The Primacy of Silence

I am rationalizing as fast as I can.  Without a goal, though, it's much like treading water, no rescue of self or others the end point, just lactic acid weighing down the legs and my uselessness made manifest by drowning.

At camp one summer, I qualified for the final exam in a Red Cross Certified Advanced Life Saving course. The elite bunch of us candidates were given instructions on what to wear.  Jeans, a leather belt, a button-up long sleeve shirt, a short-sleeved tee underneath, lace-up shoes, ankle-length socks, and a hat.  I remember how unspecified the hat seemed.  How color did not matter, how function trumped style.  We all had on, as a final layer and defense against pubescence, one-piece bathing suits.

It was early morning and there was fog on the camp lake.  We took our final exam off the end of a rickety pier.  The examiners seemed matronly, an odd remembrance, since I am sure they were not matronly. Maybe everyone looked a little heavy, given the extra layers we had piled on.

So all candidates jumped into the cool, slightly stinky pond water, and tread water for a specified time.  Then we were to take off the jeans, shirt, tee, belt, shoes, and socks.  I suppose we did something with the hats, but I cannot remember what.  Some of these items were to be transformed into flotation devices.  Some of them I saw fit to let drift to the slimy pond's bottom.  I lost points for giving up on my lace-up boots. Perhaps, if I had saved them and made it to an illusory desert island, they'd have supplied sustenance enough for the whole class, for a month, at least.

Then we showed off our proficiency by floating a bit, hanging on to those inflated blue jean legs, for example, or resting our heads on pouffed out tee shirts.

That's when I began to have cramps in my calves, as I was more treading water, still, than honestly floating with confident reliance on my deflated jeans.  Still wish I could visualize the hat.  I keep thinking that it was some sort of oddity, like an old lady's gardening helmet, and not what you'd expect, like a San Francisco Giants baseball cap.

I long ago decided that I was not going to trapped inside my family's predilection for silence, and its awful predatory and coercive ways of underscoring the primacy of silence.  This blog, every email I write, most of my conversations -- they all honor that long ago decision.  It comes off as narcissism, as a form of anti-socialism.  It reads as an inability to edit, not just my verbal production, but my private thoughts, as well.

I am reminded of how Rothko, Picasso, and many "unknown" artists would occasionally allow rancor under their skin, and be coerced into producing the finest of representational art, in some unexpected and banal medium.  To prove that they were classically trained.  To prove that they could draw intricacy like nobody's business.  They usually managed to achieve something reminiscent of the best boy or best girl in the final year of prestigious art school, a something or other to promote their impressive portfolio.  Especially fun are the naive artists, the primitives, when they break into some Parisian metro near-photographic pen-and-ink brilliance. Everyone feels secretly foolish after these displays.  "See, I can do what you think I cannot.  I simply choose not to, I choose another way.  Which I have now, of course, dirtied and demeaned for wont of proving this silly ability to you." We like to blame the other for our pricked pride, our mainlined production, our betrayal of ourselves.

My hat was of woven grass and had a plastic flower, something approximating a yellow mum without the fragrance.  I guess it was supposed to float up side down, and perhaps serve as repository for my boots, spare keys to our dorm, a cabin-without-a-lock, and my pyrography award plaques.  Next time, a fez, or a Stetson.

One of the instructor's had to save me, and she went all out -- "for the sake of demonstration," she whispered in my ear.  My chin ensconced in her palm, to both keep my head above the pond's water and to maintain control of my body, should I decide to panic and, as the drowning sometimes do, attempt to take my rescuer with me to my watery grave.  I am glad she did not decide on that scenario, as a firm grip on my hair would be the next step.

With a smart scissor kick and a modified side-stroke, she brought me successfully to shore, or, in reality, to the slimy ladder on the side of the pier.  I scrambled to my feet, and rejoined my classmates.

It wasn't an ego-destroying failure, but it stung.  Had I passed, I'd have been part of the group swim from the cordoned safe-swim area for all campers across the lake to wild waters and a very famous rope swing. As it was, I ate ice cream and watched two of my compatriots forget to let go of the rope whilst safely over open water. Ouch.


© 2013 L. Ryan

high, low and in-between

yes, i know that i've posted this video/song before.  i will probably post it again.  get over it.

I come from a long line

High and low and in between

Same as you

Hills of golden

Hails of poison

Time’s thrown me through

And I believe I’ve come to learn

That turnin’ round

Is to become confusion

And the gold’s no good for spending

And the poison’s hungry waiting

What can you leave behind

When you’re flyin’ lightning fast

And all alone? 

Only a trace, my friend,

Spirit of motion born

And direction grown.

A trace that will not fade

In frozen skies

Your journey will be

And if her shadow doesn’t seem much company

Who said it would be? 

There is the highway

And the homemade lovin’ kind

The highway’s mine

And us ramblers are getting the travelling down

You fathers build with stones

That stand and shine

Heaven’s where you find it

And you can’t

Take too much with you

But daddy, don’t you listen

It’s just this highway talkin’

All things that are alive

Are brothers in the soil

And in the sky

And I believe it

With my blood

If not my eyes

I don’t know why we can’t

Be brothers here

I know we should be

Answers don’t seem easy

And I’m wonderin’

If they could be

-- townes van zandt

Prayer of Pan Cogito – Traveller

Prayer of Pan Cogito – Traveller

Lord
Thank you for creating the world beautiful and of such variety
And also for allowing me in your inexhaustible goodness
To visit places which were not the scene of my daily torments

- for lying at night near a well in a square in Tarquinia while the swaying
bronze declared from the tower your wrath and forgiveness

and a little donkey on the island of Corcyra sang to mi from
its incredible bellowing lungs the landscape’s melancholy

and in the very ugly city of Manchester I came across
very good and sensible people

nature reiterated her wise tautologies the forest was
forest the sea was sea and rock was rock

stars orbited and things were as they should be – Jovis omnia plena

- forgive me thinking only of myself when the life of
others cruel and irreversible turned round me like the huge
astrological clock in the church at Beauvais

for being too cowardly and stupid because I did not understand
so many things

and also forgive me for not fighting for the happiness of
poor and vanquished nations and for seeing only moonrise and museums
- thank you for the works created to glorify you which
have shared with me part of there mystery so that in gross conceit

I concluded that Duccio Van Eyck Bellini painted for me too

and likewise the Acropolis which I had never fully understood
patiently revealed to me its mutilated flesh

- I pray that you do not forget to reward the white-haired old
man who brought me fruit from his garden in the bay of the island of Ithaca

and also the teacher Miss Hellen on the isle of Mull whose
hospitality was Greek or Christian and who ordered light
to be placed in the window facing Holy Iona so that human
lights might greet one another

and furthermore all those who had shown me the way and said
kato kyrie kato

and that you should have in your care the Mother from Spoleto
Spiridion from Paxos and the good student from Berlin who
got me out of a tight spot and later, when I unexpectedly
ran into him in Arizona, drove me to Grand Canyon which
is like a hundred thousand cathedrals standing on their heads

- grant O Lord that I may forget my foolish and very weary
persecutors when the sun sets into the vast uncharted
Ionian sea

that I may comprehend other men other tongues other suffering
and that I be not stubborn because my limitations are
without limits

and above all that I be humble, that is, one who sees
one who drinks at the spring

thank you O Lord for creating a world very beautiful and varied

and if this is Your temptation I am tempted for ever
and without forgiveness

--Zbigniew Herbert



© 2013 L. Ryan

Wonderful Competency

This is a pleased-as-punch pass-along of a report published yesterday in Consultant for Pediatricians, as part of their "photoclinic" --

• HOME
• VOLUME 13 - ISSUE 7 - JULY 2014
• PHOTOCLINIC
• COMPLEX REGIONAL PAIN SYNDROME
• 
  

    [Citation: CFP. 2014;13(7):330-331]

There's not one thing remarkable about it.

Except it shows evidence of prompt response to a new case of CRPS, an awareness of IASP "Budapest criteria," and a complete absence of NeuroStupidity.

Way to go, Mfon Ekong, MD; Anissa Meher-Homji, BS; and Lynnette Mazur, MD, MPH of the University of Texas Medical School at Houston!


Complex Regional Pain Syndrome

A 10-year-old girl presented with a 3-month history of right knee pain and difficulty walking after her pet German shepherd bumped her leg. She also complained of a 2-week history of hair growth below her right knee.

On physical examination, she had edema, a 12 × 10-cm patch of hair, and decreased range of motion of the right knee. Results of complete blood count, erythrocyte sedimentation rate, complete metabolic profile, creatine kinase tests, and myoglobin tests were normal. Findings on magnetic resonance imaging were unremarkable.

The girl received a diagnosis of complex regional pain syndrome (CRPS) and was hospitalized for inpatient physical therapy. An indwelling catheter was placed for a femoral nerve block. Ropivacaine was continued for 8 days, after which the girl was transferred to a local rehabilitation facility to continue physical therapy, along with continuous passive motion (CPM) of the knee. She was started on gabapentin, fluoxetine, vitamin D, and as-needed diazepam, and was discharged after 1 month to continue her treatment at home.

CRPS, formerly called reflex sympathetic dystrophy, is a painful syndrome accompanied by physical changes in the affected extremity. Dysfunction of local sympathetic and autonomic nerves may be responsible.1-3

Our patient reported 3 of 4 symptoms (allodynia to clothing, edema, and decreased range of motion) and 2 of 3 signs (hyperalgesia to pinprick and allodynia to light touch) meeting the clinical diagnostic criteria for CRPS set forth by the International Association for the Study of Pain (IASP) (Table).4

[read the rest of this wonderful competency HERE]

CRPS in the Context of (Neuro?) Autoimmunity (With Thanks to Mice)

The study suggests Complex Regional Pain Syndrome 

could be caused by harmful serum-autoantibodies

Researchers at the University of Liverpool have taken a major step forward in understanding the causes of a disorder which causes chronic pain in sufferers. 

Complex Regional Pain Syndrome (CRPS) is a serious condition affecting a limb after an – often small – accident or operation.  It can cause severe pain lasting many years, as well as limb swelling, hair and nail growth changes, and muscle atrophy, but until now there has been no clear evidence of the cause. 

Now the research team from the University’s Institute of Translational Medicine alongside colleagues at the University of Pécs, Hungary have successfully transferred antibodies from the serum of patients with CRPS to mice, causing many of the same symptoms to be replicated. 

Dr Andreas Goebel *, who works in the University of Liverpool and is a Consultant in Pain Medicine at The Walton Centre NHS Foundation Trust, led the study.  He said: “CRPS is a serious condition which isn’t fully understood.  The findings of this study hint at a cause for it – harmful serum-autoantibodies – and raise the possibility of finding a treatment.”

[Read more of the story HERE from HealthCanal - Health News]
[ * Dr. Goebel's considerable research in chronic pain and CRPS HERE]

What to say?  It sounds momentous, yes?  But really, quite a bit of research, years old already, has been done that points to "clear evidence of the cause." Unfortunately, "THE cause" sort of thinking goes hand-in-hand with the "Silver Bullet Cure" crowd, and denies the complexity of the "syndrome." Be that as it may, it's a reflection more on the dumbing-down of pseudo-medical journalism, and not a reflection on the quality or bounds of the research on which the article is "reporting."

Why, for instance, do proponents of immunological causation feel the need to ignore the brain?  Just thought I'd toss that out there, as something not particularly helpful, but indicative of either/or thinking that just does not fly when dealing with the intricate relations and processes of the human body.  The peripheral and central nervous systems and their functional counterparts as parasympathetic and sympathetic impulses/small fibre neuropathy/glands run amok (hypothalamic-pituitary-adrenal -- HPA -- axis dysfunction)/immune system dysfunction/inflammation/psychosocial and environmental influences/and the darned partridge in a pear tree.

***********     **********     **********     ***********

A CRPS-IgG-transfer-trauma model reproducing inflammatory 

and positive sensory signs associated with complex regional pain syndrome

ABSTRACT
The aetiology of complex regional pain syndrome (CRPS), a highly painful, usually post-traumatic condition affecting the limbs, is unknown, but recent results have suggested an autoimmune contribution. To confirm a role for pathogenic autoantibodies, we established a passive-transfer trauma model. Prior to undergoing incision of hind limb plantar skin and muscle, mice were injected either with serum IgG obtained from chronic CRPS patients or matched healthy volunteers, or with saline. Unilateral hind limb plantar skin and muscle incision was performed to induce typical, mild tissue injury. Mechanical hyperalgesia, paw swelling, heat and cold sensitivity, weight-bearing ability, locomotor activity, motor coordination, paw temperature, and body weight were investigated for 8 days. After sacrifice, proinflammatory sensory neuropeptides and cytokines were measured in paw tissues. CRPS patient IgG treatment significantly increased hind limb mechanical hyperalgesia and oedema in the incised paw compared with IgG from healthy subjects or saline. Plantar incision induced a remarkable elevation of substance P immunoreactivity on day 8, which was significantly increased by CRPS-IgG. In this IgG-transfer-trauma model for CRPS, serum IgG from chronic CRPS patients induced clinical and laboratory features resembling the human disease. These results support the hypothesis that autoantibodies may contribute to the pathophysiology of CRPS, and that autoantibody-removing therapies may be effective treatments for long-standing CRPS.

An interesting site:  Centre for Immune Studies in Chronic Pain

© 2013 L. Ryan

Tantalizing Woo?

This is the sort of article that should light the short fuse of my intolerance for woo.  Am I becoming tolerant of woo?  Oh, no.  Rather, desperation has opened my mind.  Also, I've experienced too many strange things in my journey with CRPS, and have had occasion in the past few weeks to much (too much?) reflect on that.

Should you be unfamiliar with the term "woo," here is the definition from the Skeptic's Dictionary:

Woo-woo (or just plain woo) refers to ideas considered irrational or based on
extremely flimsy evidence or that appeal to mysterious occult forces or powers. 

Here's a dictionary definition of woo-woo: 

adj. concerned with emotions, mysticism, or spiritualism; other than rational or scientific; mysterious; new agey. Also n., a person who has mystical or new age beliefs. When used by skeptics, woo-woo is a derogatory and dismissive term used to
refer to beliefs one considers nonsense or to a person who holds such beliefs. 

Sometimes woo-woo is used by skeptics as a synonym for pseudoscience,
true-believer, or quackery. But mostly the term is used for its emotive content
and is an emotive synonym for such terms as nonsense, irrational, nutter, nut,
or crazy.

I receive "alerts" from various search engines whenever there is a publication about CRPS.  It's a freewheelin' situation, that!  Most of the publications touting CRPS in some form or other are instances of pure crap that do not even rise to the level of woo.  In other words, clicking on those links keeps me supplied with malware and buck-toothed rodent infestations, making me grateful for an excellent internet security system.

The thing is, sometimes there's a gem buried in the steaming piles.

Today's discovery involves anecdotal "evidence" noted and relayed by a layperson, and what's worse?  The layperson is also the parent of a child with CRPS.  Red flags should have been strewn across my visual field and my stomach ought to have spewed acid with abandon.

Did I mention that the CRPS symptom being addressed involved spasms and disordered movement?  Did I note that the father in question is some sort of "neuroscientist"?  The flashing lights of the local Early Woo Alert System are making rainbows through the prisms hanging in the bedroom window.

Pretty!

Maybe it's the honesty of the tale that makes me open to its possibilities.  Perhaps it's the appeal of something simple taking down the hubris of CRPS.  For sure, it makes me think of my own quirky discoveries with the disease -- a certain antibiotic consistently correlated with marked improvement in the burning sensations common to neuropathic pain, for example.  Many positive experiences related to any diet, drug, or choice that fought "inflammation." All unsupported by science, all unsupported, even, by people upon whose opinions I'd come to rely.  That's the nature of orphan diseases -- one clings to evidentiary science but is surrounded by opinion and storied marketing forces.

One of the touchstones among the advances in research and treatment of CRPS, for me, is the narrative behind the use of ketamine and other NMDA receptor antagonists.  The whole "ketamine coma as a treatment for CRPS" came about by an astute observation in a single case.  A woman was in a terrible car accident that necessitated a medically-induced coma for some weeks.  Ketamine was used to induce the coma.  She was noted to have CRPS in one extremity, and as time passed, improvement was noted in the limb as she remained comatose.  A hypothesis was born more than any earth-shattering scientific discovery. Someone dared to wonder "what if...?"

Well, I've about exhausted the theme of observational wonders in the application of intellect to the problems encountered by CRPS patients and their caretakers.  It's reassuring to learn that we have some smarty-panted people in our midst.  Now let's listen to them, but with discerning ears, caution, and a heightened awareness of woo as ballast for our desperate hopes and need.

**   ****************************************************************   **'

Could Something as Simple as a Mouthguard Be the Cure to What Ails You?
BY EMMA YOUNG • June 24, 2014 
When Vince Clark’s son, Ryan, became sick, he devoted himself to understanding the neuroscience and trying to find effective treatments.

Complex regional pain syndrome (CRPS) doesn’t really involve normal pain networks, but rather enhanced sensory perception. “Just blowing on your skin is excruciatingly painful. That’s what it was like for Ryan,” Clark says. Physical activity became torture. Muscle tremors and spasms, which can happen with CRPS, were also a huge problem. The initial treatment, with a very high dose of an antidepressant drug, made things worse. “For minutes, sometimes hours at a time, he couldn’t breathe easily. It was a parent’s worst nightmare,” Clark says.

Eventually, through a patient support group, Clark made contact with another neuroscientist whose daughter had CRPS. “He came to me and said, I’ve found this thing—it seems crazy—but look what it does. Let’s try to figure out how to understand this.”

This “thing” was an orthotic—a mouthguard, on which patients bite down. There’s evidence that orthotics can relieve pain and ease movement in people with problems affecting the head and neck. It’s so cheap and simple, Clark thought it was at least worth a try with his son. “At one point, Ryan was in the wheelchair and we couldn’t give him drugs, and he was in too much pain to do the physical therapy he needed to do. So we got him to bite down on a simple wooden tongue depressor. That was the first day he walked for almost a month.”

Clark plays me a video of Ryan. He’s leaning heavily on a walking frame, struggling to take a step. Then the tongue depressor goes in, and he bites down on it with his back teeth. Suddenly, he stands, and he can walk with just a single stick. Clark plays me another video. A woman walks awkwardly, bent over, dragging her legs. A car crash years earlier left her seized up, struggling to move. She bites down on an orthotic—a more stylized version of a bunch of tongue depressors—and she stands straight up and walks. The person recording the video is stunned. “This blows my mind,” he says. “I can’t believe this!” Clark says. “There are people with motor illnesses, Tourette’s, dystonias, tremors where the person can’t open their eyes any more…. I can show you videos of patients with all those illnesses and more. If you just put a stack of tongue depressors on their teeth and they bite down, the symptoms of their illness can disappear almost completely.”

Clark is as well aware of the placebo effect as anybody else. But an imaging study, which he has just completed, shows what he calls “pretty significant changes” in brain function as people bite down. The changes are in the cerebellum, a region that plays an important role in controlling movement. Clark thinks that biting down might work by stimulating the trigeminal nerve, a thick nerve that connects to the central nervous system. “Historically, before anesthesia, when doctors did surgery, they let a patient bite down on something. The modern assumption is that this was so you don’t grate your teeth and break them. But why do people grate their teeth when they’re in pain?”

Clark is well aware that much more work is needed on a possible role for orthotics in helping with pain and movement disorders. But orthotics, like transcranial direct-current stimulation (tDCS)—which is showing great promise in preliminary trials for treating pain—are of no interest to pharmaceutical companies. And there’s a mindset in the U.S., at least, Clark argues, that makes it hard to drum up support for funding trials of cheap, simple devices like this. “We’ve come to believe that more complicated technology is always better. I think that’s a fallacy. It’s not always better. It’s certainly almost always more expensive. You look at these images of patients getting better with an orthotic. If this was after brain surgery or a new drug, people would be swarming to learn how to do it. We don’t have doctors lining up.” In the U.S., he argues, on the whole, doctors look for more expensive treatments, because they can make more money from them.

Clark would love to see funding for big randomized controlled trials of simple, cheap devices, like orthotics, or even colored lenses for kids with developmental disabilities, which were adopted in the California school system after pressure from parents but which have not been well-evaluated. Given the growing evidence for the effectiveness and safety of tDCS, the case for expensive, gold-standard trials in this area is perhaps even stronger. “On average drug companies spend five billion dollars for every new drug that comes to market. A lot of that is on failed drugs,” says Clark. “If you spent five billion dollars on tDCS, you would, I suspect, get the same benefit as developing 100 new drugs—it looks like it could be applied so many different ways.” He urges the U.S. National Institutes of Health to fund the necessary work.

This post originally appeared on Mosaic as “Low-Tech Pain Relief” and is republished here under a Creative Commons license.  I found it in Pacific-Standard: The Science of Society.



© 2013 L. Ryan

Balanchine's Agon: Diana Adams and Arthur Mitchell, Anxiety and Beauty

Agon (1957) is a ballet for twelve dancers, with music by Igor Stravinsky and choreography by George Balanchine. Composition began in December 1953 but was interrupted the next year; work was resumed in 1956 and concluded on April 27, 1957; the music was first performed on June 17, 1957 in Los Angeles conducted by Robert Craft, while the first stage performance was given by theNew York City Ballet on December 1, 1957 at the City Center of Music and Drama, New York (White 1979, 490). The composition's long gestation period covers an interesting juncture in Stravinsky's composing career, in which he moved from a diatonic musical language to one based on twelve-tone technique; the music of the ballet thus demonstrates a unique symbiosis of musical idioms. The ballet has no story, but consists of a series of dance movements in which various groups of dancers interact in pairs, trios, quartets etc. A number of the movements are based on 17th-century French court dances – saraband, galliard and bransle. It was danced as part of City Ballet's 1982 Stravinsky Centennial Celebration.

Just what was needed for this day, these times:  A 27-minute ballet with 12 dancers, the creation of Igor Stravinsky and George Balanchine.  Within that frame, a 1 minute 44 second concentration on Diana Adams and Arthur Mitchell, who danced the début for the New York City Ballet in December 1957.  That short video elicited this comment on YouTube (Yes, a YT comment worth repeating!):

mproche571:Diana Adams and Arthur Mitchell in Agon. It just doesn't get better. Later dancers brought more strength and athleticism, but no one demonstrates the anxiety and beauty of this most particular Balanchine ballet and Stravinsky score the way that they do.

With its emphasis on form, erotic play, and design, Agon has been called an "argument-free ballet." It was the last collaboration between Stravinsky and Balanchine, and I think that is what many people miss -- this only works, this music and that choreography, through collaboration.  Presented as a concert, Stravinsky's work is almost universally panned.  What I'd give to see the score outline, which apparently includes the contemporaneous description of the dance.  Collaboration.

Igor Stravinsky and George Balanchine in rehearsal
while working on Agon in 1957. Photograph: Martha Swope

In 1934, as George Balanchine was working on what would become the first ballet he would choreograph in America, Serenade, Igor Stravinsky was asked by the press about whether he personally saw a future for ballet. Stravinsky replied, with characteristic frankness, "There is not a great deal of good ballet music. Either it is sunk in the dance or it is irrelevant to it as a rule. Music and dance should be a true marriage of separate arts, a partnership, not a dictatorship of the one over the other." 

Diana Adams and Arthur Mitchell rehearsing Agon
From "Moments in Time: Tracing the history of diversity in ballet"
by Gus Solomons jr

December 1957: George Balanchine pairs Arthur Mitchell and Diana Adams in Agon’s erotically charged pas de deux. In a world still a decade away from the civil rights movement, this was casting as political act, and it shocked some members of the ballet community. Twelve years later, Mitchell founded Dance Theatre of Harlem, a haven for classical dancers of color.

Embedding has been disabled for "NYC Ballet's Megan LeCrone on George Balanchine's AGON," but please watch it... for Megan LeCrone is to Agon as Diana Adams was to Agon.  It's eerie.

The pas de deux is one of Agon’s most unique features. The music sounds disjointed, with few instruments being used at a time, but it is still possible to identify the basic components: an adagio, two variations and a coda with the key difference of a role reversal for the dancers, the woman seeming to lead the male into assorted extreme poses rather than the opposite. There are several famous images such as the one where the ballerina wraps around her partner with her leg in attitude, or her 180º arabesque whilst the male dancer is lying on the floor.

Uploaded to YouTube by NeryssaPaige -- 11 July 2012


Compare to this later video of a rehersal with Arthur Mitchell paired with Allegra Kent. I'd love to know the date, should any Dear Readers know it.  (Not to be missed, though to be read with a calming agent at hand, is Kent's autobiography, Once A Dancer.  Preface it by reading Joan Acocella's review... and give the book purchase a second thought.)


Uploaded to YouTube by Approximatesonata --  5 December 2012

Agon is the Greek word for contest; the movements of the ballet are named after French court dances. The score was commissioned by New York City Ballet with funds from the Rockefeller Foundation and dedicated to Lincoln Kirstein and Balanchine by the composer. Together, Balanchine and Stravinsky designed the structure of the ballet during the creation of the music. The outline for the score specifies in detail, with exact timings, the basic movements for twelve dancers clad in simple black and white costumes.

Agon, part of the repertoire of the Dance Theatre of Harlem --
 DTH Founder and Artistic Director Emeritus: Arthur Mitchell 

The "12-tone serialism" technique employed in Agon for the first time by Stravinsky is explained well, for those of us stupid in music, at the Ballet Bag, a website dedicated to "freshening" the art, and supplies helpful interpretive notes, too:

Even though Agon starts with a diatonic, non-serial structure, Stravinsky combined parts that had a tonal centre (think of the violin solo in the coda of the first pas de trois) with serialist parts (the flute, mandolins & harps in the Galliard). In order to concentrate on other works and further his experience with serialism Stravinsky shelved Agon for a couple of years and then returned to create the central – very serialist – part of the work (the first coda and the bransles, ie. the moves from side to side), following Schoenberg and Webern’s ideas. 

Besides the new composition techniques, Stravinsky also used specific instruments to identify the dancers in the ballet – brass for men and woodwind for women – as well as traditional French court dance references: the bransles (couples dancing in circle, side to side), galliards (an athletic dance with plenty of jumps),  sarabande and pas de deux/quatre.

Sadly, a satisfying video of the whole, I cannot find.  Below is an honorific, of sorts -- part of a gala on the occasion of the 10th anniversary of Balanchine's death -- The Balanchine Celebration in 1993.



Peter Boal, Zippora Karz, Kathleen Tracey, Albert Evans, Arch Higgins, Wendy Whelan, Darcey Bussell, Lindsay Fischer,

And just to leave you laughing... and why not, with all this unexpected balletic divertissement... here is a charming interview with Arthur Mitchell who relates Balanchine's personal vision for "sixteen nubian dancers":

The Ways of Worry, With a Side of Depression

A reposting from 17 March 2010. Why? Well, it's been hit on quite a lot by visitors to The Manor over the weekend. When I reread it, it also struck most of the chords being played in Marlinspike Hall today, right down to the major 13th chord that Fred conquered in the wee hours of this Monday morning.  Enjoy!

*****     *****     *****     *****     *****     *****     *****

Interesting times.

I continue to struggle with excesses of pain and disability, not always doing so in a way that is particularly laudable, but I do the best that I can.

Dealing with serious health problems without the benefits and protections of health insurance, I spend most of my time flying along the continuum between abject terror and irresponsible giddiness -- picture a nearly-out-of-control luge run down the streets of San Francisco. Woo hoo!



Any neat freak knows that when entropy works up a head of steam... cleaning, straightening, organizing, list-making (and all their anal adjuncts) become the logical and necessary response.

Yes, my world was much improved when I broke down the Sushi Maker Kit into its individual components. Storing my little jar of Wasabi powder with its spicy compatriots almost eliminated the need for my three antidepressants. Putting the Pickled Ginger in the fridge next to the Fish Sauce almost completed my brief, unmedicated happiness. That means that adding the Sushi Rice Vinegar and a very sexy dark Soy Sauce to our existing collection of vinegars and prepared sauces provided such an over-the-top sense of personal plenitude that my mouth risked being permanently puckered.

But then came the unexpected addition of stuff like two insulins (plus the prohibitive cost of those dumb little blood sugar test strips), expensive antibiotics, a trip to the emergency room, and the necessity of consulting certain specialists again. As I shelled out the big bucks for medications and health services over the course of the last month -- and I mean just those medications and attention that were absolutely necessary to life -- my insecurities continued to win out over any residual sense of well being.

There was nothing left to organize, and the only things available for tossing belonged to Bianca, Fred, or the various remnants of the Haddock clan.

Intolerant of my troubled need to eliminate all that is not essential, the ingrates keep hauling their possessions back from the county dump. Sometimes, they even scream and yell, calling down Iniquities from Heaven onto my Humble Head. I suppose I should be grateful not to have to deal with the cursing power of The Captain. His distant cousins seem only to be able to manage some stuttered denigrations.

I mean... think of what Captain Haddock might say, based just on the things he's said before:

Pachyrhizus-eses-eses! Parasites! Patagonians! Pestilential Pachyderms! Phylloxerae! Pickled herrings! Pirates! Pithecanthropic montebanks! Pithecanthropic pickpockets! Pithecanthropuses! Pockmarks! Politicans! Poltroons! Polygraphs! Polynesians! Profiteers! Psychopaths! Purple profiteering jellyfishes! Pyrographers! Pyromaniacs!

And that is just the letter P.

A brief aside in my otherwise tightly-knit narrative: {!lordy!::!lordy!} My Dearest Readers, allow me to share my discovery of a website that will help us all, from neophyte to habitués, in the conjuring of powerful and effective curses. I mean curses in their most witchy sense. This gem of a site has come in quite handy and I join hundreds, nay thousands, of people whose cursing abilities (and, by extension, quality of life) have been vastly improved by its use. Take the case of this poor person whose own curses were just too doggoned weak and downright pitiful to make people stop calling her names. Without busting a barnacle, The Captain could have reduced her to tears in under ten words. But, good news! She came away reassured that, by properly casting her circle and by healing any breaches in her perfect Sphere of Protection, she is "untouchable by such others, even invisible to low-life." Help is out there, folks, for most every problem humankind can come up with... **
When the physical symptoms of this runaway osteomyelitis decided to ramp up their influence on my general ill-being, it became even more difficult to clean, sort, organize, disinfect, and prioritize -- to rule over my environment.

So I decided to get deeply depressed.
Despite having already paid for those three antidepressants.

As if I had planned my Descent Into Neurotransmitter Hell, somewhere in that period of murky time, I stopped taking the one [very, very expensive] medication that really was helpful to my chronic blues and switched to one that was featured on the $4 Walmart Generic List. It has not YET proved a suitable replacement.

So there I was: unable to use my arms very much -- which put quite the crimp in my vacuuming and polishing routines -- and tormented by the CRPS demons that daily tempted me to perform Do-It-Yourself amputations with a rusty scalpel.

I thought a lot about suicide. Oh, hell, I always think about suicide. There was, though, a qualitative difference and [a whole bunch of deleted, très personal crapola that can be reduced over high heat and finished with a tablespoon of unsalted butter...].

Yes, I did just refuse to share something with You! (And aren't You glad?)

And yes, I did just find shelter within a well-crafted and delectable Cooking Analogy!

Because once I determined that my suicidal thoughts were pretty effing dangerous and did actually threaten my survival? The search for Comfort began in earnest and that included, obviously, Comfort Foods. In fact, I mean to submit for publication my written philosophical proof that the correct formulation is "eat to live." No, wait. That should be: "Live to eat." Hmm. Well, I *do* know that to NOT publish is to perish... and if I don't get insurance soon? Taking "live" out of the equation simplifies matters enormously.

Don't worry, I won't include my "permanent and total" uselessness as part of the argument. I won't ever let on that I miss, I need, I cherish, those university days of endless investigation, teaching, sharing, exploring. Ah, the rarefied air of pumpkin-carving, martini-guzzling, day-of-the-dead-ing academics. You won't read about *that* regret here, no sir!

And so it was that the denizens and mavens of Marlinspike Hall (as well as some of our closest starving neighbors) were treated to three different kinds of Rice Pudding, a sad reproduction of Lunchroom Tamale Pie, all sorts of composite salads, aromatic pans of roasted and caramelized root vegetables, various bhaji (onion remaining the favorite), paneer, and -- of course -- sushi.

Okay, so sushi is not traditional Comfort Food. But think Bento Box. A sushi roll, some tempura,and simple things like half a hard-boiled egg, raw baby veggies, some beloved furikake (we like a not-too-salty gomashio) over rice. I am a neophyte at pickling but have heard the call -- and witnessed chefs accomplishing it in the space of half an hour, making the process even more appealing.

I suppose what I am describing is more Comfort Cooking than Comfort Food, although we have indulged in several incarnations of childhood Macaroni and Cheese. Throwing myself into time-consuming processes is really just another variation of the classic advice given to people dealing with clinical depression: *do* something! Whereas once I might have played a few sets of tennis or taken a dip in The Moat, now I do "quick pickles"of onions and carrots, or stuff roasted poblano peppers with tiny cubes of eggplant. At least my compulsive needs and tendencies serve to nourish the bodies of the souls I love.

[O! How could I have forgotten SOUPS! It has gotten to the point where I can barely tolerate canned prepared soups -- all that salt and tired taste. There is something so very grounding about a successful soup. Building flavors and foundations, eliminating the superfluous, elevating the humble. Also, let's face it, I am the Queen of the One Pot Meal.]

Then, too, there's the resultant mess. I get to moan and groan but secretly delight in the cleaning up necessary to my continued culinary success. Yes, it is painful to wash dishes. Yes, it hurts like the bedeviled dickens to mop the kitchen floor. Still, when these tasks are moved from the "just because" category to the "must be done" rationale? Someone has to do it... Lately, I do hit the wall during meal preparations and even though I clean as I cook, I have had to turn the mess over to my compatriots. There is much less guilt involved, though, because I have, at least, fed them.

However, on certain days, even several days in a row, I cannot even get out of bed. Getting up to go to the bathroom reduces me to tears and invites that peculiar terror of falling.

How do I manage my Uninsured Anxiety then, when even more than usual my infected bones and burning legs take charge?

That is where I was yesterday. I tried napping, reading, watching the Idiot Box, playing bridge, poker, mahjong. Tweeting, emailing, and pontificating ensued. (There has to be severe melancholia for me to venture to Facebook.)

All to no avail.

The need to clean, fix, straighten, prepare, chop, serve, wash -- that need was not being met.

And so it was that I found the latest incarnation for my sublimation needs: old letters and cards. We all have them, stashed away somewhere. Through the years, I have gotten rid of some pieces of mail that probably should have been kept. Nonetheless, I have a small trove of keepsakes -- and in my depressed, anxious, uninsured state, gathering them together for storage in one suitable spot seemed The Thing To Do.

You probably know the punchline.

As I read through letters from my brother, from friends, I tried hard to stay suitably depressed, to lament times gone by, never to be recaptured. Instead, as you already know, giggles and hoots and even a few guffaws were the result.

I know some funny people.

Here, let me show you:

In my first year of college -- at a college I only attended for one year -- I met a wonderful woman, a Senior to my FreshPerson. She presided over the Poetry Club and over the hearts of two remarkable, diametrically opposed, men. The Poetry Club was her excuse for hanging out with one of those men, the one she would not go on to marry but whom she loved most. He was the son of an oil baron -- no, I am not kidding -- who flitted around the world in dissipated fashion when not attending Our Humble School. Very Lord Byron ("mad, bad and dangerous to know").

We will call the byronesque, filthy rich heir Bill because that is his name.
Her, we will call Kathleen, as that is her name.
We won't mention the very successful lawyer husband because he was, in many ways, irrelevant at the time of Kathleen's various missives. They went on to make beautiful children and achingly darling lives.

Oh hell. His name is Jim.

The summer before she married Jim, erudite lawyer-to-be and classic Good Guy, Kathleen experienced a massive amount of doubt. I learned to listen and not opine (especially as I was against the upcoming union). At the time, I was at a large public university earning an undergraduate degree at the speed of light. She was finishing a Master's in Anthropology at the better known school down the road.

It was a December day when I found this muted Paul Klee postcard from Kathleen in my mailbox. The writing is minuscule (I had forgotten her incredible handwriting!):


I haven't had any sleep in forever. Insomnia for two days followed immediately by four nights of sleeping in the living room of a trailer which then housed seven other people. My family drove to Pennsylvania to see relatives and Jim joined us for about 40 hours, 35 of which were spent either sleeping in separate rooms or in the company of a vast number of relatives. Still, everybody likes Jim and somehow he managed to impart to me a faith in our relationship's future which had recently been missing on my part. The paper I sweat blood to write is finished -- so finished it looks as if it must have been effortless to write. I'm fighting letdown, wondering if I really have the courage to hand it in only to have somebody say "So what?" And there is so much shit work to do to finish off the semester. I can't remember if I've written to you since you called, but even now, when I think about the little shit "Bob,"* I literally get blind for a minute because I'm so pissed off that somebody would do something like that to you. It's things like that that make me realize I'm very capable of violence. I love you, take care of yourself.

Postscript: A week or so ago, I read The Portrait of a Lady. I understand better why Bill was so much against marriage for me. In fact, he once compared me to Isabel Archer. Speaking of Bill, Jim drew me a lovely portrait of Bill at Our Wedding: with a red cushion strapped to the top of his head (both rings on top), Bill will come leaping down the aisle (great graceful bounds) with his hair streaming in the breeze behind him and his beard leading to the fore, he will pirouette ethereally above the assembly in a pale green leotard. Breathtaking thought, hmm?

*The "Bob" of which she speaks is this one.

A week before she was finally and irrevocably betrothed, Kathleen canceled the wedding and called for my Incredible 1965 Baby Blue Cadillac to carry the both of us away to my family's beach cottage at Morehead City, on Atlantic Beach. We had a grand time: She got quite the sunburn; We drank a lot of wine. We talked, but barely mentioned boys or men.

We ate our weight in boiled shrimp, served on fresh newspaper, dipped in ketchup and garlic butter.

The wedding was put back on the schedule but we stayed at the beach until the day before... lost in the sun, sand, and water. We did not answer the phone. We were out of reach and touch, out of time.

As it worked out, Bill did not attend.

Struggling to remain upright on my stilt-like Fancy Sandals, I still saw Kathleen's eyes sweep the church, and knew who she was looking for. We both later received clever "cara mia" letters of explanation, Italy the postmark.

The Klee on the front of the postcard is titled Parcimonieusement garni de feuilles, 1934, but I also see a cold winter night in a small mountain town, on an even smaller college campus -- a center of sober rectitude -- Bill in an old pea coat and impressive boots, dashing from tree trunk to tree trunk as Kathleen and I stagger, laughing, through the snow. One of us, I'm sure, is reciting poetry. If you squint and tilt your head to the left, you can just make out my second floor dorm room, in Cannon Hall.

So, I am putting this little bit of Kathleen, Bill, Jim, and "Bob" in the accordion folder purchased just for such a project as this.

Next, Brother-Unit Grader Boob's 2001 Christmas card, "made for [me] by Adjuncts on Bicycles -- Impoverished Athletes Extraordinaire."

Odd, I don't feel quite so depressed, and while my legs remain a source of suffering, the suffering seems dim and far away. The fever, sweats, and shoulder pain from infected bone? Pshaw!

So, for anyone wondering, that's where I am at -- cleaning what is often not even dirty, cooking when often there is no one even hungry, and lost inside temporal dislocations of memories that I am pretending to sort and organize.

Here is a list of everything I have learned

Exactly how transparent am I?
That bad, huh?

Did you ever grow so sick of yourself that waking up still here provokes the first apology of a day crammed to the rafters with apologies, and Apology's Echoes?

Here is a list of what I have learned in the short time since my brother was diagnosed with an awful metastatic case of cancer:

He can still be an asshole.
I continue to direct my emotional issues, like projectile vomit, onto others, and try to absolve myself of the guilt by choosing "strangers."
We're none of us strangers.
Should you work in the medical field, and our paths cross, woe unto you, and woe unto me, and, especially, waves of great sadness at the destructive forces of anger.
There are no excuses for the rampant stupidity of the medical folk I've been gifted with these past few weeks.
There is an abundance of hope and good feelings about the medical folk who now surround my dear brother, and I know the feelings of affection that grow in their heart for him.
It's inevitable.
Ants and spiders, particularly of the small and "cute" variety, are allowed to live.  I vacuum and mop around them.  I escort them into the great outdoor holdings of the Haddock Family Corporate Manorship. Marlinspike Hall has never been so clean, nor so infested with small, suddenly fearless insects scavenger types.
Dreams are finally a relief.
My pain did not become subsumed in the pathos of his pain.  It remains.  It's inevitable.
I beg others to forbear and badly need to develop the talent in its most personal, intimate form.
I still have the talent to be one with him -- without his knowledge and consent, but since he can still be an irritating asshole, the need to apologize for the psychic intrusion simply does not exist.  How liberating!
When I eat a green salad that is also full of vibrant reds, yellows, and more shades of "green" than the descriptor can imply, it's into his stomach -- pleasantly balanced and accepting of the vegetative offering -- that it goes.  I use about a teaspoon of excellent red balsamic vinegar as dressing most of the time and tend, at least in the last week, to eat the salad entirely with my fingers.  But I don't lick my fingers, 'cause that would be gross.  He sighs with contentment.
I recognize the edge of my own skin as the edge of myself.  His skin, however, has become amorphous, penetrable.  Until your fingertips hit the cancers' limn.  That's the wrong word, or is it?  To carefully outline, tentatively touch, desirous to probe but fearful.
Death is not the enemy, never has been.
God is not interesting.
Pound's ant's forefoot will, indeed, save you, if salvation is needed.
Love is precious, and everywhere.
Fred is afraid of dying.  I must tend to that, maybe later today, or early tomorrow, if he can manage to get his ass out of bed before noon.
My brother remains my touchstone for most of the good and right things that I know.  That goes, actually, for both of my brothers, but as they both can be assholes, and since only the one is in immediate peril from pain and suffering, Grader Boob's status as Primary Touchstone shall prevail, for the time being.  I've completely overwhelmed our elder brother with my inappropriate emotional lability and neediness.  Actually, I'd like to call it "emotional incontinence," as that makes me laugh.  I am trying, actually, though you'd never guess it, to make that elder brother laugh, as he does zing through Captain Haddock's wormhole in the moat for the occasional stealthy visit.  I love them both from *here* to eternity.  Does anyone mind, except for the medical professionals propped up in all my corners, if I take a few ibuprofen?
How are they "assholes," and how dare I call them "assholes"?  They are not, of course. They simply refuse to conform to my standards, needs, and a way of behaving that would make life infinitely easier for ME.
Am I aware of my seeping narcissism?  Oh God, yes.
Every day since his diagnosis, which now seems an aged elephant whose stink has been in my nostrils for at least a decade, my brother has accepted the resultant intrusions of advice, concern, panic, judgment, and other violences, large, small, and medium, with grace.  The asshole.
He even issued me a blanket, nonrefundable statement of forgiveness.  The asshole may regret that, as my sins pile high, but I believe him.  He is, to my knowledge, the only person of import in my existence who has never lied to me.
He is afflicted with the same genetics and inheritances, however, and that saddens me the more I think on it, and have, therefore, cut down on the time spent thinking of nature and nurture, genes versus the oppression of our progenitors.  Sometimes, I even remember the beauty of my father's eyes and the taste of a "mortgage buster" tomato sandwich.

How do we tolerate these things we learn:
"These matters that with [ourselves we] too much discuss
Too much explain?"




Yeah, well, you know Eliot HAD to happen on this blog, in this matter, eventually.  Dr. Seuss shall have equal time in my brother's cancer journey.  Maybe I will even have something original to say.

I'd offer you quotes from the Brother-Unit, himself, but he is being an asshole, and nothing but a quipster, at the moment.  Actually, and this is quite serious, he is obsessed with his "ass," and how it hurts.  No one is particularly quotable when ass pain has reached such a consuming proportion of an already overwhelming amount of pain.

Maybe I should cut the boy some slack.

Have I tried subsuming his pains, his cancer, calling it into my own wrecked body and self, instead?  Well, duh, Dear Reader.  And the universe doesn't roll that way, or didn't you know?

Time to relocate my legs, and perhaps add opiates to the ibuprofen.

Love to the Brother-Units.  For those in the know -- the StepMother-Unit is recovering from her emergency surgery, though her 85-pound little self also tried to assault one of her nurses, prompting the name plate on her hospital door to be changed to "Boom-Boom Baba," and our stepsister to be nominated for sainthood. The tiny pugilist has successfully farted, reports the dear stepsister, and therefore may now have broth. This should improve her mood immensely, we hope, and cheer her, somehow.

The biological Mother-Unit remains in-and-out of dementia, and cursed with the actions of sociopathic offspring.  Karma is a bitch.

I'm in a world of pain, and withdrawing from a drug that my new insurance, represented by its plethora of doctors, nurses, and pharmacists, could not see its way to renewing, despite two week's worth of effort, at least, on Fred and my parts.  We spent most of Friday in a pharmacy, and thought ourselves victorious over The Beast, only to discover that the pharmacist managed to refill another drug that began with the same two first letters as the one I need.  It's one of three drugs I use to fight the screaming ninny spasms of CRPS, so this weekend has been fun, fun, fun.

So, I say again:  Karma is a bitch.

It's lovely outside, but too hot. The felines are wonderful, and Fred is fine, as soon as we take care of that Death Fear issue.  He's been beyond "fine," actually, more in the range of "wonderful."

Be well, all.







© 2013 L. Ryan

If It Is Tuesday...

Cape May During Hurricane Sandy

If it's Tuesday, then Monday must be over.

Anyone wishing to argue about space and time continua or parallel string bikinis may simply go take a dip in the moat.

Because, damn it, Monday is over.  We start fresh.  All devices have been charged.  The Manor is pristine, the grounds are pruned, raked, and -- where absolutely necessary -- mowed.  Sven Feingold putters about giggling, so something is up with the latest ManorFest Maze design.  La Bonne et Belle Bianca Castafiore stays on her cell, when she can get reception, because she is *this* close to garnering a position as spokesperson for a major weight loss company that specializes in busty divas.  Just the exercise and muscle toning from running up and down turret stairs and sprinting around Captain Haddock's miniature submarine wormhole gateway will make her lose a few dozen dress sizes.  Should Marlinspike Hall ever successfully be enveloped in a wifi bubble, the Milanese Nightingale may well gain back all the fat she's discarded chasing a phone signal.

Our various herds and fruit orchards are all in their proper states.  The monks next door are reworking their Christmas Catalog of Wasted Calories and the Abbot, Fred, and I have been designated taste-testers.  Life is sweet.

But Monday.

The Mother-Unit that actually raised moi decided to need emergency surgery.  In a test of the emergency surgery system in the coastal backwaters of her slice of paradise, she encountered the requisite number of idiots at the local beach bum hospital over the weekend.  So, in a way, Monday was her salvation, as it brought an influx of actual medical practitioners leaking grains of sand onto the spit-shined checkerboard hallowed hospital halls.

I was a tad bit worried when I looked up her surgeon's credentials to find that he also enjoyed the practice of ophthalmology.

I've not seen her in decades but every description begins with her diminutive stature.  She has everyone and everyone's brother worried about her weight -- no busty diva, she.  I want to scream sometimes.

Oh, about what?  I need to particularize my need?

I want to scream at the "but she's so tiny," "she can't take it, she has no... reserves!"

Puh-leeze.  This is a woman who was a fierce ballerina.  I watched her employ many tricks of the dancing trade as she guarded her lithe status through the years -- as if it mattered once she was no longer expected to enter rooms via a grand jeté.  She is not anorexic in the strict definition of the malady.  Nor is she an alcoholic, nor does she abuse prescription drugs, in spite of a lifelong celebration of Happy Hours and a honking bottle of bazillions of phenobarbital kept in the last drawer of her dressing table.

Anyway, she survived the weekend, and made it through a scary surgery with style.  And got -- with us -- to Tuesday!  Yay, Mom!  Point your toes and twirl, twirl, twirl!

Equally wonderful about this day?  Grader Boob gets his first doses of chemotherapy!  His story has become so sad, beset with that ogre of physical pain and the great deceivers of the mind that pain welcomes. If you're a Dedicated Reader, you've seen me act out that drama, o'er and o'er.  Therefore, rejoice in Tuesday, for shrinking those tumors will result in less pain, and less pain will allow sleep, and sleep will further decimate the pain cycle.

All together now:  "Shrink, tumors, shrink!  Shrink, tumors, shrink! Shrink, tumors, shrink!" I have an accompanying tune in mind, but don't want to limit your creativity as you dance your way through this Tuesday, chanting, cavorting, and casting Grader Boob tumor cells into Tumor Cell Inferno.

Use any musical genre that works.  Though I have to admit that "country/western" somehow doesn't fly. Feel free to prove me wrong. Something in a Texas Two-Step, maybe?  Just be stylish.  This is my brother we are talking about.

He's simply riddled with cancer, the reprobate.  His new oncologist, who seems a very good dood, is starting the meds today whether he is admitted to the clinical trial or not.  And no, I am not stupid.  Prevailing winds, insight, what is not said -- I'm on it.

Given that it's been over 6 weeks since the official diagnosis, it is fair to say that the new oncologist's very life may have hinged on that decision, as I was gathering weaponry to bring down on his toupéed head if something were not done this week.

Would I kill to improve Grader Boob's Quality of Life?  Let me see.  Hmm. Yes, of course I would.

Wouldn't you?  If I were willing to personally extrajudicially execute Pinochet, Jesse Helms, and various other errors, an attempt on the life of someone impeding the life of Grader Boob is one of those famed "slam dunk" decisions. The weird problem with my Kill List, and this has been the case since roughly the 1970s, is that once penciled in for an extrajudicial execution, my Listees just... drop dead.  Or are taken out in the wrong fashion, a tragedy equal to the horror of their continued existence.  If you have any insight into how I might stem the tide of these unworthy deaths and promote the karma-cleansing of my efficient Kill List, the comment section is all yours.

If you're lathered in a cold sweat and thinking of calling the Interwebs Keystone Kops, relax. I was voted the Family Member Least Likely To Commit Murder.

So, it is Tuesday.  The Mother-Unit may yet gambol along the edge of her watery front yard, scotch and soda in one hand, the other arm gracefully indicating the vastness of the Atlantic.  The Brother-Unit may get to drop the F-bomb on another set of undergraduates, or he may be granted furlough to gambol alongside the Mother-Unit, leaving now and then to swim out past the breakers.

Have I told you lately, Dear Readers, that I love you?  Particularly You... That's right, You.

Instructions for Tuesday:

• Point your toes and twirl, twirl, twirl!
• Shrink, tumors, shrink!  Shrink, tumors, shrink! Shrink, tumors, shrink!

© 2013 L. Ryan

Amputation for Complex Regional Pain Syndrome

photo, amputated limbs, "field day," civil war...

Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I

Marlies I. Bodde, MD; Pieter U. Dijkstra, PhD; Ernst Schrier, MSc; Jan J. van den Dungen, PhD; Wilfred F. den Dunnen, PhD; Jan H. Geertzen, PhD
J Bone Joint Surg Am, 2014 Jun 04;96(11):930-934.
http://dx.doi.org/10.2106/JBJS.M.00788

ABSTRACT

Background: Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.

Methods: We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.

Results: Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological “green, yellow, and red flags” were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.

Conclusions: Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.

FOOTNOTES

Investigation performed at the Department of Rehabilitation Medicine, Center for Rehabilitation, and the Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, the Netherlands