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Tails, tetanus and turner
0895-4356/90 53.00 + 0.00 Pergamon Press plc
J Clin Epiddol Vol. 43, No. 4, pp. 405-411, 1990 Printedin Great Britain
Second Thoughts TAILS, TETANUS AND TURNER RICW
V. LEE*
Department of Medicine, Children’s Hosp& of Buffalo and State University of New York at Buffalo, NY 14222, U.S.A. (Received in revised form 3 February 1989; receivedfor publication 31 August 1989)
When we first started shepherding we were a little nonplussed to find that lambs came with long tails that had to be amputated in order to satisfy the aesthetic anxieties of sheep fanciers about ovine personal and reproduction hygiene. We lost a fine month-old ram lamb to tetanus one winter. It was a horrible, grotesque event. The disease was biologically understandable but ugly notwithstanding, uglier because it was the result of cosmetic surgery. The episode began when our boys, Matthew and Benjamin, then in their early teens, put on the thick elastic band which is used to occlude the blood supply to the tail. A few days later, after the distal part of the tail was avascular, they docked the tail. The rubber band technique works well for tails and testicles. It is easy and relatively bloodless, but it carries the risk of leaving a layer of ischemic or necrotic tissue at the site of the docking which may act as a comfortable home for anaerobic bacteria such as Clostridium tetani. Ben found him during the early morning chores, on his back, legs rigid in the air. We tried to save him despite the odds. The family carried out a saddening nursing routine every 2 hours trying to get fluids and muscle relaxants into him but the heart-stopping myoclonic jerks of the poor creature’s body brought tears; I gave him penicillin and human tetanus immune globulin because the old anti-tetanus horse serum
*All correspondence should be+addressed to: Richard V. Lee, M.D., Department of Me&tine. Childreri’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, U.S.A.
was hard to get. For 2 days and 2 nights we were witness to the dreadful disharmony of disease. Nature’s cruelty, and what seemed to be our abetment of it, ceased, unwitnessed but not unfelt, while I overslept my 2 hour schedule the third morning. We were a subdued family that day: the boys.startled by the seemingly aimless brutality of the natural process, Susan and I distressed at our failure to be good animal husbanders. None of us could hide the dismay at the undesirable effects of tail docking. Mulling over the dismal events on the way into the hospital later that day, several clinical items became apparent. The appearance of tetanus in a month-old lamb indicated an absence of maternal antibodies, something of a surprise to me since I had once thought that domestic animals could acquire immunity from exposure to tetanus toxin altered and made antigenic by the digestive process, I wondered if we :would have to give our small flock tetanus toxoid. Immunization seemed a benign human intervention compared to tail docking. Cosmetic concerns are not without hazard. Despite good statistics, adverse, even ugly, effects can be produced by contemporary plastic surgery. Perhaps one of the greatest hazards to health at the close of the decade of the 1980s is the relentless pursuit of thinness attested by the epidemic awareness of anorexia, bulimia, and fitness fanaticism. There is something ugly, offensive, about the skeletal self-righteous parsimony of the anorectic and fitness fanatic or the profligate puking of the bulimic. These conditions defy not just medical precepts but
405
406
Second Thoughts
notions of beauty. If nothing else, I ruminated, the tetanus death of our lamb brought home the importance of beauty and the idea of nature to my notions of and practice of medicine. Beauty and nature! Uncommon words on hosptial wards. Medicine deals directly with nature and with beauty. But in the oscilloscopic, bloodletting, high tech teaching hospital these are distant, vaguely suspect, seemingly irrelevent ideas. There is a tendency to regard hospitals as pest houses for the ugly detritus of humanity. We are awed by a Mother Theresa who can find love, beauty, and solace nursing the sick and slums of Calcutta. There is, in fact, much beauty in medicine and we physicians talk a lot about the natural history of disease. Perhaps some of the lamentations about contemporary medicine derive from a decline of a medical aesthetic sense. Does medicine have an aesthetic? I believe it does. In many ways medicine is the art of nature: human attempts to manipulate biology in response to perceived disharmony, ugliness, irregularity. Medicine is as much a quest for beauty as is the creation of a landscape painting. The aesthetic sense of medicine is shaped by ideas of nature. There are as many ideas of the beauty in medicine as there are ideas of nature. Usually we look upon the living organism as we do a well-ordered landscape. The regular and intricate rhythms of vascular and endocrine function cycle peacefully and unobtrusively. Disease is disharmony, irregular rhythms, excessive phlegm, a plant or creature out of place. There are those that take nature to be the fierce neo-Darwinian world of “nature red in tooth and claw.” In this ambience, disease is like any other predator, a necessary part of the biological order and possessing its own frightening beauty and virtue. There are others who, terrified and saddened by the all too solid, rottable flesh, pursue Cartesian abstraction and Oriental mysticism. For them the reality of nature is the mind; the goal of healing is redemption, release from the cycles of biology by training the mind to discipline and ultimately to discard the flesh. The Himalayan mystique includes the exquisite other worldly awareness of being wholely a part of nature, a loss of individuality. Human intervention and intrusion about nature possesses the capacity to be extraordinarily beautiful or extraordinarily ugly. Medicine is home to some of the most daring, risky, and grotesque human intrusions; and medicine is therefore the home of continuing
debate. The polarity ranges from fatalism to aggression, from Christian science to heart transplantation. Questions about what is appropriate medicine are inseparable from notions, no matter how vague or suspect, of beauty and of nature and of man’s place in it. Ideas of nature and beauty guide medical intervention, research, diagnosis, therapy. To fully understand medicine physicians need to examine art and philosophy and the history of ideas, as well as anatomy and physiology and pharmaceutics. Some years after our sad case of tetanus, after the boys had grown up and left for university and the sheep flock had been dispersed, I stood amongst the Turner collection at the Tate Gallery. Joseph Mallord William Turner’s glorious landscapes-busy, bold, colorful, large, heroic canvases-recalled my sad ruminations on beauty and the sense of intimacy with nature. Experiencing Turner’s art was another aspect of medicine. Not obvious, maybe even obscure, but to me it was clear that Turner, the great English sea and landscape artist of the 18th and early 19th century, signaled major changes in medical thinking. Portraits dominated British art and aesthetics in the 17th and early 18th century and The Royal Academy was dominated by the great portraitist Sir Joshua Reynolds. Hogarth, Gainsborough, Romney, and Raeburn emphasized through their portraits the greater importance of human beings over mere nature. Turner’s art (1775-1851) tells of growing bothersome awareness of the vulnerability of humankind to the accidents of nature and the catastrophes of human ingenuity. No longer was landscape, the world of nature, only backdrop for the grandiose human portraits or the grandeur of precise, clockwork Deism of the Flemish landscapists of the 17th century. Turner’s world was one in which man was put in his place. The Shipwreck, first exhibited in 1805, is one of Turner’s most famous, large oil paintings. Turner seems preoccupied with the vision of human beings as victims, as creatures at the mercy of destructive forces beyond their ken or control. This preoccupation found expression in a spectrum of Turner’s work from Biblical themes (The Deluge) to warfare (The Field of Waterloo) to technology (Rain, Steam and Speed-The Great Western Railway). In The Shipwreck, human figures are overawed by the scene and the size of the canvas [Figs l(a) and (b)]. The crowded life boat and rescue boats in
Second Thoughts
Fig. 1. (a) The Shipwreck, (b) detail. (The Turner Collection, Tate Gallery, London.)
407
408
Second Thoughts
the foregrounds are surrounded by perilous, foaming, stormy water beneath menacing mountainous waves and the derelict bulk of the shipwreck. You cannot make out the faces of the victims but you know they are victims. They display their fear and anguish by posture and place. Turner does not let you ignore them or shrug your shoulders saying, “Too bad.” The sweaters and scarves and hats and the hands are done in disarming, poignant detail. Here is a portrait of human fragility in the face of nature. The artistic transition from portraying the human creature as dominating the landscape to many human creatures dominated by potent forces beyond their control is exemplified by Turner’s painting, The Field of Waterloo (Fig. 2). In this enormous dark canvas, illuminated by a distant flare, burning buildings, and the torch of camp women searching for the bodies of loved ones, we see a landscape of death, the postmortem of the Battle of Waterloo. Turner’s sense of tragedy is not the individual agony of one but the slaughter of many. It remains a controversial painting. As I jotted down notes, I heard the other viewers’ comments: “Carnage-is that a great painting?,” “Gross picture,” “Dreadful painting.” Turner’s grand scapes of land and sea and sky evoke an abiding, discomforting sense of human vulnerability.
Turner’s medical contemporaries included William Withering, Edward Jenner, Renee Laennec, and Pierre Louis. Physicians whose work started the return to a medical world less abstract and sentimentalized than the theoretical medicine and clockwork universe of the Deist Englightenment. P.C.A. Louis applied statistics to therapeutic evaluation and demonstrated oft times fatal delusions of theoretical medicine. Heroic bleedings, purgings, and blisterings prescribed by grandiose medical systems were scientifically destroyed. Such medical excesses were popularly rejected with the return to medical respectability of herbal medicine that followed William Withering’s essay on the diuretic properties of Digitalis purpura. The idea that nature held real powers of prevention and cure was dramatically illustrated by the studies of Edward Jenner and the rise of vaccination. Laennec devised the stethoscope, a new method of examining and experiencing the human body, and the classic pathologic descriptions of cirrhosis of the liver and tuberculosis. Priestlay, Gauss, Gay-Lussac, Gibbs, Watt, Lyell4istinguished scientists, experimenters, and observers were prominent intellectuals during Turner’s long life. Experience, experiments, repetitive observation, careful record keeping were becoming the crux of medicine and science.
Fig. 2. The Field of Waterloo. (The Turner Collection, Tate Gallery, London.)
Second Thoughts
Turner painted what he saw and experienced-immediate, realistic-in contrast to the well ordered landscapes, still-lifes, and portraits of the 17th and early 18th century exemplified by Flemish painters like VanRuysdael and Steen. The importance of personal observation and record keeping is nowhere better illustrated than in Turner’s painting Snowstorm-Steamboat Off Harbour’s Mouth Making ‘Signals in Shallow Water, and Going By the Head. The Author was in the Storm the Night the Ariel Left Harwich (Fig. 3). Turner is reported to have said of this painting, “I did not paint it to be understood but I wish to show what such a scene was like; I got the sailors to lash me to the mast to observe it; I was lashed for hours and I did not expect to escape, but I felt bound to record it if I did” [I]. Turner’s realism foreshadowed the anxieties and ambivalences of the Industrial Revolution. Although Turner could transform the ominously imposing furnaces, steamships, and railroads into mythic beauty, the theme of human vulnerability remains. Rain, Steam and SpeedThe Great Western Railway, one of his most
409
popular paintings, depicts a machine careering at breakneck speed out of rainswept, misty indistinctness onto a bridge across the Thames upon which stands the viewer (Fig. 4). No individual human being is around to witness your subjugation, perhaps even collision, with this behemoth: an anxious painting. In contrast to art history scholars I am not puzzled that Turner, who was fascinated by the mountains and sea, fire and storms, uncontrollable by man, was one of the few really great painters to depict the new man-made marvels of industry, science, and technology [l]. More than the doctors and scientists, Turner, the artist, had a sense of the illusory optimism of the idea of progress. Even before his death William Blake and Charles Dickens began warnings about the ugliness and despair that accompanied the Industrial Revolution. Turner’s genius in portraying the beauty and exquisite agony of humankind’s vulnerability to natural and man-made forces accounts for my affinity for his paintings. A Turner painting illustrates the medical dilemma and the clinical interaction: “The exaggeration of scale by which
Fig. 3. Snowstorm-Steamboat off Harbour’s Mouth Making Signals in Shallow Water, and Going by the Head. The Author was in the Storm the Night the Ariel left Harwich. (The Turner Collection, Tate Gallery, London.)
410
Second Thoughts
Second Thoughts
man is reduced to a cypher, the arrangement of mysterious exhalations of light, and finally the love of a vista which carries our eye into the depths of the picture” [l]. Clinical medicine demands the capacity to make beautiful and humane the “mysterious exhalations” of the natural world in which human beings are only a small and recent part. Nothing better describes diagnostic acumen than “the love of a vista which carries our eye into the depths of the picture.” It is the magic of Turner the artist to
411
transform the catastrophe of a shipwreck into an image that compels-us to look again, and to look again with affection and compassion. It is the magic of the medical woman or man to transform the misery of illness into health and harmony.
REFERENCE 1. Thomas D. 3. M. W. Turner. London: The Medici Society; 1979: 2-24.
J Clin Epiddol Vol. 43, No. 4, pp. 405-411, 1990 Printedin Great Britain
Second Thoughts TAILS, TETANUS AND TURNER RICW
V. LEE*
Department of Medicine, Children’s Hosp& of Buffalo and State University of New York at Buffalo, NY 14222, U.S.A. (Received in revised form 3 February 1989; receivedfor publication 31 August 1989)
When we first started shepherding we were a little nonplussed to find that lambs came with long tails that had to be amputated in order to satisfy the aesthetic anxieties of sheep fanciers about ovine personal and reproduction hygiene. We lost a fine month-old ram lamb to tetanus one winter. It was a horrible, grotesque event. The disease was biologically understandable but ugly notwithstanding, uglier because it was the result of cosmetic surgery. The episode began when our boys, Matthew and Benjamin, then in their early teens, put on the thick elastic band which is used to occlude the blood supply to the tail. A few days later, after the distal part of the tail was avascular, they docked the tail. The rubber band technique works well for tails and testicles. It is easy and relatively bloodless, but it carries the risk of leaving a layer of ischemic or necrotic tissue at the site of the docking which may act as a comfortable home for anaerobic bacteria such as Clostridium tetani. Ben found him during the early morning chores, on his back, legs rigid in the air. We tried to save him despite the odds. The family carried out a saddening nursing routine every 2 hours trying to get fluids and muscle relaxants into him but the heart-stopping myoclonic jerks of the poor creature’s body brought tears; I gave him penicillin and human tetanus immune globulin because the old anti-tetanus horse serum
*All correspondence should be+addressed to: Richard V. Lee, M.D., Department of Me&tine. Childreri’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, U.S.A.
was hard to get. For 2 days and 2 nights we were witness to the dreadful disharmony of disease. Nature’s cruelty, and what seemed to be our abetment of it, ceased, unwitnessed but not unfelt, while I overslept my 2 hour schedule the third morning. We were a subdued family that day: the boys.startled by the seemingly aimless brutality of the natural process, Susan and I distressed at our failure to be good animal husbanders. None of us could hide the dismay at the undesirable effects of tail docking. Mulling over the dismal events on the way into the hospital later that day, several clinical items became apparent. The appearance of tetanus in a month-old lamb indicated an absence of maternal antibodies, something of a surprise to me since I had once thought that domestic animals could acquire immunity from exposure to tetanus toxin altered and made antigenic by the digestive process, I wondered if we :would have to give our small flock tetanus toxoid. Immunization seemed a benign human intervention compared to tail docking. Cosmetic concerns are not without hazard. Despite good statistics, adverse, even ugly, effects can be produced by contemporary plastic surgery. Perhaps one of the greatest hazards to health at the close of the decade of the 1980s is the relentless pursuit of thinness attested by the epidemic awareness of anorexia, bulimia, and fitness fanaticism. There is something ugly, offensive, about the skeletal self-righteous parsimony of the anorectic and fitness fanatic or the profligate puking of the bulimic. These conditions defy not just medical precepts but
405
406
Second Thoughts
notions of beauty. If nothing else, I ruminated, the tetanus death of our lamb brought home the importance of beauty and the idea of nature to my notions of and practice of medicine. Beauty and nature! Uncommon words on hosptial wards. Medicine deals directly with nature and with beauty. But in the oscilloscopic, bloodletting, high tech teaching hospital these are distant, vaguely suspect, seemingly irrelevent ideas. There is a tendency to regard hospitals as pest houses for the ugly detritus of humanity. We are awed by a Mother Theresa who can find love, beauty, and solace nursing the sick and slums of Calcutta. There is, in fact, much beauty in medicine and we physicians talk a lot about the natural history of disease. Perhaps some of the lamentations about contemporary medicine derive from a decline of a medical aesthetic sense. Does medicine have an aesthetic? I believe it does. In many ways medicine is the art of nature: human attempts to manipulate biology in response to perceived disharmony, ugliness, irregularity. Medicine is as much a quest for beauty as is the creation of a landscape painting. The aesthetic sense of medicine is shaped by ideas of nature. There are as many ideas of the beauty in medicine as there are ideas of nature. Usually we look upon the living organism as we do a well-ordered landscape. The regular and intricate rhythms of vascular and endocrine function cycle peacefully and unobtrusively. Disease is disharmony, irregular rhythms, excessive phlegm, a plant or creature out of place. There are those that take nature to be the fierce neo-Darwinian world of “nature red in tooth and claw.” In this ambience, disease is like any other predator, a necessary part of the biological order and possessing its own frightening beauty and virtue. There are others who, terrified and saddened by the all too solid, rottable flesh, pursue Cartesian abstraction and Oriental mysticism. For them the reality of nature is the mind; the goal of healing is redemption, release from the cycles of biology by training the mind to discipline and ultimately to discard the flesh. The Himalayan mystique includes the exquisite other worldly awareness of being wholely a part of nature, a loss of individuality. Human intervention and intrusion about nature possesses the capacity to be extraordinarily beautiful or extraordinarily ugly. Medicine is home to some of the most daring, risky, and grotesque human intrusions; and medicine is therefore the home of continuing
debate. The polarity ranges from fatalism to aggression, from Christian science to heart transplantation. Questions about what is appropriate medicine are inseparable from notions, no matter how vague or suspect, of beauty and of nature and of man’s place in it. Ideas of nature and beauty guide medical intervention, research, diagnosis, therapy. To fully understand medicine physicians need to examine art and philosophy and the history of ideas, as well as anatomy and physiology and pharmaceutics. Some years after our sad case of tetanus, after the boys had grown up and left for university and the sheep flock had been dispersed, I stood amongst the Turner collection at the Tate Gallery. Joseph Mallord William Turner’s glorious landscapes-busy, bold, colorful, large, heroic canvases-recalled my sad ruminations on beauty and the sense of intimacy with nature. Experiencing Turner’s art was another aspect of medicine. Not obvious, maybe even obscure, but to me it was clear that Turner, the great English sea and landscape artist of the 18th and early 19th century, signaled major changes in medical thinking. Portraits dominated British art and aesthetics in the 17th and early 18th century and The Royal Academy was dominated by the great portraitist Sir Joshua Reynolds. Hogarth, Gainsborough, Romney, and Raeburn emphasized through their portraits the greater importance of human beings over mere nature. Turner’s art (1775-1851) tells of growing bothersome awareness of the vulnerability of humankind to the accidents of nature and the catastrophes of human ingenuity. No longer was landscape, the world of nature, only backdrop for the grandiose human portraits or the grandeur of precise, clockwork Deism of the Flemish landscapists of the 17th century. Turner’s world was one in which man was put in his place. The Shipwreck, first exhibited in 1805, is one of Turner’s most famous, large oil paintings. Turner seems preoccupied with the vision of human beings as victims, as creatures at the mercy of destructive forces beyond their ken or control. This preoccupation found expression in a spectrum of Turner’s work from Biblical themes (The Deluge) to warfare (The Field of Waterloo) to technology (Rain, Steam and Speed-The Great Western Railway). In The Shipwreck, human figures are overawed by the scene and the size of the canvas [Figs l(a) and (b)]. The crowded life boat and rescue boats in
Second Thoughts
Fig. 1. (a) The Shipwreck, (b) detail. (The Turner Collection, Tate Gallery, London.)
407
408
Second Thoughts
the foregrounds are surrounded by perilous, foaming, stormy water beneath menacing mountainous waves and the derelict bulk of the shipwreck. You cannot make out the faces of the victims but you know they are victims. They display their fear and anguish by posture and place. Turner does not let you ignore them or shrug your shoulders saying, “Too bad.” The sweaters and scarves and hats and the hands are done in disarming, poignant detail. Here is a portrait of human fragility in the face of nature. The artistic transition from portraying the human creature as dominating the landscape to many human creatures dominated by potent forces beyond their control is exemplified by Turner’s painting, The Field of Waterloo (Fig. 2). In this enormous dark canvas, illuminated by a distant flare, burning buildings, and the torch of camp women searching for the bodies of loved ones, we see a landscape of death, the postmortem of the Battle of Waterloo. Turner’s sense of tragedy is not the individual agony of one but the slaughter of many. It remains a controversial painting. As I jotted down notes, I heard the other viewers’ comments: “Carnage-is that a great painting?,” “Gross picture,” “Dreadful painting.” Turner’s grand scapes of land and sea and sky evoke an abiding, discomforting sense of human vulnerability.
Turner’s medical contemporaries included William Withering, Edward Jenner, Renee Laennec, and Pierre Louis. Physicians whose work started the return to a medical world less abstract and sentimentalized than the theoretical medicine and clockwork universe of the Deist Englightenment. P.C.A. Louis applied statistics to therapeutic evaluation and demonstrated oft times fatal delusions of theoretical medicine. Heroic bleedings, purgings, and blisterings prescribed by grandiose medical systems were scientifically destroyed. Such medical excesses were popularly rejected with the return to medical respectability of herbal medicine that followed William Withering’s essay on the diuretic properties of Digitalis purpura. The idea that nature held real powers of prevention and cure was dramatically illustrated by the studies of Edward Jenner and the rise of vaccination. Laennec devised the stethoscope, a new method of examining and experiencing the human body, and the classic pathologic descriptions of cirrhosis of the liver and tuberculosis. Priestlay, Gauss, Gay-Lussac, Gibbs, Watt, Lyell4istinguished scientists, experimenters, and observers were prominent intellectuals during Turner’s long life. Experience, experiments, repetitive observation, careful record keeping were becoming the crux of medicine and science.
Fig. 2. The Field of Waterloo. (The Turner Collection, Tate Gallery, London.)
Second Thoughts
Turner painted what he saw and experienced-immediate, realistic-in contrast to the well ordered landscapes, still-lifes, and portraits of the 17th and early 18th century exemplified by Flemish painters like VanRuysdael and Steen. The importance of personal observation and record keeping is nowhere better illustrated than in Turner’s painting Snowstorm-Steamboat Off Harbour’s Mouth Making ‘Signals in Shallow Water, and Going By the Head. The Author was in the Storm the Night the Ariel Left Harwich (Fig. 3). Turner is reported to have said of this painting, “I did not paint it to be understood but I wish to show what such a scene was like; I got the sailors to lash me to the mast to observe it; I was lashed for hours and I did not expect to escape, but I felt bound to record it if I did” [I]. Turner’s realism foreshadowed the anxieties and ambivalences of the Industrial Revolution. Although Turner could transform the ominously imposing furnaces, steamships, and railroads into mythic beauty, the theme of human vulnerability remains. Rain, Steam and SpeedThe Great Western Railway, one of his most
409
popular paintings, depicts a machine careering at breakneck speed out of rainswept, misty indistinctness onto a bridge across the Thames upon which stands the viewer (Fig. 4). No individual human being is around to witness your subjugation, perhaps even collision, with this behemoth: an anxious painting. In contrast to art history scholars I am not puzzled that Turner, who was fascinated by the mountains and sea, fire and storms, uncontrollable by man, was one of the few really great painters to depict the new man-made marvels of industry, science, and technology [l]. More than the doctors and scientists, Turner, the artist, had a sense of the illusory optimism of the idea of progress. Even before his death William Blake and Charles Dickens began warnings about the ugliness and despair that accompanied the Industrial Revolution. Turner’s genius in portraying the beauty and exquisite agony of humankind’s vulnerability to natural and man-made forces accounts for my affinity for his paintings. A Turner painting illustrates the medical dilemma and the clinical interaction: “The exaggeration of scale by which
Fig. 3. Snowstorm-Steamboat off Harbour’s Mouth Making Signals in Shallow Water, and Going by the Head. The Author was in the Storm the Night the Ariel left Harwich. (The Turner Collection, Tate Gallery, London.)
410
Second Thoughts
Second Thoughts
man is reduced to a cypher, the arrangement of mysterious exhalations of light, and finally the love of a vista which carries our eye into the depths of the picture” [l]. Clinical medicine demands the capacity to make beautiful and humane the “mysterious exhalations” of the natural world in which human beings are only a small and recent part. Nothing better describes diagnostic acumen than “the love of a vista which carries our eye into the depths of the picture.” It is the magic of Turner the artist to
411
transform the catastrophe of a shipwreck into an image that compels-us to look again, and to look again with affection and compassion. It is the magic of the medical woman or man to transform the misery of illness into health and harmony.
REFERENCE 1. Thomas D. 3. M. W. Turner. London: The Medici Society; 1979: 2-24.