04/15/13

A Game of Shadows 1

Shadows

A GAME OF SHADOWS
by Edison McDaniels, MD

A truism: the evolution of neurosurgery has largely paralleled the evolution of imaging of the nervous system. Great strides have been made since the 1970’s, when the first CT scans became available and it thus became possible to localize an anatomic lesion within the central nervous system with great accuracy.

There was imaging available before the 1970’s, of course. The period before about 1974 or ’75 might be called the era of shadows—for that is what the imaging amounted to. In fact, even today, plain x-ray imaging is really a game of shadows.

Different tissues of the human body are composed of different densities, with the most dense being the teeth, followed by the bones, and the least dense being the air-filled structures, especially the lungs. The denser the tissue, the more prominent the shadow on x-ray.

With the exception of the teeth, bones cast the most prominent shadow on x-ray. Indeed, the shadow of a bone may be so dense as to obscure everything both in front and behind it (remember, plain x-ray is a 2D affair—it’s as if the body has been flattened to a single plane, like a photo, which is exactly what an x-ray is; as an example, if you take a picture of a person, the person obscures everything behind them—in the case of an x-ray, the bone obscures everything behind and in front of it).

2015-05-25 11.30.43

This is an xray of the lumbar spine. There are actually 4 screws, but because they overlap each other it looks like only two.

Reading a plain x-ray is thus, largely, about learning pattern recognition—what sorts of shadows various tissues cast. Sometimes, the shadows overlap, the densities summing to appear to show something when in fact there is nothing there. This is known as a superfluous confluence of shadows.

The situation is made all the more complicated by the idea that the shadows are often not representative of the structures themselves, but only of their relative presence or absence. What? One example will do nicely to illustrate the situation.

Consider the state of the art in neuroimaging prior to the mid-1970’s, pneumoencephalography (the title image is a pneumoencephalogram). This test, invented in 1919 by one of the founding fathers of modern neurosurgery, Walter Dandy, involved replacing the CSF with air injected into the ventricular system within the brain. The ventricles are normally fluid filled and thus, on plain x-ray at least, have a density similar to that of the surrounding brain (for the purposes of plain x-ray, brain and water have nearly the same density). As such, a normal or even abnormal ventricle is not visible on a plain x-ray and certainly is not discernable from the surrounding brain.

Dandy, for various reasons, had the idea to replace the CSF of the ventricles with something either more or less dense than the surrounding brain and thus make them visible on x-ray. Why? Because of the whole shadow idea. If the ventricles could be made visible, their shape would be discernable. If their shape was discernable, the prying eyes of the physician would be able to see if they were enlarged, say by hydrocephalus. Or, more to the point, if they were distorted—that is the ventricles were shifted out of their normal position or shape—by the presence of a tumor. In visualizing this, the location of the tumor would thus be suggested and the tumor localized not directly by the shadow of the tumor but indirectly by the abnormal shadow of the ventricle.

And localizing the tumor was of course, the holy grail of neurosurgery since one could not safely or even comfortably operate upon a tumor in the human brain if one did not have a fairly good idea of where it was to be found in the first place.

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. 

Click here for Part 2: More on pneumoencephalography, and the development cerebral angiography—one of the great advances in medicine. 

04/13/13

Saving King

Killing King

The time is the 4th of April 1968, a cool Spring evening close on six pm. The place is a predominantly black neighborhood on the south edge of downtown Memphis, Tennessee. An area of run-down homes and low incomes. At 450 Mulberry Street there sits a small, modestly upscale boarding establishment, the Lorraine Motel. It is two stories and there is a pool, installed by the motel’s long time owner, Mr. Walter Bailey. The motel is popular among black musicians who frequent the nearby Stax Records. Over the years these have included Ray Charles, Lionel Hampton, Aretha Franklin, Ethel Waters, and Otis Redding before his death the year before.

Across the street and beyond a small brushy knoll is a two-story brick rooming house. 422 Main Street. On the second floor of this shoddy establishment, at the window of a small bathroom, a man named James Earl Ray waits with a 30.06 rifle. Ray has a clear view of the Lorraine Motel, of room 306 on the second floor.

It is one minute after six in the evening and, in the time it takes a bullet to fly the length of the knoll, everything changes.

Martin Luther King, 39 years old, has already survived one assassination attempt. Ten years earlier, on September 20th, 1958, a deranged black woman with the bewitched name of Izola Curr plunged a steel letter opener into his chest—his sternum actually—while he was holding a book signing at a Harlem bookstore. Three hours of emergency surgery at Harlem Hospital saved his life. The blade missed his aorta by a hair’s breath.

He will not be nearly so lucky this time…

 

In all of American history, surely one of the most atrocious acts of gun violence took place on the evening of April 4, 1968. No less a personage than George Wallace, the avowed segregationist, called the shot that rang out at 6:01 pm in Memphis, Tennessee “a senseless, regrettable act.” President Lyndon Johnson canceled an important trip to Hawaii—he had been scheduled to meet with his military commanders about strategy in Vietnam—upon learning of King’s death.

Over 100 American cities erupted into rioting on the news of what this single gunshot wrought: the stilling of the greatest single voice in the American civil rights movement, the Rev. Dr. Martin Luther King, Jr.

These facts are well known and not in dispute: King was shot at 6:01 pm and was pronounced dead at 7:05 pm at St. Joseph’s Hospital after a failed attempt at open cardiac massage. He was 39 years old.

According to King biographer Taylor Branch (At Canaan’s Edge: America in the King Years, 1965-68), King was standing on the balcony outside room 306 on the second floor of the Lorraine Motel when Jesse Jackson hollered up to him: “Doc, you remember Ben Branch?” King replied “Oh yes, he’s my man.” King then said, “Ben, make sure you play ‘Precious Lord, Take My Hand,’ in the meeting tonight. Play it real pretty.”

Ben Branch replied “Okay, Doc, I will.”

There was no reply.

King had spoken his last words, and in the words of biographer Taylor Branch, time on the balcony had turned lethal and King’s sojourn on earth went blank.

But did it? Did it do so immediately? Was King doomed the moment that bullet crashed through him? Is there any action that might have saved his life as he lay supine on that balcony. Bleeding profusely from a wound to his right jaw and neck? He wasn’t pronounced dead for 64 minutes. Was he, in fact, alive during that time? Was there ever a chance he could have been saved by the relatively crude trauma care of 1968? And how about today? If King was shot in 2013, might he survive?

The answers to these questions and more are interesting and worth pursueing. They illustrate, if nothing more, how far trauma care has come in the forty-five years since that fateful night. Based on a close reading of eyewitness reports, the autopsy filing, the 1978 House Select Committee on Assassinations’ investigation into the assassination of Martin Luther King, and other sources, I have put together a creative but nonfictitious account of the efforts to save Dr. King’s life in the 64 minutes that followed his shooting.

This is an intense, no holds barred look at what transpired in 1968, and an equally intense account of what might occur under similar circumstances today. If you have any interest in medicine, surgery, the drama of the emergency room, or trauma in general, you won’t want to miss this.

SAVING KING is about one of life’s harder moments. Available now for the Amazon Kindle. Just 99¢ & you can touch a piece of history.

Killing King

Click on the book image to buy for 99¢ for the Amazon Kindle

Now that’s damn interesting!

03/3/13

“Then, sir, you will go as a corpse.”

“Then, sir, you will go as a corpse.”

425px-Edward_VIIWhen Queen Victoria died in 1901 after more than 50 years on the throne of England, her  59 year old son Edward succeeded her. He was set to be crowned King Edward VII on June 26, 1902.

Twelve days before this, on June 14, 1902, the future king developed abdominal pain. He was examined by the physician-in-ordinary to the King (they have such wonderful titles in Great Britain), Sir Francis Laking. Edward worsened over several days and by the 18th Sir Frederick Treves was sent for. Treves was, at the time, the most famous and best known surgeon in London. 

Treves is known by many today as the physician who rescued John Merrick, the so-called Elephant Man, from his appalling life as an exhibit in a circus sideshow. This story was popularized in the movie The Elephant Man, in which Anthony Hopkins played the doctor.

Treves had originally gained famed by performing the first appendectomy in England in 1888. Appendicitis was a deadly disease at the time, and remained so for much of the first two decades of the twentieth century. At the time of Edward’s illness, surgery was usually considered only as a last resort.

Edward appeared to improve for several days, even traveling to London from Windsor on Monday, June 23rd and hosting a large dinner party for coronation guests. But that night he took a dramatic turn for the worse and by the following morning it was apparent to Treves and the other attending physicians that an operation was necessary to secure the King’s life. 

The King refused, not wishing to delay the coronation. It was at this point Treves uttered his now famous words, “then, sir, you will go as a corpse.”

The operation was carried out by Treves at 12:30 pm on June 24th, 1902. Lord Joseph Lister, who had discovered antisepsis and ushered in the era of antispetic surgery (which eventually made modern day aseptic surgery possible), was among those in attendance. The operation was carried out in a room at Buckingham Palace. 

Interestingly, the appendix itself was not removed, probably because it was too scarred in to mobilize easily. Instead, the pus pocket surrounding it was entered and drained through the front of the abdomen (today this is a routine part of treating any abscess—incision and drainage to the outside). The King recovered uneventfully, though it is said Treves did not leave his bedside for seven long sleepless days and nights.

Treves was made a Baron, among many other honors, and appendix surgery finally ascended to its rightful place in the British surgical lexicon. 

Ironically, Treves own daughter died of appendicitis.

Frederick Treves

Frederick Treves

03/1/13

Grapes of Wrath

The Grapes of Wrath

Nine

My father is the tallest child in this picture. He was about 13 or 14 at that time.

It was 1937, the dust bowl years. My family was living in Henderson, Ok. They were sharecroppers, cotton mostly. My father used to tell me how he chopped rows and rows of it in his boyhood, rows that went on for miles, and how much he hated it. 

After that cotton season, the family set out in what was sometimes described to me as a beaten down old station wagon, sometimes as a truck. It held fourteen people, kids and adults, as well as luggage and dogs. My dad, Edison, spent the trip in the back seat, with a girl named ‘Pumpkin’ on his lap for most all the way. I guess I never thought to ask her real name.

A note. Papa (my father’s stepfather—his own father died in a streetcar accident in NYC when my dad was three) once owned a shiny new car. This would have been a few years before the move. But according to my dad, it stalled crossing the tracks one day and was struck by a train. Papa barely got out before the car was totaled. Apparently the kids in the area spent the summer playing on the wreckage. If this story sounds a bit far-fetched to you, so it did to me. But he swore it was true.

They spent the entire summer of 1937 making their way across Texas. They stopped often to pick cotton, were received warmly nowhere, and mostly sucked dust blown up by the tires as they wheeled down the road. They frequently picked cotton from first light to darkness. There was no school.

My dad never knew why they left Oklahoma exactly. Probably, he thought, because his parents realized they were getting nowhere as sharecroppers. That’s certainly the sense he had of it. 

My dad is the oldest child in this picture, holding his youngest sister. My youngest uncle was yet to be born, c. 1937.

He remembered the state of Texas as endless, the cotton as endless. At night they parked on the side of the road, put up a tent or two (not enough for all of them) and ate a dinner of hoecakes. My dad described them as essentially nothing more than flour mixed with water and then fried in a pan until all the water was steamed out. The hard cake left behind wasn’t bad if you ate it with syrup. They also had plenty of vegetables and fruit, mostly watermelon. My dad couldn’t recall eating meat once on that trip.

He recalled the nights as difficult, mostly because one of his older sisters (he never said which one—he had six) had her boyfriend along and the sound of them secretly making love every night was a misery to his ears. He was afraid she would get caught and he was afraid to say anything to her directly because he didn’t think she knew he could hear her. He said this single issue nearly drove him nuts. He was fourteen at the time.

He remembered Arizona as more friendly (to the day he died he hated Texas) and hot as the blazes. The cotton grew taller, often over their heads I guess, and for some reason there were lots of people taking pictures of them. At least that’s how he remembered it.

Sometimes they encountered rattlesnakes in the cotton, but nobody ever got bit.

They passed into California at Blythe. Their reception was not kind. The place was filthy, full of homeless folks (like themselves) and at the border they were forced to dump all their fruit and vegetables. My dad remembered as appalling the mountain of fruit and vegetables on the side of the road there. In the days that followed, when there wasn’t always enough food, that sight haunted him.

They managed to leave what he called Okie camp fairly quickly and made their way to an uncle’s place. The man, his name remains unknown to me, somehow owned a sizable farm just outside of Indio, Ca. Later, they settled in Palm Springs and my dad attended the inaugural four years of Palms Springs High School, which he described as a blissful place where racism was unknown and the American Dream was still alive. He felt he owed much of his success to the four years he spent there. In his last year, he was captain of the football team and they won seven out of eight games. His letterman’s certificate is dated December 6th, 1941, the day before Pearl Harbor.

In February of 1943, shortly after he graduated, he was drafted into the Army. 

Nothing would ever be the same again.