A Paradise Detour

A friend emailed a list of seven paradoxical sins without mentioning my peccadillos. Was his list a hint to cleanup my act? Here are the seven paradoxical sins:

• Truth---if it becomes a weapon against persons
• Beauty---if it becomes a vanity
• Love---if it becomes possessive
• Loyalty---if it becomes blind trust
• Tolerance---if it becomes indifferent
• Self-confidence---it it becomes arrogance
• Faith---if it becomes self-righteous

Come to think of it I have been guilty of all the paradoxical sins sometime in my 72 years and I most likely suffer from a few right now. 

As I was considering which paradoxical sins currently condemn me I began to ponder the seven deadly sins. I thought of five: pride, wrath, sloth, gluttony and lust. Had to look up the other two---envy and covetousness.

Then I thought of purgatory. (The mind races to strange places when one has bipolar illness.) 

Purgatory was a Roman Catholic Church invention to increase the Church coffers through indulgences, a way to reduce the amount of punishment one has to undergo for sins. The theory proposes that sinful Catholics on the way to paradise take a detour to a place of repentance called purgatory. By praying hard enough family and friends can help the sinner exit quickly from purgatory. Prayers supplemented with gold, silver and other lucre can speed an entry into paradise. 

In 1245 at the First Council of Lyon purgatory became a formal doctrine of the Roman Catholic Church. Martin Luther's Ninety-five Theses of 1517 a dispute against indulgences and subsequently purgatory led to the Protestant Reformation.  

According to my theological friend the purgatory interpretation came from a passage in the Apocrypha a section of history, stories and aphorisms found in the Roman Catholic Bible but omitted from Protestant Bibles. The purgatory proposal can be read in Chapter 12: 39-46 in the Apocrypha's Book of Maccabees II, a history of the Jewish revolt against the Seleucid Empire around 200 BC. 

Dante Alighieri (1265-1321) dramatized the purgatory concept in the Divine Comedy, the epic that Cliff Notes saved us from reading in college. The eighth deadly sin---using Cliff Notes---will keep most of us in purgatory.  

According to Dante purgatory is a huge mountain on a small island that contains seven ascending terraces providing atonement for the seven deadly sins:

• Terrace I, the proud are bowed down by rocks that must be carried up the mountain.
• Terrace II, the envious have their eye lids sewed shut
• Terrace III, the wrathful breathe smoke
• Terrace IV, the slothful run without rest
• Terrace V, the avaricious (covetous, rapacious, materialistic) grovel face down
• Terrace VI, the gluttons starve
• Terrace VII, the lustful walk in a river of fire

Anyone who took Great Books of the Western Literary Tradition 101 knows the Divine Comedy is divided into three books of which Purgatorio is one. The other two are Inferno and Paradiso. 

The carnage and savagery in Inferno remind me of George R. R. Martin's A Story of Ice and Fire. The law of retribution determines punishment in the Inferno. A river of blood drowns the violent. Flatterers are bogged in excrement. Hurricane winds bombard carnal sinners tempted by passion's tempest. 

In Paradiso virtues are rewarded with the most meritorious circling closest to God. All the souls in paradise are perfectly contented with whatever degree of blessedness God has willed for them.

I'm aiming for Paradiso but to get there I must atone for those paradoxical sins. Dante here I come. 

The Mentor

He began shaping my life when I was seventeen. My uncle had told him I wanted to be a doctor. Around midnight a few weeks later I was awakened. “There has been a terrible accident. A man is badly hurt. Do you want to help in surgery?”

Gentle reader entertain conjecture of a time unburdened by paper work, a time free of medical malpractice suits, a time when physicians not the government or insurance companies determined what was best for the patient, a time when a good history and physical examination preempted diagnostic tests. Contemplate when a simpler time rendered medicine fun and fulfilling. 

The era you have imagined had no pagers, no cell phones, no fax machines, no computers, no copiers, and no highway patrol with radar guns. The roads were narrow and poorly marked. The cars had no seat belts.

Under this veil of simplicity a middle-aged man taking a curve in a country road too fast was thrown from his car. A telephone poll made him a wishbone. He entered the operating room with a ripped pelvis, two fractured hips, a ruptured spleen and assorted other injuries considered major on an ordinary Saturday night.

That man’s misadventure introduced me to the mystery, majesty, and magic of surgery. Except for back-seat-of-the-car moon flooded nights that surgical experience was the most fun I had as a teenager.

After that I worked as his surgical assistant for four summers. In addition to the routine gall bladders, appendectomies, and bowel and bladder surgery, we also repaired abdominal aneurisms, patched those gored by bulls, thrown from horses, flipped by tractors, bit by mules, and hit over the head with beer bottles.

I went with him on house calls. I sat up with him at night watching over gravely ill patients. I was there when he told the family that their loved one had inoperable cancer and when we visited the homes of those who had died. I helped with autopsies and worked in his lab. By the time I was in medical school I had seen and done more than a first year surgical resident.

His hands were small but powerful and steady, always steady.  He worked methodically and meticulously. Like a chess master he had five or six moves planned ahead. He was always on the offensive, defeating disease, death, and destruction. He never hurried yet he finished his cases in record time. I never saw him flustered or tired. After a long night of trauma surgery he was eager to start on the scheduled gall bladders and hernias.

I was not blinded to his faults. He was sloppy. Each new day his hair competed with his clothes for most rumpled. He slumped. Slurred his speech. Chain-smoked. He burped and scratched at the most inopportune times. His deficiencies would have rendered Emily Post speechless.

Although he pioneered several surgical techniques his empirical approaches remained unknown because he was the least of self-promoters, if that’s a fault. Grimes county citizens and those that lived beyond had no idea that a surgical Michelangelo lived among them.

Of all those professional experiences that are a pleasure to recall my time with Leonard loom largest. He taught the character and skills of a good physician. He was a modest, kind gentlemen most informal in his daily contacts beloved by just about everyone who looked forward to his visits that offered encouragement, optimism and hope to all he met. To relieve suffering and to heal the sick—that was Leonard’s work.

Memory can be a perpetual stimulation for living life well. A yearning for past experiences can be relieved by enthusiasm for things yet undone.

The Way We Were

He painted the way we were. His warm humor, images of daily events made poignant, the ability to reflect the heart and soul of 20^th century America made us pause and ponder: A boy with pants pulled halfway down studying a framed medical degree hung on the wall while the doctor prepares to give him an injection; a little girl beating disgruntled boys in marbles; a young man anticipating the excitement of new discoveries, his father pondering the past. These illustrations stimulate enduring feelings that represent the heart of us all. 

Most Millennials and those younger are unfamiliar with Norman Rockwell (1894-1978) while older generations rank him with baseball, apple pie and Chevrolet. He painted nearly 4000 images, including 800 magazine covers—322 for the Saturday Evening Post—and ad campaigns for more than 150 companies.

He painted common places, common values, common feelings that moved beyond the trite and banal encouraging us, bringing us hope for the common man, inspiring us toward a better life. He moved beyond kitsch, beyond the old-fashioned to seal the American way that senoirs find a pleasure to recall. 

Troubled that he was an anomaly among leading artists of his day—Paul Cezanne, Edgar Degas, Matisse, Pablo Picasso he briefly studied cubism, surrealism, fauvism in Paris. He returned to New England convinced that painting from the heart was better than painting for art critics.

Blessed with keen observation, enamored by personal interaction, Rockwell summed up a story in a single frame inspiring filmmakers of our day. In the film Empire of the Sun a young boy is put to bed by loving parents inspired by Rockwell’s Freedom from Fear painting. American Graffiti is a montage of Rockwell paintings enlivened on film. Forest Gump has a scene that re-creates Rockwell’s Girl with a Black Eye with young Forrest in place of the girl. 

Rockwell’s  keen sense of how people interact enabled him to  incorporate the larger narrative of world events into a narrowly focused microcosm of community, family and nation, an idealized American that has become a faded canvas in the 21^st century.

Rexulti: A New Improved Abilify

Rexulti (brexpiprazole) differs from Abilify (aripiprazole) in several ways. Both medications are D₂ partial agonist. This property reduces dopamine output when dopamine concentrations are high thus reducing psychotic symptoms and increases dopamine output when dopamine concentrations are low thus improving mood symptoms.

In contrast to Abilify, however, Rexulti has less intrinsic activity at D₂ receptors thus reducing the chance for akathisia—motor restlessness­ and other extra pyramidal symptoms (EPS) such as muscle stiffness, spasms, tremor and jerky movements. Clinical trials confirm that Rexulti has a much lower incidence of akathisia and other motor side effects than Abilify.

In addition Rexulti has more potent serotonin 5HT_2A antagonism than Abilify providing antipsychotic and antimanic activity with a more auspicious side effect profile. As a more potent serotonin 5-HT_1A partial agonist Rexulti may prove to be a more suitable choice for adjunctive treatment for major depression than Abilify.

The recommended starting dose for Rexulti as adjunctive treatment for Major Depressive Disorder is 0.5 mg or 1 mg daily for one week with an increase to a 2 mg target dose by the second week. The maximum adjunctive dose is 3 mg daily.  With a 91-hour half-life steady state concentration is attained in approximately 2 weeks. 

Akathisia remains the most common side effect of Rexulti but at a much lower rate than found with Abilify. 10% of patients on Rexulti experienced mild weight gain compared to 4% with placebo. There were no clinically relevant changes in lipid profiles or other metabolic parameters. Effects on prolactin levels were minimal. Rexulti does not appear to lengthen the ECG QT_c interval. In a 52-week maintenance study the discontinuation rate due to adverse events was less for the Rexulti treated group than the placebo treated group.

I Can

I can:

• Respect myself
• Develop my gifts and talents
• Cultivate a healthy marriage 
• Hope
• Love
• Enjoy
• Become a critical thinker
• Honor my body through daily exercise and a reasonable diet
• Be enthusiastic about life
• Cultivate healthy relationships
• Avoid negative people
• Control my impulses
• Develop frustration tolerance
• Delay gratification
• Do first things first
• Praise God daily
• Live life with liveliness

I can if I only will