My personal remembrance of Mrs. Audrey Greenlee: In celebration of a long and great life

It has been a month since the passing of Mrs. Audrey Greenlee; I am still trying to adjust my daily routine of life.  After leaving the clinic I would stop by at hospital, if needed, then stopping by to see her, once every so often, before going home.  Gone are those days, nevermore.

It hasn’t escaped my observation that the life Mrs. Greenlee spent in her last years was an envy of all.  She was constantly surrounded by loved ones and care takers; here or from out of state.  Patty, one of her loving caretakers, always tried to keep me informed about the busy schedule of her loved ones coming home.

Over the years I always tried to ask various subspecialty doctors to see her when the need of her care was beyond the scope of my practice.  But that was not always the case; on certain occasions I did it lest my emotional attachment would cloud my medical judgment as if I were treating my own immediate family member, then I realize that she was indeed the grandmother of my three daughters and my and Katy’s American mother!

Mrs. Greenlee’s short term memory deserted her in her last years, but she maintained her kindness to people, her humor and her fortitude to pain and suffering to the end; the examples abound.  Shortly before I left for Boston; about 10 days before her passing.  I stopped by to see her while she was sitting in front of TV; I bent down to see her feet, she asked me what I was doing, I said I was examining her feet.  Then I stood up with a stethoscope in my hand saying “Let me take a listen,” she quipped, “listening to my feet?” She quickly took advantage of my not saying thing properly—I should have said “Let me take a listen to your heart and lungs.”

In addition to her large and extended family, she and Dr. Greenlee also raised or welcomed foster children, foreign exchange students and medical residents into their home.   I recall one of her chest x rays reported her heart was a bit enlarged; that was an understatement; her heart was as large as the sea is deep.   She once had mild congestive heart failure; nothing could be further from the truth; a heart like hers could never fail.

Even though we have had a good fortune to be Greenlee’s neighbor for nearly 40 years.  We still do not know all their good deeds, some of which have become legends.  Mrs. Greenlee was very active in community in her younger or even not-so-young days, volunteering her time at Greene County Memorial Hospital, Eva K. Bowlby Library and the Waynesburg Senior Citizen Center, delivering Meals on Wheels for many years.

Abigail Adams’ last words were, “Do not grieve, my friend, my dearest friend.  I am ready to go,” she then turned to and comforted John Adams, “and John it will not be long.”  I do not recall that were Dr. Greenlee’s last words, but there is no doubt that he believed, as confident as Abigail was, they will be together again and they are now.  Dr. Greenlee was, is and will always be the Number One of Audrey Fan Club.

Primary carcinoma of the gallbladder: a timeless article of Dr. D. Paul Greenlee in the Archives of Surgery in March 1941

When Tuner and Paula gave me a copy of the Reprint of Dr. Greenlee’s article published in the Archives of Surgery (by American Medical Association) in March 1941, I jokingly said “Let me read it to see what outdated medical knowledge it might be,” as seventy some years is a long time for the progress of modern medicine.  Much to my surprise, his experience, observation, wisdom and recommendation are still very true and practiced to this day.

My conclusion was drawn after comparing Dr. Greenlee’s article with that of UpToDate—the most popular, authoritative, unbiased opinions among current medical professionals.

To operate or not to operate for the asymptomatic (“silent”) gallstone was the question Dr. Greenlee pondered in 1941 and is still the dilemma that we (physicians and patients alike) are facing today.

The dilemma arises from the fact that the incidence of gallstone turning to gallbladder cancer is very low, but the outcome is so dire.  Dr. Greenlee wrote, “The prognosis in most cases of carcinoma of the gall bladder is poor; few patients live more than one year after the diagnosis has been made.”  Sadly this remains true with the accelerated advance of high tech medicine that gave us so many tools of image studies, such as ultrasound, CT scan and MRI etc.

“Despite the increased risk of gallbladder cancer (GBC) in patients with gallstones, the overall incidence of GBC in patients with cholelithiasis [gallstone] is only 0.5 to 3 percent.”  This is from UpTodate.  Dr. Greenlee cited various reports of average incidence ranging from 0.5 to 6.5 percent; he wrote, “It seems safe to say that the average incidence is about 2 to 3 percent.”

Dr. Greenlee’s approach and recommendation was very reasonable to this day; few can argue against it.  The following paragraph is an excerpt from the COMMENT section of his article.

“While, perhaps, one could not argue too strongly for operation on the gallbladder in any case of gallstones on account of the possibility of malignant tumor developing later, there are some other justifiable bases for early operation:  (1) to prevent the distress of recurrent colic and dyspepsia;  (2) to avoid stone in the common duct with infection and hepatic damage, and  (3) to prevent remote visceral degenerative changes.  It seems that the possibility of carcinoma could be given as a fourth reason for early operation in such cases.”

I wonder Dr. Greenlee’s inclination of advocating early surgical intervention for the ‘silent’ (or just one uncomplicated episode) was influenced by Dr. William Mayo (the founding father of Mayo Clinic, where Dr. Greenlee was trained in 1920s) who expressed in 1911 that nearly all gallstones produced symptoms and regarded “innocent” gallstones as a myth, whereas Dr. William Osler (1890s-1910s) believed that most gallstones caused no symptoms.

I came across an article at N.E.J.M. (9/23/1982) of “The natural history of silent gallstones—the innocent gallstone is not a myth”; an obvious dispute to Dr. William Mayo’s claim and that of Dr. Greenlee’s (Mayo brothers were still active practicing surgery when Dr. Greenlee was there.)  The study group consists of 110 men and 13 women with gallstones, all faculty members of the University of Michigan, none died of gallstone disease in 15 years of follow up and only 18% developed biliary pain or complications (thus, not entirely “innocent” as the author claims.)

The incidence of gallbladder cancer, rare though it may be, Dr. Greenlee pointed out, “When it is considered that between 8 percent to 10 percent of adults have gallstones, the importance of the proper concepts regarding the many problems of disease of the gallbladder cannot be overestimated.”

There was a school of thought suggesting that “stones are the result rather than the cause of primary carcinoma of the gallbladder” in Dr. Greenlee’s day.  He explained in a very convincing way in the article that the other way around was the case.  He was again correct as we read in UpToDate, “gallstones are present in 70 to 90 percent of patients with GBC, and a history of gallstones appears to be one of the strongest risk factors for the development of GBC.”

Dr. Greenlee also stated that “cancer of the gallbladder is much more common in females than in males, the ratio being about 4 or 5 to 1”, we read “women are affected two to six times more often than men” in UpToDate.

“Gallbladder cancer is an uncommon but highly fatal malignancy with fewer than 5000 new cases diagnosed each year in the United States” (from UpToDate), I am surprised to read that Dr. Greenlee encountered “Five cases of primary carcinoma of the gallbladder have been observed in a year and a half, and 4 of these were observed within six months.”

Dr. Greenlee wrote, “The diagnosis is made for the most part either at operation or during routine laboratory examination [pathology report] of the removed gallbladder.”  With so much high tech medical advance seventy some years later we’re still no better than Dr. Greenlee was.  We read in UpToDate, “Malignancy diagnosed incidentally on pathologic examination after a simple cholecystectomy is the most common mode of presentation of early stage disease.”

(There are 13 pages of his original article; here are the scanned copies)

 

 

 

 

Oh My God! Obama omitted “Under God”!

Some may say “Oh My God! Obama omitted ‘Under God’!” But this is Much Ado About Nothing, to say it or not, either one is correct.

I always go to Carl Sandburg’s Lincoln for authoritative writing.  The page I scanned here is Page 471 of the The War Years Volume II.  These are Lincoln’s own hand writings.

The top one is the copy that was in Lincoln’s hand when he made the speech; “under God” was not on the page.  Lincoln wrote the speech on the train to Gettysburg and had a final touch at the Wills residence the night before the speech.

But he clearly said ‘that the nation shall, under God, have a new birth of freedom . . .” It was speculated that Lincoln inserted “under God” impromptu, looking out over battlefield.  Charles Hale, a Boston Advertiser reporter took down the slow-spoken words of Lincoln and “under God” was there; the same is true on many other newspaper reports.

Lincoln later re-wrote several copies (one for Everett, the other George Bancroft) and “under god” was clearly there, further proving that Lincoln did say it.

Obama simply read the text provided for him; the White House staff might think leaving “under God” out may be the best policy and will generate less controversy.  If Lincoln were to live long enough to write his memoir; I would bet he would say he meant to say it and he did say it.  And President Obama should, too.

Lincoln made a speech today 150 years ago

Today (November 19) in 1863, 150 years ago, Lincoln made a short speech that has since been known as Gettysburg Address.  Edwin Stanton, Lincoln’s Secretary of War (our fellow Pittsburgher) suggested Lincoln might take a train leaving Washington D.C. in the early morning of November 19 and he should arrive at Gettysburg in time for the dedication ceremony.  Lincoln insisted going the day earlier lest some unexpected mishap may happen.  Lincoln knew he was destined to make history for the greatest speech in all time.

The political philosophy of Dr. Sun Yat Sen (孫逸仙), the founding father (國父) of modern China is “The Principle of Three People” (三民主義); he was most likely inspired by Gettysburg Speech.

Today is the occasion to read two of my previous posts: one is the meaning of Gettysburg Battle; the other is what I wrote three years ago today.

http://doctorjytsai.blogspot.com/2013/07/the-meaning-of-battle-of-gettysburg.html

http://doctorjytsai.blogspot.com/2010/11/lincoln-spoke-at-gettysburg-today-nov.html

Posts introducing Elizabeth I are coming soon

Today (Nov. 17) in 1558 Elizabeth I acceded to the throne upon the death of Queen Mary (her half-sister).  Her coronation took place at Westminster on 15 January 1559.  Elizabeth I was sent to the Tower of London by Queen Mary; one could imagine how she would feel on her way to Westminster for coronation, passing by the Tower.

She also used Hampton Court as her palace—the one used by her father, Henry VIII.  So for my “England” travel series I will use the Tower, Westminster and Hampton Court Palace to introduce Elizabeth I who fascinated me more than any queens of England.

Lin Yu-Tong (林語堂) once said, “Names like ‘the Age of Johnson’ are more suggestive to us than a name like ‘the eighteenth century,’ for only by recalling how Johnson lived, the inns he frequented, and the friends with which he held conversations does the period become real to us.”

The same is also true saying ‘Elizabethan literature’, to which Shakespeare’s work belonged, makes more sense than saying ‘late sixteenth century literature’.  I think theater also began in Elizabethan era.

Mourning of Charles I in front of the Banqueting House in London

Walking from Parliament Square half way through to Charing Cross/Trafalgar Square, one will see the Banqueting House, which is one of the historical royal palaces.  To me Banqueting House is the place to mourn Charles I.

The “House” was completed in 1622; it is influenced by the Italian Renaissance as the architect, Inigo Jones studied there.  It miraculously survived the Great London Fire in 1698.  The name is misleading as it was designed for all sorts of royal/governmental functions, not just for ‘banqueting’, although a state dinner here would be stately.  It will be closed to the visitors for official functions, if any.

Once inside one needs to look up the ceiling painting by Rubens; it is all about the royal glory and exaltation of James I (Charles I’s father).  This was despised by Oliver Cromwell and his Parliamentarians, with whom Charles I had a British Civil War, leading to his execution in front of Banqueting House 1649.

The execution was witness by a then student at Christ Church (College) in Oxford; he had a leave and was home at Whitehall, where the Banqueting House locates.  “. . . The Blow I saw given, & can truly say with a sad heart; at the instant whereof, I remember well, there was such a Grone [our modern Groan] by the Thousands then present, as I never heard before & desire I may never hear again.”

It is fitting for Charles II (son of Charles I) to celebrate the restoration of the throne here eleven years later.

Oliver Cromwell had no military experience, but must have military genius; his so-called New Model Army was called Ironsides. (Dr. Oliver Wendell Holmes’s poem, Old Ironsides, saved the USS Constitution; I wonder whether Dr. Holmes was inspired by Cromwell’s Ironsides or not; they share the same first name.)

Oliver Cromwell’s vein ran the blood of Thomas Cromwell, Henry VIII’s counselor.  Oliver Cromwell's great-grandfather, Richard Williams, the nephew Thomas Cromwell, changed his name to Cromwell.

Poet John Milton (of Paradise Lost fame) worked for Oliver Cromwell and he had to go hiding from the followers of Charles II.  Milton probably witnessed the execution of Charles I.

Charles I’s last words were “I go from a corruptible to an incorruptible Crown, where no disturbance can be!”

Lincoln liked to recite the lines of Macbeth (Act III Scene 2)—after King Duncan was murdered.

Duncan is in his grave;
After life’s fitful fever he sleeps well;
Treason has done his worst: nor steel, nor poison,
Malice domestic, foreign levy, nothing,
Can touch him further.

 

British Civil War is the struggle of power between the king and the parliament.  There was also some heated debate or accusation of whether keeping the Reformed Church of England or going back to Catholicism.  Was the execution of Charles I a heinous regicide? Was it legal? Just? or even Necessary?  This is a travel post, one need not to keep the travelers away.  (Some of the photos are from  the event staged by Charles I Society in 2009).

 

Without Charles River, Boston will not be Boston as we know it.  Harvard and MIT are set up along it.  When Captain John Smith presented the map of Massachusetts to Charles I, he suggested the king to change any of the “barbarous names (usually Indian names)” and the king named this river for himself.  So all of you Bostonians, shall we say Charles I River?  I say this lest the young would think it is named after “Prince Charles”, the only royalty they are familiar with.

 

 

Henry VII Chapel: the introduction of Westminster Abbey

Unless you’re like me, a history buff with a middle name of anglophile as Joy said, Henry VII may not catch your attention; even Shakespeare skipped him.  The Bard did Henry IV (Part I & II), Henry V, Henry VI (Part I, II & III), Richard III and Henry VIII.

But Henry VII is not a king of no importance.  If you treat Henry VII the way I do him, his importance will fall into place naturally and thing will be simpler to understand.  He is associated with three things:

1)  He ended the wars of roses when he defeated and killed Richard III at the Battle of Bosworth and united the Houses of Lancaster (red rose) and York (white rose) by marrying Elizabeth of York, daughter of Edward IV, in 1486.

2)  He was the founder of the Tudor Dynasty that ended when Elizabeth I died.

3)  He built a chapel in Westminster Abbey that now bears his name and that is the story of this post, a good way to introduce Westminster Abbey.

Henry VII initially built this chapel at the eastern end of the Abbey to hold the body of Henry VI (his uncle) and used as a Lady Chapel (a chapel inside Westminster Abbey dedicated to the Blessed Virgin Mary).  He tried to persuade the Pope to canonize Henry VI; but it never happened as the “price proved too steep”.  Instead it became his mausoleum, thus Henry VII Chapel.

 

I have told the story of why the pious Henry VI deserved consideration of a sainthood in this post,

“Henry V and Henry VI; Father & Son and how we should tour England”,

http://doctorjytsai.blogspot.com/2013/10/henry-v-and-henry-vi-father-son-and-how.html

Like Henry VI’s King’s College Chapel (of Cambridge U) or Eaton College Chapel, Henry VII Chapel is also a great royal chapel of the Perpendicular age.  The most striking feature is its pendant fan vault ceiling, an architectural wonder of all time. 

 

One cannot top what Washington Irving said in describing the flamboyant, festive interior decorations,

 

 

“The very walls are wrought into universal ornament, encrusted with tracery, and scooped into niches, crowded with the statues of saints and martyrs.  Stone seems, by the cunning labour of the chisel, to have been robbed of its weight and density, suspended aloft, as if by magic, and the fretted roof achieved with the wonderful minuteness and airy security of a cobweb.”

 

The architect of the chapel is English, but the decoration reflects the Italian Renaissance.  Henry VIII (son of Henry VII) commissioned the Italian master, Pietro Torrigiani to build the tomb of Henry VII and his queen, who died in childbirth.  The four young angels sitting at the corners of the King and Queen’s tomb-chest displays “the Florentine Renaissance at its purest and most poignant.”  And that leads Francis Bacon to say the parsimonious King “dwelleth more richly dead than he did alive in any of his palace.”

 

 

While in the chapel one will also look for the tombs of Elizabeth I, Mary I (Elizabeth’s half-sister), Mary Queen of Scots, Charles II (Charles I is not here, that’s is another story), William III, Mary II and Queen Anne.

Blenheim Palace: The story of Duke of Marlborough, Winston Churchill’s ancestor

One place I like to visit is Blenheim Palace (Woodstock, Oxfordshire, England, OX20) , not only is it the birthplace of Winston Churchill (the savior of civilization as we know it from Hitler’s Nazi), but also its rich history of England.  It is only 8 miles away from Oxford where we will visit Christ Church (College) and Trinity College.

Blenheim Palace (the only private mansion in England that is called a palace) was given to John Churchill, by Queen Anne (her death in 1714 marked the end of Stuart era) for her appreciation of Churchill’s (later the first Duke of Marlborough) victory over French force at Blenheim (a German town) in August 1704, an important battle that kept French from the gates of Vienna.  The mansion was named after this battle.

Great Hall

The palace was built by the architect Vanbrugh in commemorating the glorious victory at Blenheim; one will see the splendor of the Great Hall, in which one will see a map of Blenheim battle field and Great Court, in which one can see a 30-ton marble bust of Louis XIV, which was a spoil of war that the Duke had taken from Tournai in 1709.  The visit to Blenheim is not complete without seeing its splendid gardens.

While researching to write the biography of his ancestor, Winston Churchill visited Blenheim, Germany in 1932; he somehow missed the chance to see Hitler, who was then already in power.

It is safe to say that the greatest [political] affair between FDR and Churchill saves  the civilization from Hitler’s Nazi.  They spent 113 days together and had more than 1000 correspondences during the war.  FDR sent the first letter to Churchill on 9/11/1939, it began with “My dear Churchill:--It is because you and I occupied similar positions in the World War [WWI]  that I want you to know how glad I am that you are back again in the Admiralty.. . .I shall at all times welcome it, if you will keep me in touch personally with anything you want me to know about. . . I am glad you did the Marlboro [Marlborough] volumes before the thing started--and I much enjoyed reading them.” 

At that time Churchill was not appointed as the Prime Minister yet.  FDR misspelled Marlborough as Marlboro as he must have been thinking or smoking his Marlboro cigarettes.  I haven’t read Churchill’s “Marlborough: His Life and Times” (a 4-vollume set) yet, but I’ll as my ambition is to read everything Churchill wrote, except his one novel.  One will get the most of the visit if one reads Churchill’s Marlborough.

Being an admirer of FDR’s New deal, Churchill sent a copy of his Marlborough (Volume 1) to the White House, inscribed, on October 8, 1933, “With earnest best wishes for the success of the greatest crusade of modern times.

”Here is a YouTube of the Blenheim Palace,

http://www.youtube.com/watch?v=z5bbgtI9z_g

 



Clock Tower

Westminster walk in London: when a man is tired of London, he is tired of life

Samuel Johnson said in 1777, “when a man is tired of London, he is tired of life; for there is in London all that life can afford.” it is still true to this day.

The so-called Westminster Walk is from Westminster Bridge, along Palace of Whitehall northward to Trafalgar Square (see map).  It will take 2 days to walk 0.9 miles in my estimate, given the places worthy of visit along this walk.

Big Ben with London Eye in the background

Walking Westminster Bridge across Thames River, one will see the Big Ben and the Houses of Parliament; a Churchill statue is also here and Churchill War Room is nearby (once in England I cannot miss anything Churchillian).  The nearby St. James’s Park may not be much of a tourist’s attraction.  But it is a MUST VISIT for me, as it was where Henry VIII hunted his Big Game and Anne Boleyn.

I recall reading Henry VIII’s hunting in St. James’s Park in Dan Brown’s Da Vinci Code.  Henry VIII was a hunting enthusiast or used it to ‘escape’ Queen Catherine of Aragon (1^st wife).  He went out hunting for one month; the words came back that he won’t be back another month.  And we know that this occurred after he had his eyes on Anne Boleyn who just returned from studying in France and who was also known going hunting with Henry.

Between Westminster Abbey and the Houses of Parliament was St. Margaret’s Church, which is the parish church of the House of Commons, witnessing many important events of the long British national life.  I believe Christopher Wren is one of the many architects of this church.

Churchill spoke in the House of Commons on 5/8/45, "That this House do now attend at the Church of St. Margaret, Westminster, to give humble and reverent thanks to Almighty God for our deliverance from threat of German domination." This is the identical Motion which was moved at end of WWI. Sadly the history repeated itself; the motion to have a service at St Margaret's church was exactly the same for both World Wars.

One will look for the Flemish stainless 'fiercely coloured' east window commemorating the wedding of Henry VIII and Catherine of Aragon; it was part of her dowry.  Sir Walter Raleigh was buried here after his execution, commemorated by the west window with John Milton (a parishioner) window on its right. Winston Churchill and Harold Macmillan got married here. Macmillan Publisher is the latter’s family business.  Macmillan’s The Blast of War is his WWII memoir; I call him the “General” in political affair, going places where Churchill needed him.  He later became British Prime Minister. (“blast of war” was actually uttered by Henry V in Shakespeare’s Henry V, “But when the blast of war blows in our ears”.

Look for Charles I's statue outside the east wall; "he gazes across the traffic directly at the statue of Oliver Cromwell (Charles I's nemesis during the British Civil War) in the lee of Westminster Hall."  Charles I was executed outside the Banqueting Hall in Whitehall House (also along this walk) on January 30, 1649.

At present I don’t know how much time should be allocated for Westminster Abbey, which, as someone said, is not just made of stone and marble, but is also made up by words (history and  memory).  Visiting buildings such as Westminster Abbey, Tower of London or St. Paul, one will not just see, one will feel, think or reflect; one’s heart will be heavy in the Tower.  Visiting England is just a field trip of my reading history of England.