March 23, 2017


Ekphrasis: Commentary on a visual work

About suffering they were never wrong,
The Old Masters; how well, they understood
Its human position; how it takes place
While someone else is eating or opening a window or just walking dully along1

Maybe it was the Agent Orange. All those years in the helicopters, you know, over the jungles of Viet Nam. Or maybe the betrayal of genes, that unaccountable baggage we bear all our years. Or maybe it was the long subsequent sitting in commercial cockpits — the irregular hours, the undisciplined eating, the lack of regular exercise. Anyhow, diabetes came, stealthily at first but eventually not to be denied. At first, the biggest problem seemed to be how to keep his urine free of sugar so that he could pass the flight physicals — and vigorous, if temporary, attention to what he was eating and what he was drinking let him slip past the monitors and continue his career. Then came the ravages: the ischemic cardiomyopathy with its attendant heart failure; the minimally successful attempt at coronary artery bypass surgery; and then the strokes that changed the man he was and at last put an end to his life in the skies.

They never forgot
That even the dreadful martyrdom must run its course
Anyhow in a corner, some untidy spot
Where the dogs go on with their doggy life and the torturer’s horse
Scratches its innocent behind on a tree.1

On Thanksgiving Day he showed me his tender right foot. Slightly swollen, but seemingly not too bad. I told him that his doctor needed to look at his foot, but he had never liked going to doctors, or admitting that something might be amiss. Eventually, of course, he had to. He ended up in the VA Hospital, and a ray amputation of three gangrenous toes. Recovery was slow — all those days and weeks in hospital, the arduous rehabilitation, the clunky orthotic shoes, the learning to limp through life. She (his wife, my sister) slipped free from work to be with him, and when he went home, she rearranged the house and located personnel from the neighborhood to sit with him during the day so that she could continue her now-imposed role as sole wage-earner in the house.

In Breughel’s Icarus, for instance: how everything turns away
Quite leisurely from the disaster; the ploughman may
Have heard the splash, the forsaken cry,
But for him it was not an important failure;1

The fitted shoes were a pain to put on and wear, a condition that only got worse as his foot muscles realigned to produce a hammer-toe deformity of the one small toe left on his right foot. He found it easier to shuffle about in stocking feet than to push his foot into the shoe and traumatize the cocked-up toe. A painful callus formed on the sole of the surgically deformed foot, but she did not fret unduly until the hammer-toe looked black and there seemed to be a small amount of blood around the nail. A call to his primary care doctor led to the advice that this was more than could be handled in the office; she should carry him the 25 miles back to the VA Hospital. In the Emergency Room there, a nurse looked at the toe and ordered a radiograph. Having not been told otherwise, when the X-ray was done, she took him home. A frantic phone call from the nurse told her to bring him right back: the X-ray suggested bone infection; he needed urgent admission and intravenous antibiotics.

On the ward, the resident physicians doubted the diagnosis of osteomyelitis. He was given intravenous antibiotics until an MRI scan could be arranged. In the meantime, she called me and we discussed what to do. He had a deformed toe that was causing trouble and was of no functional use. “Maybe,” I thought aloud, “it needs to be surgically removed whether it is infected or not.” She relayed this notion to the resident staff, and asked for orthopaedic consultation.

The next day, the medical student assigned to the team came to the room: “Good news,” he said, “the MRI shows no evidence of infection. He doesn’t need antibiotics and can go home this afternoon.” When she asked about the orthopaedic consultation, the resident said: “That can be done as an outpatient.” True enough, it could be done as an outpatient — at a visit displaced in time and location and convenience from the hospital bed he already occupied, but wouldn’t it be easier to have Orthopaedics see him now, to decide whether he needed elective amputation and, if so, when? I decided to call the resident myself. When I finally reached her, she was very pleasant. I outlined my argument for orthopaedic advice about his deformed toe and the possibility of prophylactic amputation. She did not disagree, but said that her prior experience with orthopaedics led her to believe that they would consult only on urgent problems needing immediate surgery. Had she at least asked them to come by? “No,” she said, but (and I persisted) she would try. “Let me know if they do not want to come, and I will see what I can do,” I said.

Late that afternoon, he was officially discharged, but told to wait because he would be seen in the Surgery Clinic. Around 6:00 pm, he was evaluated, not by Orthopaedics, but by the Vascular Surgery team. They found no vascular lesion that would require amputation.

“But what about the deformed toe? Does that need to be removed?” she said.

“Oh!” came the reply, “That’s an orthopaedic question. We can arrange an outpatient consultation in a couple of months.”

the sun shone
As it had to on the white legs disappearing into the green
Water; and the expensive delicate ship that must have seen
Something amazing, a boy falling out of the sky,
had somewhere to get to and sailed calmly on.1

  1. Auden WH. Musée des Beaux Arts in Another Time. Random House, New York, 1940.
    Used with permission from Penguin Random House

Dr. Francis Neelon came to Duke as an intern in 1962, and except for 3 years at the NIH, remained here on the faculty in Endocrinology and in General Internal Medicine until retiring in 2002.  Thereafter, Dr. Neelon practiced medicine as Medical Director of the Rice Diet Program, and then the Rice House Healthcare Program, in Durham until 2016.  For many years a print of ‘ Breughel’s Icarus’ hung in the original Medical PDC in Duke South; he marveled whenever he went past it.