07/6/15

The Matriarch of Ruins

Today, the Gettysburg Trilogy continues…

In Book 1, Not One Among Them Whole, a novel of Surgeons and the Wounded at Gettysburg, the harrowing story of life at the front edge of a 19th century battlefield hospital was told.

Now, from the author of that acclaimed novel, comes the story of the civilians among the wounded in that surreal time:

 

Husbands and wives.

Sons and daughters.

Soldiers and surgeons.

Men and slaves.

Widows and ghosts.

The living and the dead come alive in this epic novel of a widow struggling to keep her family together amid the carnage of the Battle of Gettysburg—and the memories of her dead husband. A story of ordinary folks caught in the maelstrom of an extraordinary time.

It is 1863 and the war has come home to the Gamble farm in Southern Pennsylvania. With her husband buried under the willow tree in the back yard, and only four months in the ground, the widow Purdy Gamble must cope with losing him all over again when a rebel surgeon conscripts her farm—and Purdy’s growing respect despite herself. Hannah Gamble Griel, Purdy’s daughter, disappears into the chaos of war to chase her own ghosts, both imaginary and real. And then there are the twins Loli and Coal, just fourteen. One, struck dumb by a mule kick at age five, will find a disturbing peace amid the flames of war. The other will twice save a man’s life, unburying a horrid family secret in the process—a secret at once as alive as warm flesh and as dead as cold bones mouldering under the earth. 

The Matriarch of Ruins is a haunting story of lost love, moral dilemmas, and psychological traumas amid the ruins of war, by the author of Not One Among Them Whole. This is a vivid, suspenseful tale, told with heart-breaking empathy and stunning detail.

READ AN EXCERPT: CLICK HERE.

Now available for the Amazon Kindle. Soon in paperback as well. From Northampton House Press. Buy it today and be transported to another era. 

The Matriarch of Ruins (Gettysburg Trilogy, #2)


06/28/14

The First Clinical Xray

FirstGSWSpineLogo

 

This is an historic image.

On January 1st, 1896, Wilhelm Rontgen presented the first ever xray, an image of his wife Anna’s left hand. Later that year, a young doctor by the name of Harvey Cushing—who would go on to become one of the most prolific surgeons in history and the father of modern neurosurgery, produced this image, the first clinical x-ray (they called them rontgenograms back then)—a gunshot wound to the neck and spine.

There are actually two images here, one from the front (on top) and one from the side (on bottom). Each image took an incredible thirty-five minutes to expose.

The xrays show the bullet frgament (the dark blob) either within or overlying the C6 vertebra. So which is it—within the bone or in front of it?

It’s worth recalling that x-rays are 2-D representations of 3-D space. Consider a regular photograph. Everything visible in the frame of a regular photo will be condensed to a single plane, with only the items in the forefront visible. Everything behind will be hidden. With an x-ray however, everything in the frame will be condensed to a single plane including the items in the background. What?

If I take a picture of my hand over my face, my face is hidden by my hand. You can’t see how big my nose is or how many teeth are missing, because they are in hidden by my hand. But if I take an xray of my hand over my face, you’ll see not only my hand bones, but all the bones, teeth, and various soft tissues of my both my hand and face. In fact, that’s the hallmark of an xray—it looks through what’s on top to show what’s behind.

Put another way, in a photo only the visible foreground information is used to generate the image. By contrast, in an x-ray, all of the information in the frame (hidden or not to the naked eye) is used to generate the image. 

So how do we know if the bullet is in the bone or in front of it? The answer, of course, is we have to have two images in different orientations. Fortunately, Harvey Cushing intuited this even back in 1896. The image on top is an AP image—an exposure taken from the front. The dark spot overlying the C6 vertebra is the bullet. C is the skull and D is the ribs and lungs. The image is severely underexposed, so the soft tissue does not show well (including the lungs). Of course, since it was the first x-ray of its kind, we can forgive the underexposure.

The lower image is a side view. It shows the bullet overlying the C6 vertebral body as well. Since both the AP and side (lateral) xrays show the bullet overlying the bone, it must in fact be within the C6 vertebral bone itself—and not just in the soft tissue in front of or alongside the bone.

FirstGSWSpineDetail

On the lateral image, A is the spinal canal (where the spinal cord itself lives, here it has been colored in for clarity). B is the so-called pre-vertebral space, the soft tissue in front of the spinal column. There isn’t much detail here compared to today’s imaging, but there’s enough for us to say there is no fracture of the bones despite the presence of the bullet in the body of the C6 vertebra. The body of any vertebrae lies in front of the spinal cord, and very often a bullet may be lodged there without damage to the cord itself (especially if it is a low velocity missile image, as it likely was here). 

At other times, severe spinal cord injury (paralysis) may result from a gunshot wound to the spine, even one that completely missed the spinal cord itself. This is caused by blast effect, a sort of shock wave that goes through the tissue as a result of the kinetic energy of the gunshot wound as it passes through and disrupts the anatomy. Think of it as the ripples emanating from a pebble thrown into a quiet pond of water.

Of course, it’s possible the bullet passed through the spinal cord before it came to rest in the C6 body. That’s doubtful here though, since there’s no apparent bony fracture and such a path would very likely have disrupted bone. More likely, this bullet entered the front or side of the neck and came to rest just in front of the spinal cord, within the C6 vertebral body. From a stability standpoint, such an injury is very stable (that is, it does not compromise the spine’s ability to hold the head up—the patient would not need to be externally braced). We would not operate to remove such a bullet today, unless CT showed a blood clot compressing the spinal cord. Even then, the primary goal would be to remove the blood clot; retrieving the bullet would be secondary. Of course, there might be a non-neurosurgical reason to operate, such as damage to the trachea, etc.

Occasionally, serial imaging will show the bullet’s position is not stable, that is, that the bullet is migrating around. In such a case, removal may become necessary. There is a famous case in the neurosurgical literature of a very heavy bullet migrating through brain tissue. Imagine the damage that could cause!

Was this patient paralyzed? No way to tell from the images and his or her clincial fate is lost to us.

What about Harvey Cushing, the enterprising young doctor who made the x-rays? As noted, he went on to become the father of modern brain surgery. Almost single handedly he reduced mortality in brain surgery from a wopping 70-90% to much more tolerable though still astounding 10% (today it’s well below 1%).

Harvey Cushing operated on over 2,000 brain tumors. After he lost a patient in surgery as a medical student (he was responsible for anesthetizing the patient while the professor repaired a hernia during a lecture—when the patient died, the operation proceeded anyway!), he developed the anesthetic record, being the first to use serial recordings of heart rate and breathing. Blood pressure was added later after he discovered the BP cuff on a trip to Italy and brought it back to the United States with him (standard of care is to record all of these vitals and much more in modern day surgical anesthesia).

He made numerous advances in our understanding of the pituitary gland (Cushing’s disease, a dysfunction of the pituitary gland, is named after him).

Along with William Bovie, he developed electrocautery, which is used in 99% of operations today to minimize bleeding. Without it, modern surgery would not be possible.

He also won the 1926 Pulitzer Prize for his biography of Sir William Osler (considered by many the father of modern medicine, and one of the founders of Johns Hopkins Hospital). By the way, Cushing, who manned a military hospital in France during the last year of WWI and made many contributions to military medicine and surgery as well, was present when Osler’s son Revere died of his war wounds in France.

Cushing, a chain smoker, died of heart disease in 1939 at age 70. An autopsy showed he had a benign form of brain growth called a colloid cyst—which might well have been operated on using today’s standards.

05/14/14

Because We Are Not Animals

BECAUSE WE ARE NOT ANIMALS

by Edison McDaniels II, MD

This was published in the Opinions Section of Navy Times, April 2002.

My name is Edison McDaniels and I am a neurosurgeon on active duty with the United States Navy.  Recently, I was ordered to Guantanamo Bay Naval Hospital in order to do urgent surgery on one of the detainees from the war in Afghanistan.  The man had been rendered paraplegic by an abscess in his spine.  Since returning, indeed even as I was packing to leave for Cuba, I have repeatedly been asked why we should provide medical care to these people.

The answer, of course, is because we are not animals.

Winston Churchill once said:  “Prisoner-of-war, you are in the power of your enemy.  You must obey his orders, go where he tells you, stay where you are bid, await his pleasure, possess your soul and patience.”

Of course, it is not my place to debate whether or not these men are prisoners of war.  However, it certainly seems that they are wartime detainees, and, as such, the significant implications of Churchill’s statement must apply.  In times of captivity, the onus is upon the captors to see to the well being of their captives.

So what, you ask?

Consider the horrific consequences of not doing so.  Actually, you need only to look at history for examples too numerous to count.  Read, for example, the following account of captive life at Belle Isle during the Civil War, from a young union soldier named Charles Fosdick captured at Chickamauga:

“When we first went on the island, our rations consisted of a piece of cornbread…a little bit of bacon, and a cup of pea soup. With multitudes of weevils or black bugs which would rise to the top to the thickness of an inch, at first we would take a spoon or paddle and fish out those insects.  But later on, we became so famished for food that we would break our bread into the soup and devour it, bugs and all… The pea or bug soup was set out in wooden buckets which made it very convenient for a herd of dogs, the favorites of the officers and men on duty, to go and eat and drink as their appetites suggested. This was done before our eyes…  Finally one day, one of these dogs chanced to come within the prison limits and no sooner in, than it was seized and killed.  It was then dressed to cut up and cook and furnished a pleasant repast for several hungry men.  After this occurrence, and once a taste of fresh meat, the boys contrived all manner of projects to decoy an unwary dog to cross…  And they were so persistent in their efforts, that in a short time there was not a live dog left on Belle Isle.”

Not vivid enough?  Try this morbid account of life at Andersonville prison in 1864 from inmate Charlie Mosher:

“July 31st.  I have been very sick for the past week with a dysentery.  So sick that it did not seem as if I could hold together any longer.  This is the worst sickness I have had, and there are thousands who are as bad and worse than I have been.  It is awful.  Men are lying all around in the hot sun, face up with their mouths wide.  The fleas, lice, and maggots are holding high carnival in here.  Human nature is made of good stuff or it could not stand the strain.”

Or consider the following:  On 9 April 1942, 10,000 Americans and 62,000 Filipinos were captured at the surrender of Bataan.  The ensuing march to Camp O’Donnell, Luzon, Philippines, between 12 April and 24 April 1942 resulted in the deaths of at least 10,000 (and possibly as many as 18,000) of them.  The well known atrocities that occurred during the march included the failure to provide even the most basic human needs, including food and water.  And the dying didn’t end when the march did.  In the first forty days of Camp O’Donnell, an additional 1,500 Americans and 25,000 Filipinos died as a result of malnutrition.

In the Revolutionary War, at least 11,000 American prisoners died on a single British prison ship, the HMS Jersey.

During the Civil War, 25,956 Confederates and 31,000 Union soldiers died in captivity.

Of 43,648 Americans known to have been held as POWs by the Japanese in WWII, 12,953 of them died.

These are hellish numbers, and though they may seem to refute the statement made above, “because we are not animals,” they certainly do not justify letting a man die in his own excrement.

One of the detainees, waking from an operation to remove a blind eye, told his translator that he was surprised to be alive.  He thought he was being executed as he went to sleep.

What separates Americans from those that would do us harm, is not the belief that we are any better, but rather a certain knowledge that all people are better, that all people have not just some intrinsic worth, but the same intrinsic worth.  The central core value of the great mechanism that is American society, the crowning glory of the American way of life, is tolerance for race, for gender, and for religious belief–even when that belief is far a field from most western values.  It is only when that belief crosses the line that separates man from animal that one can justify forceable intervention.

Though their acts may mark them as animals, we know better and must behave accordingly, because we are not animals.

We (the American people) have provided the detainees with food and water, shelter, lodging, and basic medical care.  Nothing more and nothing less.  In a reasonable and just society, it falls to those appointed over us to determine the ultimate fate of these wretched and troubled souls.

 This was published in the Opinions Section of Navy Times, April 2002.

04/19/13

A Game of Shadows 3

Shadows

A GAME OF SHADOWS, 3/3
by Edison McDaniels, MD

Beginning in the mid 1970’s, when the first CT scans became available, the ease and ability with which neurosurgeons could localize anatomic lesions within the skull skyrocketed. The initial CT era, which spanned about 15 years, saw the development of higher resolution imaging as well as faster machines. An entire head CT in 1990 took about 10-12 minutes or even longer. Today, about 20 seconds. This means very few patients have a serious enough injury to bypass CT and go straight to surgery. If they can be stabilized at all, a stop in CT will generally increase their chance of survival by allowing detailed imaging of not just the brain, but the chest, abdomen, pelvis, and other injuries as well. In fact, such imaging in trauma not only allows the recognition of injuries requiring surgery, it also allows the recognition of injuries suitable for nonoperative observation—injuries that would have been operated in the past but, under close observation and supervision, are not operated today.

That 15 years also saw the development of contrast agents of various sorts. These contrast solutions, you might think of them as dyes, make tumors which would otherwise be invisible on CT or MRI visible. Many tumors have the same density as the surrounding brain and are only rendered truly visible by this contrast solution. A large tumor will give itself away by the distortion it causes to the surrounding structures whether or not it is itself visible, but such distortion may not be apparent post-op. In such a case, regrowth of the tumor can be checked for with contrast solutions. This has had a tremendous effect on modern day neuroimaging and neurosurgery.

E MCD 004

MRI of a large brain tumor sitting between the frontal lobes. It is only visible because the patient has been given a contrast agent, otherwise it would appear quite similar to normal brain—though distortions in that normal brain would still announce its presence to the informed eye. This tumor is almost certainly benign (not cancer).

By the way, the difference between CT and plain x-ray is that CT does have a 3D aspect to it, which allows very fine discernment of tissue density. What looks like a solid structure on plain x-ray, the heart for instance, actually can be seen as a multichambered muscular organ on CT. In a practical sense, this means a radiologist can tell the difference between normal gas inside the small intestine, and abnormal gas within the wall of the small intestine, as might be present if the small intestine has been damaged by tumor, infection, or trauma. This means the surgeon can operate early rather than waiting for the patient to develop signs of peritonitis—life threatening infection—first.

In fact, the ability to discern the fine details of anatomy is so good on CT and MRI, that some medical schools are now foregoing real human cadavers and teaching anatomy virtually, using programs composed of thousands of pictures (CT and/or MRI slices) of the human body.

MRI has come into its own since about 1995. MRI is extraordinarily sensitive in terms of anatomic detail. One can see very fine vessels, perhaps just 2-3 mm in diameter, on MRI. Very small tumors, too small even to be operated upon, are also visible. In fact, sometimes we find things which aren’t tumors at all but incidental curiosities. These are things we would only have found at autopsy in the past. As a neurosurgeon, I see several patients a month with such findings. We generally don’t operate on these incidental findings.

ICHVeryLarge

CT of a large, life-threatening hemorrhage (the white stuff). It’s on the right side of the brain. This patient is almost certainly comatose. Without an emergent craniotomy, he or she will not survive. With surgery, his or her long term outcome might be surprisingly good if operated in time. In neurosurgery, Time is Brain. Time is life. This is one of the first lessons a neurosurgeon in training learns.

Sometimes the incidental findings seen on MRI are important. A small lesion shows up in the frontal lobe, perhaps too small to cause symptoms just yet. Is it a tumor? Or just a curiosity? Sometimes we can’t know. Such cases have to be individualized. Occasionally surgery is recommended to biopsy the lesion or remove it entirely. More often a wait and see approach is taken, wherein the imaging is repeated in a few months looking for growth or some other change.

Up until recently, most all imaging has been anatomic. Today that is changing. More and more, functional MRI is coming to the forefront. fMRI actually observes and measures physiology—neuronal activity and connectivity. This is useful to avoid damage to elegant areas of the brain during tumor surgery, or to identify the focus of seizure activity. Or, in the case of post-surgical recovery or after a stroke, to assess neural plasticity. Much of this is still experimental and only available at tertiary centers, but stay tuned. It has been called Neurosurgery 2.0.

By the way, functional imaging of the human brain has another promising use. It is now possible to see nonorganic disease—psychiatric disorders—in action. This technology is in its infancy, but imagine being able to visualize how a human thinks in an objective fashion. Schizophrenia may show activity is one particular area, mania in another. One can imagine scanning a patient to check on the efficacy of a particular treatment or medication. Taking it still further, might it be possible to ferret out a murderer in this fashion, or maybe even a future murderer?

In other words, be careful what you think—big brother just might be watching…

Edison McDaniels, MD, is a board certified neurosurgeon practicing in the American South. Follow him on twitter @surgeonwriter and read his fiction on Amazon in both paperback and kindle.