by

PTSD and The Singing Tree

The Singing Tree by Kate Seredy, 1939, is a children’s book that illustrated PTSD for me long before I went to medical school. The Singing Tree is the sequel to The Good Master, and describes the survival of a Hungarian family and farm during World War I.

The good master is Marton Nagy, and he is called up as a Corporal, leaving the farm to be cared for by his wife, son, niece and workers. The farm suffers because so many men are called up. They are getting behind on the work and then find a diary from Marton, which gives suggestions and instructions for the year round work on the farm. One of the instructions is “to make out an application for Russian prisoners if necessary.”

They do. They apply and take 6 Russian prisoners, homesick farmers, who don’t speak Hungarian. Jansi and his cousin Kate take the chains off them and the prisoners quickly become part of the family. “Comrade, eh? Friend?” says one of the prisoners. And they are. They are also excellent workers and homesick.

As the prisoners are taken home in the wagon, they also take Peter, a deserter from the Hungarian army. He has panicked about his wife and new baby. He is crazy with worry. He is hidden under the six Russians, who sympathize. After seeing the baby he returns to his regiment. But Peter is angry and expresses his rage at Jews, even though it is Uncle Moses, the Jewish shopkeeper, who has helped hide him.

    Mother took Jancsi’s arm then and they left he room. They didn’t speak; what was there to say? Something, somebody had poisoned Peter’s soul against those who had been good to him all his life. Into Jancsi’s mind flashed the words Father had said: “The stampede… the mad whirlwind that sucks in men…and spits out crippled wrecks.” Crippled in body and soul, Jansci thought then, with an understanding far beyond his years.
    “Poor Peter,” he said aloud. Mother pressed his arm. “I knew you would see it that way, Son. I only hope the war ends before this poison has spread too far.” p 163.

Marton is missing and they have not heard from him. Jansci and Kate make the wagon trek to bring back their grandparents, because the front is now too close for them to be safe. Kate and Lily smuggle the cat along. The cat gets “sick” and the girls insist at stopping at a hospital. The sickness is kittens. The nurses laugh at the girls, but then let them help on the wards. Injured soldiers who are healing.

    “Almost an hour passed before all the patients had been fed. “There was only one asleep,” Lily said, coming back with the empty bowls; “he even had the sheet pulled over his face.” The nurse followed Lily’s pointing finger with her eyes. “Oh, the amnesia case. He sleeps most of the time.”

    “Whats am-amnesia?” Kate wanted to know.

    “Loss of memory. They forget who they are and have to begin life all over again; like babies.” “Does it hurt?”
    “No,” smiled the nurse. “It comes from a shock; like a big scare, you know.” She looked toward the bed again. “He is such a nice man too, poor fellow. He tries so hard to remember. if we could find out who he is, find something to remind of his home, he might remember. You wan tto see him?” she asked as Kate kept staring at the bed. “Come on then, but be quiet.”
    “No. 54, Amnesia,” was written on the headboard. The nurse gently lifted the sheet. Pandemonium broke loose immediately. Kate, with her famous tin-whistle scream gong at full blast, threw herself on the bed. “UNCLE MARTON! UNCLE MAAARTON! IT’S KATE. Can’t you….? UNCLE MARTO-O-O-ON!”

    Every patient was sitting bolt upright. Doctors and nurses were running in, Lily joined Kate, tugging at Uncle Marton’s hands. “Say something…you know us, don’t you? Say something.”

    “Kate, if you don’t stop that infamous yelling this minute, I’ll take Milky away from…Say! Where am I? Who are these people?” Uncle Marton was looking around dazedly.

    “Never mind them,” sobbed Kate, laughing at the same time. “You know who you are now, don’t you?”

    “Why shouldn’t I? Let me out of this bed!” Uncle Marton cried, trying to peel Kate and Lily off his chest.
    “Take it easy, take it easy,” said a doctor who stepped up. “What is your name?” “Lieutenant Marton Nagy of the Seventh Infantry,” snapped Uncle Marton, glaring at him. “Seventh Infantry… Seventh…oh…”His eyes clouded.
    “Now it all comes back, doesn’t it? You’ll be all right now, Lieutenant Nagy. Don’t think about that now. Tell me who this…this calliope is. That scream was the best I ever heard.” The doctor sat down on the bed, smiling at Kate. “I wish we could produce for each amnesia case we get; we wouldn’t have any.” pp 186-189

He gets to go home.

    “From Corporal to Lieutenant in a year. Pretty good, Lieutenant Nagy,” an officer with a lot of gold braid all over him said to Father. “And a handful of medals to catch up with you, as I heard. What did you do?”
    Father looked him straight in the eye. The muscles in his jaws were working. “I don’t know sir. I would rather not try to remember.”

    The officer sighed. “Go home, Lieutenant. Forget, if you can. I wish I could.”

And will he have to return?

    “Then Father went to report to the hospital and this time Mother and Jansci went with him. The doctors found that in body he was sound, but only time, long months or even years, could make him forget the things he never spoke about.
    “There are none braver than he is,” the doctor told Mother, “but the human mind can stand just so much of horror and no more. We dare not tke the risk of sending him back to war.”
    “Thank God!” Mother had exclaimed, and the doctor smiled very sadly.
    “I hear that every day now. Wives, mothers thanking the Lord for an injury their beloved ones have received. A broken bone, a brave mind darkened with nameless fear, anything that takes a long time to heal, has become a blessing, a gift. They are safe for a little while longer.”

And Jansci talks to one of the Russian prisoners.

    “Big boss come home…maybe war over?” Grigori wanted to know when they had come with Father. Jansci tried to explain and he thought that Grigori didn’t understand because for a long while he didn’t say anything. Then he sighed: “Grigori know. Hear, Jansci. Bad man, stupid man, he go kill and laugh. Good man, man with good heart, good head, no can kill and laugh. He cry inside. Baby cry with big noise. Man cry–no noise, but it hurt very bad. Me know….me know.” p. 203

Death affects the village.

    “More white envelopes were coming to the village now than ever since the war started. The hands of Uncle Moses began to tremble and he seemed to grow smaller, more bent. Aunt Sarah was like a silent little wraith, going from house to house to comfort, to help, or just sit, holding the hand of a woman who would never wait for the mail again because there was no one left to writ to her. Often she and priest met in one of the houses and the priest would bow deeply to her Once he told Father: “She seems to give more comfort, more strength to these poor women than I can.” pp 203-204

I wish that we had the sense expressed in this book about PTSD and the effects of war. When I worked at Madigan Army Hospital, some soldiers were getting ready for their fourth or fifth tour of duty. If we as a country are going to continue these wars, we must take more responsibility and have more care for the damage done. When people talk about “curing” PTSD or keeping it from happening: if we didn’t respond with PTSD as a species with horror for the evils of war, we don’t deserve to survive. We will be the Bad People, the Stupid People, who Kill and Laugh. We need to stop. This book was written in 1939 and clearly they knew the effects of PTSD. It’s been almost 80 years since Kate Seredy’s book was published: and still we question PTSD?

http://www.pdhealth.mil/clinicians/assessment_tools.asp
Civilians too: http://www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf

illustration from p. 187

by

Croup and ipecac in Anne of Green Gables

My daughter has listened to me talk about medicine all her life. And she comes up with brilliant questions.

“Mom, if the three year old in Anne of Green Gables had croup, why did she get better when Anne treated her with ipecac?”

“Hmmmm.” My daughter has learned enough from me talking about croup to know that I don’t use ipecac. I use a dose of steroids, an oxygen tent with cold mist if needed and possibly epinephrine.

“The doctor in the book says that the baby would have died if Anne hadn’t known what to do.”

I reread the passage in Anne of Green Gables. The book was written in 1908 by Lucy Maud Montgomery. Anne is such an imaginative extrovert that my daughter objected the first time we read it. “Mom, no one is like that.” I named two very extroverted girls in her class. “Oh. Ok, yes.” Anne has been a foster child who helped raise three pairs of twins. She is eleven. This is from Chapter 18:

    “Oh, Anne, do come quick,” implored Diana nervously. “Minnie May is awful sick—she’s got croup. Young Mary Joe says—and Father and Mother are away to town and there’s nobody to go for the doctor. Minnie May is awful bad and Young Mary Joe doesn’t know what to do—and oh, Anne, I’m so scared!”
    Matthew, without a word, reached out for cap and coat, slipped past Diana and away into the darkness of the yard.
    “He’s gone to harness the sorrel mare to go to Carmody for the doctor,” said Anne, who was hurrying on hood and jacket. “I know it as well as if he’d said so. Matthew and I are such kindred spirits I can read his thoughts without words at all.”
    “I don’t believe he’ll find the doctor at Carmody,” sobbed Diana. “I know that Dr. Blair went to town and I guess Dr. Spencer would go too. Young Mary Joe never saw anybody with croup and Mrs. Lynde is away. Oh, Anne!”
    “Don’t cry, Di,” said Anne cheerily. “I know exactly what to do for croup. You forget that Mrs. Hammond had twins three times. When you look after three pairs of twins you naturally get a lot of experience. They all had croup regularly. Just wait till I get the ipecac bottle—you mayn’t have any at your house. Come on now.”
    The two little girls hastened out hand in hand and hurried through Lover’s Lane and across the crusted field beyond, for the snow was too deep to go by the shorter wood way. Anne, although sincerely sorry for Minnie May, was far from being insensible to the romance of the situation and to the sweetness of once more sharing that romance with a kindred spirit.
    The night was clear and frosty, all ebony of shadow and silver of snowy slope; big stars were shining over the silent fields; here and there the dark pointed firs stood up with snow powdering their branches and the wind whistling through them. Anne thought it was truly delightful to go skimming through all this mystery and loveliness with your bosom friend who had been so long estranged.
    Minnie May, aged three, was really very sick. She lay on the kitchen sofa feverish and restless, while her hoarse breathing could be heard all over the house. Young Mary Joe, a buxom, broad-faced French girl from the creek, whom Mrs. Barry had engaged to stay with the children during her absence, was helpless and bewildered, quite incapable of thinking what to do, or doing it if she thought of it.Anne went to work with skill and promptness.
    “Minnie May has croup all right; she’s pretty bad, but I’ve seen them worse. First we must have lots of hot water. I declare, Diana, there isn’t more than a cupful in the kettle! There, I’ve filled it up, and, Mary Joe, you may put some wood in the stove. I don’t want to hurt your feelings but it seems to me you might have thought of this before if you’d any imagination. Now, I’ll undress Minnie May and put her to bed and you try to find some soft flannel cloths, Diana. I’m going to give her a dose of ipecac first of all.”
    Minnie May did not take kindly to the ipecac but Anne had not brought up three pairs of twins for nothing. Down that ipecac went, not only once, but many times during the long, anxious night when the two little girls worked patiently over the suffering Minnie May, and Young Mary Joe, honestly anxious to do all she could, kept up a roaring fire and heated more water than would have been needed for a hospital of croupy babies.
    It was three o’clock when Matthew came with a doctor, for he had been obliged to go all the way to Spencervale for one. But the pressing need for assistance was past. Minnie May was much better and was sleeping soundly.
    “I was awfully near giving up in despair,” explained Anne. “She got worse and worse until she was sicker than ever the Hammond twins were, even the last pair. I actually thought she was going to choke to death. I gave her every drop of ipecac in that bottle and when the last dose went down I said to myself—not to Diana or Young Mary Joe, because I didn’t want to worry them any more than they were worried, but I had to say it to myself just to relieve my feelings—’This is the last lingering hope and I fear, tis a vain one.’ But in about three minutes she coughed up the phlegm and began to get better right away. You must just imagine my relief, doctor, because I can’t express it in words. You know there are some things that cannot be expressed in words.”
    “Yes, I know,” nodded the doctor. He looked at Anne as if he were thinking some things about her that couldn’t be expressed in words. Later on, however, he expressed them to Mr. and Mrs. Barry.
    “That little redheaded girl they have over at Cuthbert’s is as smart as they make ’em. I tell you she saved that baby’s life, for it would have been too late by the time I got there. She seems to have a skill and presence of mind perfectly wonderful in a child of her age. I never saw anything like the eyes of her when she was explaining the case to me.”
    Anne had gone home in the wonderful, white-frosted winter morning, heavy eyed from loss of sleep, but still talking unweariedly to Matthew as they crossed the long white field and walked under the glittering fairy arch of the Lover’s Lane maples.
    “Oh, Matthew, isn’t it a wonderful morning? The world looks like something God had just imagined for His own pleasure, doesn’t it? Those trees look as if I could blow them away with a breath—pouf! I’m so glad I live in a world where there are white frosts, aren’t you? And I’m so glad Mrs. Hammond had three pairs of twins after all. If she hadn’t I mightn’t have known what to do for Minnie May. I’m real sorry I was ever cross with Mrs. Hammond for having twins. But, oh, Matthew, I’m so sleepy. I can’t go to school. I just know I couldn’t keep my eyes open and I’d be so stupid. But I hate to stay home, for Gil—some of the others will get head of the class, and it’s so hard to get up again—although of course the harder it is the more satisfaction you have when you do get up, haven’t you?”
    “Well now, I guess you’ll manage all right,” said Matthew, looking at Anne’s white little face and the dark shadows under her eyes. “You just go right to bed and have a good sleep. I’ll do all the chores.”

I finished reading. “I think that the reason ipecac worked is because it wasn’t what we call croup now. I think it was diptheria. With diptheria kids can’t breathe because there is a grey membrane of dead cells that covers the airway and can totally block it. The native americans used spiky seedpods to try to remove it. Vomiting would work too. By making the baby throw up, she was clearing her airway. I have never seen a child with diptheria because of vaccinations. I hope I never do see diptheria because it is much much worse than croup. Croup now is usually a virus like parainfluenza but diptheria is a bacteria and can kill.”

We looked it up on the CDC website. One in two people with diptheria die without treatment. One in ten die with treatment. That little “d” in your tetnus shot, the Td? That is the diptheria part of the vaccination, that you should update every ten years.

“They may have called both “croup” at the time the book was written. That was a really good question.”

My daughter was satisfied that this is a reasonable explanation for the puzzle.

http://www.cdc.gov/diphtheria/about/symptoms.html
http://www.cdc.gov/diphtheria/about/complications.html
http://www.cdc.gov/diphtheria/about/bam-villain-for-kids-fs.html
http://blogs.discovermagazine.com/inkfish/2014/03/25/classic-childrens-books-ruined-modern-medicine/

Also published on everything2.com today. The photo is my niece.

by

Guide to determining if you are constantly being mauled by bears

This is for Ronovan’s weekly haiku prompt. The words this week are guide and mad.

Beloved guide me
through red mad anger open
heart to shores of love

The picture is my son and daughter on the shore of Lake Crescent, Washington in 2004. We stopped driving for a rest. My son has just skipped a rock and I love the curve of his body and physical joy expressed. He’s trying to influence what the rock does with his body language. How can we all stay that fluid and joyful?

I stole the title from here: http://everything2.com/title/Guide+to+determining+if+you+are+constantly+being+mauled+by+bears

by

Chronic pain update 2015

As a rural family practice physician, I am in an area with very few specialists. Our county has a 25 bed hospital and we have a urologist, three general surgeons, three orthopedists (except when we were down to none at one point), two part time hematologist oncologists and that’s it. We have a cardiologist who comes one day a week. We have a physicians assistant who worked with an excellent dermatologist for years: hooray! Local derm! Our neurologist retired and then died. We had two psychiatrists but one left. We had one working one half day a week.

I trained in treating opiate addiction with buprenorphine in 2010 and attended telemedicine with the University of Washington nearly weekly for a year and a half. Then life intervened. I attended last week again, but not the addiction medicine group. That is gone. Now there are two telemedicine pain groups.

And what have I learned since my Chronic pain update 2011?

Chronic opiates suck, and especially for “disorders of central pain processing” which includes fibromyalgia, reflex sympathetic dystrophy, TMJ, chronic fatigue, and all of the other pain disorders where the brain pain centers get sensitized. We don’t know what triggers the sensitization, though a high Adverse Childhood Experience score puts a person more at risk. Cumulative trauma? Tired mitochondria? Incorrect gut microbiome? All of them, I suspect.

Jon Kabot Zinn, PhD has been studying mindfulness meditation for over 30 years. He has books, CDs, classes. Opiates at best drop pain levels an average of 30%. His classes drop pain levels an average of 50%. I’ve read two of his books, Full Catastrophe Living and ….. and I used the CD that came with the former to help me sleep after my father and sister died. Worked. Though I used the program where he says, “This is to help you fall more awake, not fall asleep.” Being contrary, it put me to sleep 100% of the time.

Body work is being studied. Massage, physical therapy, accupuncture, touch therapy and so forth. It turns out that when you have new physical input, the brain says, “Hey, turn down the pain fibers, I have to pay attention to the feathers touching my left arm.” So, if you have a body part with screwed up pain fibers, touch it. Touch it a lot, gently, with cold, with hot, with feathers, a washcloth, a spoon, something knobby, plastic. Better yet, have someone else touch it with things with your eyes closed and guess what the things are: your brain may tell the pain centers “Shut up, I’m thinking.” Well, sensing. A study checking hormone blood levels every ten minutes during a massage showed the stress hormone cortisol dropping in half and pain medicating hormones dropping in half. So, massage works. Touch works. Hugs work. Go for it.

There are new medicines. I don’t like pills much. However, the tricyclic antidepressants, old and considered passe, are back. They especially help with the central pain processing disorders. I haven’t learned the current brain pathway theories. The selective serotonin uptake reinhibitors (prozac, paxil, celexa, etc) increase the amount of serotonin in the receptors: chronic pain folks and depressed folks have low serotonin there, so increasing it helps many. As an “old” doc, that is, over 50, I view new medicines with suspicion. They often get pulled off the market in 10 to 20 years. I can wait. I will use them cautiously.

We are less enthused about antiinflammatories. People bleed. The gut bleeds. Also, the body uses inflammation to heal an area. So, does an antiinflammatory help? Very questionable.

Diet can affect pain. When I had systemic strep, I would go into ketosis within a couple of hours of eating as the strep A in my muscles and lungs fed on the carbohydrates in my blood. This did not feel good. However, the instant I was ketotic, my burning strep infected muscles would stop hurting. Completely. I am using a trial diet in clinic for some of my chronic pain patients. I had a woman recently try it for two weeks. She came back and said that her osteoarthritis pain disappeared in her right hip entirely. She then noticed that the muscles ached around her left hip. She has been limping for a while. The muscles are pissed off. She ate a slice of bread after the two weeks and the right hip osteoarthritis pain was back the next day. “Hmmmm.” I said. She and I sat silent for a bit. It’s stunning if we can have major effects on chronic pain with switching from a carb based diet to a ketotic one.

I attended one of the chronic pain telemedicines last week and presented a patient. My question was not about opiates at all, but about ACE scores and PTSD in a veteran. The telemedicine specialists ignored my question. They told me to wean the opiate. He’s on a small dose and I said I would prefer to wean his ambien and his benzodiazepines first. They talked down to me. One told me that when I was “taking a medicine away” I could make the patient feel better by increasing another one. As I weaned the oxycodone, I should increase his gabapentin. I thought, yeah, like my patients don’t know the difference between oxycodone and gabapentin. No wonder patients are angry at allopaths. I didn’t express that. Instead, I said that he’d nearly died of urosepsis two weeks ago, so we were focused on that rather than his back pain at the third visit. All but one physician ignored everything I said: but the doctor from Madigan thanked me for taking on veterans and offered a telepsychiatry link. That may actually be helpful. Maybe.

And that is my chronic pain update for 2015. Blessings to all.

http://www.cdc.gov/violenceprevention/acestudy/

http://www.umassmed.edu/cfm/about-us/people/2-meet-our-faculty/kabat-zinn-profile/

I can’t think of a picture for this. I don’t think it should have a picture.

by

Augean stable

Here I am
what a load of shit I know heracles did it
with brute strength in the allotted day I too
am assigned a day but I am just a girl you see
and small to boot I lean on the shovel and contemplate
the work what a load of shit has been produced and I
know what I have to do clean and sparkling by morning
I know the goddess to pray to and she shows up with all
her nymphs armed the bows aren’t so useful for shoveling
shit but they can shift it fast we are done long before
morning and all I have to do is pledge myself to her
to virginity like a virgin

all I have to do

my photo is from the 2009 US National Junior Synchronized Swimming Olympics