire the consequences of his rages were.  In the vein of self preservation, the boys developed a talent for disappearing in the house or surrounding countryside, leaving their mother to bear the brunt of most of the terror.

The older two boys, Kip and Jeff, learned to play the guitar and formed a rock and roll band called The Pagans.  They became local celebrities, posing in advertisements for a Rochester clothing store and even recording their own 45 RPM record.   (OK, I’m showing my age:  I know what this is and still own a large collection of “45s”, including many by Elvis Presley, Bill Haley and the Comets, and The Beatles.)  Luke Longstreet uses this aspect of their family life to define the profound influence that rock and roll music, in particular the “new music” by The Beatles, helped shape many of us who grew up in that period.  He also uses The Pagans to illustrate Roger’s unpredictable behavior fueled by alcohol.  One day he was hiring The Pagans to play a Mayo party he was hosting at his house, the next day he was cursing and saying how loud, obnoxious and worthless The Pagans were.   

Roger’s addiction and resulting erratic behavior inevitably impacted his performance at the Mayo Clinic.  His supervisors, including the Chair of the Orthopedic Department all tried to help.  Roger and Myra each sought psychiatric consultation with little benefit.  Roger blamed all of his problems on his wife, which in the 1950s and 60s was a readily believed excuse.  The environment in The Millstone deteriorated to the point that Myra packed up the boys and left for a few months in 1964.  There is a riveting chapter where Roger is beating on the door of Myra’s library with an axe while she and the children cower in fear.  Finally, one of the boys lowers himself from the balcony “Spider Man style” and runs to the neighbor s for help.

Friends of the family also tried to intercede.  A local dentist, also a close family friend, tried to talk sense into Roger.  He was rewarded for his efforts by being accused very vociferously by Roger at a public gathering of having an affair with his wife.  Roger is finally let go from the Mayo Clinic.  He travels the country searching for another job, often showing up for interviews hung over or drunk.  One night, after calling home in another alcoholic rage, he dies from a combination of booze, sedatives and insanity.  This is not a “spoiler”, since the book opens with Roger’s funeral.

Luke goes on to describe his mother’s “life after Roger” which included academic success as a reading tutor and instructor at a local college.  Myra continues to this day (she is in her eighties) to assume a lot of blame for what happened to Roger and also for the shamble of a life they provided for their sons.  The author does not describe what happened to the six boys, although all are still alive.  Data shows a high incidence of addiction issues in offspring of alcoholics, so it would be interesting to know how these boys matured.  One would hope that they defied the odds and have lived a full, rich and happy life.

This book resonated with me on several levels.  First, the Sullivan boys grew up in the same era that I did.  I fully understood their fascination with rock and roll, their excitement about the presidential election of 1960 and their despair upon hearing of the Kennedy assassination.  Secondly,  I, too, am the son of an alcoholic father.  Fortunately for me, my father got help before I was born and remained sober the entire rest of his life.  Thank the good Lord, I never witnessed or suffered anything remotely similar to what befell the Sullivans.  I never even knew until I was in late high school that there had ever been a problem.  I just thought my parents were tea-totalers.  I enjoy alcoholic beverages as much as anyone but am very cognizant of their power and potential for disaster. 

This is an excellent book.  It makes several important points.  First, doctors and their families are human beings and can fall prey to the same demons as everyone else in the general population.  Fortunately, there are much better methods to deal with the impaired physician now then there were in 1960.  The Medical Society of Virginia has an excellent program (initiated by Lynchburg’s own Dr. William Barney) which has helped many.  Secondly, it is hard to comprehend that the understanding of addiction issues and alcoholism in particular was so primitive just one generation ago.  We should all be grateful to the researchers and workers in this field who have advanced the art of treating these problems.  Finally, Thirty Rooms to Hide In underscores the value of humor in coping with life’s many trials and travails.  I am grateful for Luke Sullivan’s courage to write this book and am very glad that I read it. 

Thirty Rooms to Hide In is a self-published paperback book which is available from the usual on-line vendors.  There are electronic editions as well.   It is also available for direct purchase (at a much reduced price) at the author’s web-site.  The web-site also contains many family photos and 8 mm videos.  There are scans of Myra’s letters and the children’s diaries.  There are even mp3 format recordings of The Pagans!  

Book Review: Cutting for Stone by Abraham Verghese

(Blogger Note: This review was published in the January, 2012 edition of LAMLight, the physician newsletter of the Lynchburg Academy of Medicine.)

This could be the very shortest book review which I have ever written.  It would read:  Buy, borrow or steal a copy of this book immediately and read it.  It is fantastic.  That brevity would not, however, do this book justice or fill up the page, so here goes:

Cutting for Stone is the first novel by author Abraham Verghese, an internist and infectious disease specialist.  He has written two previous non-fiction books.  The first, published in 1995 is titled My Own Country: A Doctor’s Story of a Town and Its People in the Age of AIDS.  He was practicing at the time in Johnson City, Tennessee.  The second, The Tennis Partner was published in 1999 and told of the author’s relationship with a colleague who had an unfortunate addiction problem.  At that time, Dr. Verghese was a Professor of Medicine and Chief of the Infectious Disease Division at the Texas Health Sciences Center in El Paso, Texas.  Dr. Verghese is now on the faculty at Stanford University as a Professor and Senior Associate Chair for the Theory and Practice of Medicine.  He also has received an MFA in Creative Writing from the prestigious Iowa Writers Workshop.

Cutting for Stone is a 657 page tour-de-force novel packed with history, unforgettable characters and descriptions of medicine practiced without any of the modern diagnostic tools.  The story starts in the early 1950s in Addis Ababa, the capital of Ethiopia. Ethiopia is located on the Horn of Africa and has Middle Eastern, Muslim, Christian and Jewish heritages.   Marion Stone and his twin brother Shiva are born in chaotic fashion.  They are delivered from a Carmelite nun by emergency C-section after attempts to deliver them vaginally by the mission hospital’s surgeon nearly killed them.  Sister Mary Joseph Praise was a dedicated surgical nurse and had kept the pregnancy a secret until she was found in the late stages of arrested labor in her room.  She had worked diligently for years in the operating theater with Dr. Thomas Stone who was presumed by all to be the babies’ father.  The secrets of the babies’ conception are hidden from the reader until nearly the entire book has transpired.  Sister Mary Joseph Praise dies on the operating table and Dr. Stone disappears.  The hospital is left in a state of turmoil, having lost their most talented physician and their most respected nurse in one day.   The twin boys are adopted by the hospital’s obstetrician and her husband, an internist who takes over surgical responsibilities in the absence of Dr. Stone.

The story then follows the childhood and early adulthood of both boys.  They are raised on the hospital grounds and attend local schools.  They are literally raised by a village, including servants, hospital workers and even some of the patients.  The author reveals the stories of Thomas Stone and Sister Mary Joseph Praise in flashback chapters.  They both were born and raised in India and each arrived at Missing Hospital in Addis Ababa for different reasons.  These stories are very compelling in their own rights.  Dr. Stone became an expert tropical surgeon and wrote an internationally recognized text book on the subject.  Marion and Shiva develop quite different personalities despite being identical twins.  Marion is the serious student and romantic, Shiva is rebellious and more irresponsible.  This inevitably causes friction and the boys become estranged after a fight over a local girl, a love interest for Marion and a conquest for Shiva. 

As a physician reading this novel, it was refreshing to read of doctors using history taking and basic physical diagnosis skills to solve medical puzzles and not only make correct diagnoses but prescribe the appropriate treatments.  They accomplish this without MRI or CT scans or reams of laboratory data.  They use their medical knowledge, their physical examination skills and their insights as diagnosticians to practice their art.

This author is able to weave the history of modern Ethiopia into the fabric of the novel, much like Khaled Hosseini did for Afghanistan in A Thousand Splendid Suns.  The author describes the impact of Italian occupation on the local culture and, in particular, the architecture.  He narrates the rise to power of the diminutive Emperor Haile Selassie and multiple attempts to dethrone him.  The hospital is geographically caught in the middle of several coup attempts and the twins’ adopted father is imprisoned at one point for operating emergently on one of the resistance leaders.  Political unrest eventually leads Marion to immigrate to America to complete surgical residency.

In another comparison to Hosseini, Abraham Verghese does a terrific job of describing the plight of women in third world countries.  The female characters in Cutting for Stone are subjected to unbelievable prejudices and sufferings.  There is one chapter which graphically describes a female circumcision and its horrible aftermath which is as riveting as it is revolting.  Even the crude health care system discriminates and women are often left with the natural consequences of their diseases.   Shiva uses his precocious fascination for repairing things and anatomical knowledge that he gleans by observing surgeries performed by his adopted mother gynecologist to devise a surgical repair for vaginal fistulae.  These are an all too common occurrence in Ethiopia because of early teen and multiple pregnancies combined with inadequate gynecological care.  Because of incontinence these women become outcasts, much like lepers in previous centuries.  Shiva's notoriety becomes yet another source of irritation for Marion who has worked tirelessly for years to become an accomplished surgeon, only to have his formally untrained twin receive notoriety for his surgical innovations.

The latter portion of the book details Marion’s life as a surgical house officer in a depressed hospital in New York City.   This hospital is in such a blighted area that it is completely staffed by foreign medical grads.  It is a virtual United Nations with Pakistani, Indian and Ethiopian physicians.  The combination and clash of cultures in the house staff living quarters is entertaining.   Marion inevitably comes into contact with his biological father who has by now reinvented himself as a renowned Boston academic transplant surgeon.  After expressing his great anger, Marion more or less makes amends with Thomas Stone.  Marion becomes seriously ill which precipitates a reunion of the brothers, their biological father and their adopted mother.  The book ends with the exposition of the many secrets and fears which all of the characters had held in their hearts for thirty years.

One of the more pleasant surprises in this book is the author’s description of the foods of his native land.  His descriptions almost make the aromas of lamb, lentils and chicken waft off of the page:

“Mustard seeds explode in the hot oil.  She holds a lid over the pan to fend off the missiles.  Rat-a-tat-tat! Like hail on a tin roof.  She adds the cumin seeds, which sizzle, darken, and crackle.  A dry, fragrant smoke chases out the mustard scent.  Only then are the onions added, handfuls of them, and now the sound is that of life being spawned in a primordial fire.”

  

 (Side note:  If you would like to try amazing and authentic Ethiopian food, try Zed’s Ethiopian Cuisine at 1201 28^th Street, N.W, in the Georgetown section of Washington, D.C.  Their chicken doro watt is superb and they have great vegetarian entrees as well, such as Split Pea Kik Alicha.  We discovered this restaurant a few years ago when it was recommended to us by an Ethiopian cab driver.)  

This is a wonderful book which is extraordinarily well written.  The words flow and the paragraphs glide and the entire book is a mesmerizing and fantastic reading experience.  The characters are so vivid you feel like you have known them your whole life.  The emotions are conveyed in a sincere way and all of the melancholy, fear, desperation, hope and even happiness are felt deeply by the reader.  Cutting for Stone is also a novel of redemption, forgiveness, sacrifice and triumph over adversity.    As I said earlier, get a copy of this book, read it and savor it.  You will be glad that you did.

Pat Robertson and Alzheimer’s Disease as Justification for Divorce

Pat Robertson has uttered another outrageous commentary during a “700 Club” program on the Christian Broadcasting Network.  He advocated divorce if a spouse became incapacitated by Alzheimer’s disease, citing the disease as a “kind of death.”  (http://www.huffingtonpost.com/2011/09/14/pat-robertson-divorce-alzheimers_n_963305.html)

Pat Robertson is a native Virginian (born in Lexington and a graduate of Washington and Lee University) and founder of the Christian Broadcasting Network in Virginia Beach.  He attended law school at Yale, was ordained as a minister in the Southern Baptist Church and ran an unsuccessful campaign for the Republican Presidential nomination in 1988.  When he ran for office he relinquished any church affiliation.  He remains, however, a prominent spokesperson for the “Christian right.”

I have had many patients over the years that have Alzheimer’s.  I have watched patients progress through the stages of this cruel disease as their personality was removed layer by layer like an onion peel   These patients also have other problems including vascular and heart disease, diabetes, etc.  The Alzheimer’s adds another dimension of risk because of the difficulties with compliance (remembering their medications, for instance), mobility issues and confusion.  These patients often exhibit fairly radical personality shifts as well.  A sweet, cooperative elderly gentleman can turn into a combative and argumentative patient very quickly.  I have been amazed over the years by the supportive, caring and loving spouses that often accompany these patients to visits.  They have more than likely been “covering” for their spouse for years, helping them stay organized and functional.  They are present when their loved one says something spontaneous which is often embarrassing or silly.  These spouses suffer social isolation when other folks stop having them over.  First and foremost, they watch as their partner for decades dissolves in front of their eyes.  They lose that companionship and support which is the hallmark of long standing relationship.  They lose life as they knew it. 

According to Pat Robertson, this is the time to punt and run.  Give up.  In his own words, when asked by a viewer of his “700 Club” program if it was alright for a man to see other people if his wife was incapacitated with Alzheimer’s, Robertson said “I know it sounds cruel, but if he's going to do something, he should divorce her and start all over again, but make sure she has custodial care and somebody looking after her.”  Cut your losses, start over, live a little.  Really? 

Where’s the honor and dignity in that?  Leave aside all religion, scripture and Beatitudes and look at it from a strictly moral point of view.  Is that really the right and moral thing to do?  Is that what you would want your spouse to do for you were you to become incapacitated by Alzheimer’s or any other disease?  Why limit it to Alzheimer’s dementia?  Extrapolate this thinking to stroke victims, people with multiple sclerosis or debilitating diabetes.    What’s next, euthanasia?   When did spouses become disposable possessions to be discarded when they don’t work like they used to like an old VHS player? 

I’ve got news for Mr. Robertson.  Everybody gets something.  Everybody dies, and before they do, they usually have some sort of illness that limits them.  It’s the rare bird that lives to a ripe old age and dies in their sleep without ever being seriously ill.  I, for one, am very grateful for a spouse who I know has and will be with me every step of the way, wherever that might lead.