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NATIONAL PSYCHE Mal 11@ Ob) MIXED MESSAGES PY ena Oe ca) eens HSE slammed for playing Pee eerie Dyan) Pane eit ~ Ne ae pio leh Ey See re FISTULA SelanteMarclelfetege Posscutetia tie, ieSaRxe ge Ta Celi 7 en embering the Spier aati TOP COLUMNISTS. * elisa sire) Dr Vincent Hannon The surgeon’s archive Keo} area faat-) ee cela Nitec USE aTe) MESSAGE SCOPE Sept/Oct 2010 Volume 3: Number 4 Editor Kennas Fitzsimons Senior Writer Eimear Vize Sub-editor Sharon Murphy Designer Lucy Proctor Medical Contributors DrJuliet Bressan DrStanley Bums Dr Vincent Hannon Dr Robert M Kaplan Dr Brendan Kelly Dr Faul Stewart Contributors ‘Maureen Browne Robert Love Christopher Payne Fintan Taite Advertising Manager Leon Ellison Publisher Geraldine Meagan LG medmedia publications ‘SCOPE is publsted by MedMesa Pubeations, 25 Adesde St, DunLanghae, Co Dublin Tel 01 2803967 Fox 03-280 1076 Ema scopeamatmedia reo: wn mecimeciaie ‘he contents in fl are copy of Medved Ld. ND aries may De reproduced, eter In ful orn prt, witheut the pee writen peson ofthe pubes SCOPE DEAR READERS, ‘The patient who stares out from the cover of this issue of Scope was treated by the distinguished Irish surgeon Mr Edward Stamer O'Grady (1838-r897). Referred to (OGrady for malignant disease of the humerus, the patient’ treatment — amputa tion of the limb through the shoulder joint ~ proved successful. This patient is noteworthy in medical terms for his recovery from radical surgery ata time when procedures were frequently crude, buteven more remarkablein historical termsas the subject of one of Ireland's earliest medical photographs. ‘The photo is one of several from the archive of photo historian and ophthalmic surgeon Dr Stanley Burns, Originally reproducedas black and white lithographs to accompany case histories published in the Dublin Journal of Medical Seiencein the 1870s, the photographs themselves are published for the first time in this issue of ‘Scope. We are delighted to have the opportunity to bring them to you and extond our sincere thanks to Dr Burns for permission to do so. ‘The story of the surgeon behind the photo casebook is similarly fascinating Besides being aman of eminent distinction in hisspecialty, 'Grady was the source and subject of considerable controversy during his tenure at Mercer's Hospital in Dublin, Fimear Vize recounts the tale ‘We're also privileged to present another collection of outstanding photographs in this issue of Scope, Christopher Payne, a photographer based in New York City, specialises in documenting America's vanishing architecture and industrial land- scape. Chosen by the editots at Amazon as one of the best x00 books of 2009, his most recent publication, Asplumn: Inside the Closed World of State Mental Hospitals, explores the vast psychiatric institutions ~ once monuments of civic pride ~ that ‘now lie derelict throughout the US. Dr Brendan Kelly examines the history ofinsti- tutionalisation in an tish context. ‘Scopealso reports on the important work being carried out in Democratic Repub lic of Congo by Médecins Sans Frontieres as the aid agency battles to eradicate obstetric fistula from that part of the world. Irish nurse Helen O'Neill and surgeon ‘Mr Volker Herzog discuss the magnitude ofthe problem and the incredible impact of the surgical solution. Elsewhere in this issue Dr Paul Stewart tells the stories of some famous hypo: chondriacs, while Dr Robert M Kaplan retumsto his homeland fora conference on psychiatry, Maureen Browne rounds up important news relating to the IHCA. Finally, 'm delighted to inform you that Scope has a new publisher. In a major ‘medical publishing agreement, MedMedia Group has acquired the magazine and a further seven titles previously published by M&C Publishing, The transfer of the titles cements MedMedia's position as Treland’s largest and most diverse health care publishing operation. We look forward to bringing you the same high quality ‘Stopeand will develop the publication to continue the high standards it has set As always, Scope welcomes your feedback to scope@medmedia.ie. Kennas Fitzsimons Editor SON & ONS Serta ae naan Se The surgeon’s archive c Almost 150 years after a collection of extraordinary Irish surgical cases was captured by the photographer’s lens they are published in Scope for the first time. Eimear Vize delved into the archives to find out more about these unique Victorian images rare collection of roth-century Irish surgical pho: A \testsinstcntic! om sal ery by ophthalmic surgeon, Dr Stanley Burns. The New Yorkbased physician, and internationally distinguished photo-historian, has amassed one of the world’s largest and most important portfolios of early medical photographs. ‘Among the iconic images he has aequired are some of the ear liest Irish surgical photographs in existence, none of which has ever been published. Now, Scope is privileged to repro. duce these important photographs for the first time. ‘Viewing the spectacular collection, which dates back to the 18703, one is first struck by the fact that such a large collection of unusual surgical cases ~ many with severely disfiguring malignancies ~ should be gathered together in one album. Most of the 26 images depict patients with large tumours on their face or body; some are before” and “after” shots that demonstrate the surgeon's skill in treating challenging diseases ata time when surgical procedures swere frequently crude Intrigued, one wonders i this could be the case portfolio of several surgeons or just one talented individual, who had the good fortune of being referred a latpe number oF Ti@tinating cases? ‘And what happened to the patients? Did they survive their radical surgery? Dr Burns is similarly interested in the narratives behind these incredible images but his efforts to investigate further proved limited. To this end, he gave Scope access to this pre cious cache in the hope that a hunt through the medical archives on this side of the Atlantic might unearth the long- forgotten stories behind these images. He felt sure that these images had appeared as engravings in a Dublin surgical journal, mostly between the years 1874 and 1878. So, with contact sheet in hand, Scope sought the expertise of Mary O'Doherty, who is Assistant Librarian (Spe- ‘ial Collections and Archives) at the RCSI's Mercer Library in Dublin, She had encountereda similar album before,credited tothe esteemed roth-century surgeon Mr Maurice Henry Col lis, and suggested that these patients could have come under the care of a single physician. A trawl through the yellow. ing leaves of one ofthe top periodicals ofthe time, the Dublin Journal of Medical Science (DJMS), might tum up enough.cases linking this portfolio to a particular surgeon. Starting with volumes published in 3870, it wasn't long before the firs lithograph copied from DrBurns' photographs appeared. In fac, five of these artistic reproductions by John Falconer, of Dublin, featuredin oneimportantarticle*Report {ng on 12 cases of excision of tumours” by the brilliant and controversial Mr Edward Stamer O'Grady, who wasone ofthe top surgeons of thedayat Mercer's Hospital, Dublin. A later edition ofthe same journal also documented another case by Mr O'Grady that features in Dr Burns photographs. It appeared we had iden tified our surgeon whose patient portfolio had found its way into the Burns Archive ‘more than a century later “Thave from time to time been indebted for a large share of important surgical cases — operative or otherwise” wrote Mr Grady in the DJMS (july 1875; 60: 1). His good fortune, in this regard, he attributed to “the affectionate remembrance borne to Mercer's Hospital” by its past pupils, who referred on these odd surgical cases. “It has been my practice to Keep accurate and more-or-less extenced ‘notes’ of these cases under obser- vation in the hospital wards,” he added. Mr O'Grady also acknowledged that it was a “compara: ‘vely-infrequent ocurrence” to have the opportunity to operate on tumours that had “teached asize of any consider able magnitude, and are so situated in the soft part as to be capable of excision’. By 1875, he had taken under his care a total of 23 tumour cases since commencing his duties as sen- orsurgeon at Mercer's in 1866. A number ofthese fascinating casesare detailed on the following pages, along with a biogra: phy of the surgeon. For farther information on the Burns Archive visit wunuabumnsarchive.com or email burns @i FEATURE cial and cervicz From his written account, one could imagine Mr Edward ‘Stamer O'Grady sitting across from the 60-year-old widow whose lower right face and neck was severely disfigured by a lange tumour. “It has been 15 years growing and now in size equalled that of a cocoa-nut with the husk on,” O'Grady noted with his typical penchant for detail. “The patient, tall wiry-looking woman but with feeble circulation, says she has been healthy and accustomed to walk long distances, but for the last year and a half the shaking of the mass, specially when the wind chanced tobe high, made locomotion on foot or otherwise very painful” ‘The operation took place on 27 September 1873 and all of his hospital colleagues gave their “able assistance”, O'Grady noted. He recounted the intricate procedure: “Two incisions, enclosing between them an elliptical piece of integument an inch wide in the middle, were made, extending from the upper to the lower margins of the tumour, and kept well for ‘ward on it.The posterior flap or curtain ofthe skin was then shelled back, and the ear freed, by careful dissection, from the intimate attachments. “The integument over the anterior portion of the tumour ‘was raised with the greatest ease, a firm fibrous expansion ‘was next divided, and the growth was now grasped by alarge and powerful vulsellum, which gave great assistance by lifting and drawingitin various directions, as the deeper por- tions of the dissection proceeded. The adhesions now were intimate, and a part of the tumour dipped in deep behind the jaw; excision here had to be effected with great caution, by repeated short touches of the knife.” The excised tumour weighed a hefty five pounds and eight ounces. O'Grady recorded that, during the patient’s month- Jong recovery in hospital, her face was swollen and “quite bland and devoid of expression” on the right side. However, by the time she was discharged, she had regained facial movernent. "I have since learned that, after a little time, the puckered appearance of the skin at the operation site also faded away completely.” he stated Ps “0 Removal of large fatty tumours from sub-occipital region and back of neck; recovery A 50-year-old labourer, whom O'Grady referred to as “MM”, ‘was admitted to Mercer's Hospital on 17 February 1875 fora Jarge tumour “situated on the back of the neck and encroach {ng considerably on the base of the skull”. O'Grady observed that, while the tumour gave the appear ance of being “firmly attached to the parts beneath’, it was quite free from pain and caused inconvenience only from size and sense of weight. He described the operation to remove the sizable growth: “During the separation of the lateral integumental coverings, the haemorrhage was inclined to be free, and was carefully restrained by pressure, several small vessels being secured as the dissection progressed. As the tumour became fully exposed it was seen that tendinous bands crossed its superfi ial and deep surfaces, running from above downwards, and being most numerous towards the mesial line, These had very firm attachments above and below, asif the growth had been originally developed in and expanded the posterior liga: mentous structures of the neck. Successfully removed, the mass weighed 27 ounces and exhibited, on section, “the ordinary appearance of fatty tumours” Although “the operation was well borne and sub sequent condition of the patient was most satisfactory? five hours after surgery another problem arose, The patient, wanting to urinate, found he could not OGrady inserted a fullsized gum elastic catheter, which “passed in withall possible facility" and eight ounces of urine were drawn off “Immediately after MM fainted, and became badly col lapsed; the pulse for several minutes was not to be felt atthe wrist, the heart scarcely more than beat, surface cold, lips blue, and general appearance very alarming. Mustard sinap. isms were quickly applied over the region and to the calves of the legs, hot punch and aromatic spirits of ammonia being also freely given. Aftera time the patient slowly rallied” ‘To avoid repeated distress, on four other occasions that the catheter had to be employed, the patient first received “an opiate and stimulant draught, and no further unpleasantness occurred’. The patient *went home quite well” on 22 March. score 19] FEATURE For more than 30 years, Mr Edward Stamer O'Grady was the proverbial thom in the sides of the governors of Mercer's Hospital in Dublin. While ~ historical records indicate O'Grady had reputation for being bull-headed and. abrasive in his dealings with hospital administration and certain. members of staff, many accounts reinforce this remarkable surgeon's huge popularity ‘among his patients and peers. Hejoinedthesurgical taffin Mercer's Hospital in 1866 and “threw himself into the work with great energy. He was ‘bold operator, and earned a high repu tation throughout Ireland for his skill in this department” a colleague later wrote of im, ‘The BM] first reported in Novem- ber 1884 on a rumpus within Mercer's walls sparked by the defiant O'Grady. Apparently, he broke all protocol in urging the recently widowed wife of a patient, who he believed was mismnan- aged by the resident medical officer, to request the coroner to inquire into the circumstances of is death “for the sake of the other patients". It emerged from the subsequent inquest that O'Grady had made several similar accusations of neglect against this doctor, in writing to the proper hospital authority, but without suc- cess, despite evidence to the contrary. ‘The doctor in question had an uncle on the board of governors, Hospital authorities were livid that the whole sordid affair had been laid bare for public consumption, The fol- lowing year, O'Grady was rocking the governors’ boat again. At a meeting of the house committee in March 1885, he accused a governor of “an indecent ‘outrage...on the modesty of a female patient Predictably, several members of the board conspired to rid themselves of the troublemaker O'Grady, and a case wwas taken to the Four Courts in 1887 to hhave the senior surgeon dismissed f offences “against the duty of his office”. ‘The case dragged on for years and pro- vided salacious reading in the national and international press. ‘The numerous hearings expounded detaflsof0'Grady’srmutinousbehaviour “directed towards the governors, and of O'Grady: the powerhouse surgeon verbal abuse towards nursing staff and some of is medical colleagues. His ear lier accusations of indecent behaviour by a governor as well as his breach of protocol involving the coroner's court ‘were raised by the prosecution. In O'Grady’s defence, his colleagues gave evidence as to his competence and efficiency as a surgeon, his popular ity among the students and staff, and his “zeal and his kindness” to patients. “He often paid out of his pocket for wine, chickens and other extras for his, patients," a surgeon testified. By December 1887, the case against Grady had collapsed completely and he was exonerated. “Mr O'Grady has come out of the ordeal unscathed and with the sympathy of the public. The institution ought to be reformed and the governors could not do better than to set about this work at once,” the BM] reported (24 December 1887) However, the enduring disagree: ‘ments between the Mercer's governors and some of the staff culminated in an May 1897 when the board dismissed the entire medical and surgical staff, But O'Grady ~ “2 stout man” = refused. to leave, according to SirJohn Lumsden in his article Personal reminiscent Mercers Hospital” Us sy The “discarded officers" wereall to reapply for their jobs but O'Grady refused to seek reelection. Jn defiance, he continued to visit the wards and tend to his patients until his sudden. death on 18 October that year “No one who knew anything of him could fail to recognise his high sense of right and honour; and his dogged per- sistence in holding to the view which he believed to be right had much, per- hhaps, to:do with the opinion of those who looked at him askance, He was a generous friend of the poor, and if his friendships in the profession were not many they were very trues The ~ public and the profession have lost 2 good surgeon and a man of high and ‘unswerving honour,” his obituary in the BMjstated. [3 Dr Stanley Burns Dr Stanley BunsisaNew York ity ophthalmicsurgeon and Clini- cal Professor of Medicine and Psychiatry at New York University, Langone Medical Centre, That would keep most professionals unquestionably busy but Dr Burns has also turned his passion for vintage photography into an internationally distinguished career as author, curator, historian, collector and archivist. He is the man behind the renowned Burns Collection con- taining more than one milion images in every imaginable | 19th-century genre. It the most important private com- | prehensive collection of early photography (1840-1950) and {he wort largest collection of tistoric medical photogra- ply. Among these 70,000 medical images are the medical photographic “national treasures” of several countries, including reland. Many OF the photogrephs depict patients with diseases long since conquered, and medical treatments, technologies and practices long since outmoded. In 1975, when Dr Burns frst became interested in daquerreotypes - the first successful photographic process ~ and other early photographs, he embarked on | ‘an aggressive buying and connoisseurship agenda. By 1978, he had acquired one Cf America's most important collections of early photography. ‘Around that time, he founded the Burns Archive to share his discoveries and embarked on a prolific writing career. He has since authored 42 photo-historical texts and over 7,000 articles, and curated more than 50 exhibitions worldwide. ‘Among his 30-plus photographic medical history books are the medical special: ties series: respiratory disease, oncology, psychiatry, dermatology, nephrology and ‘ophthalmology. The books can be seen on www.bimspress.com. He i preparing five catalogues on the collection. His blog ~ www.theburnsarchive blogspot.com, = offers @ wonderful opportunity to view some of the photographs.