I was sitting in my study this afternoon, fielding calls, writing emails and other correspondance and perusing the Google Alerts I have in place for interesting topics. I came across an interesting article from The New York Times Health Section, dated 12/09/08 (you see, there are some uses for the NYT other than lining bird cages and wrapping fish) that reminded me of the many times I faced similar diagnostic dilemmas in my years of practice. 
 
The gist of the article was that, in the quest for better and ever more sensitive noninvasive methods of diagnosis, like MRI Scans, more and more pathology is being revealed. But, the pathology observed may have nothing to do with the patient’s symptoms. 
 
This leads to a number of unnecessary surgical procedures, as doctors try to treat the pathology revealed by the scan, even if that was not the actual cause of the patient’s pain. This is the paradox of the nonsurgical study–it may result in MORE surgery, not less.
 
A good example is the common finding of a torn meniscus, inside the knee, revealed by an MRI Scan. It’s now well known that many middle aged and elderly people are walking around with torn menisci, without any resulting pain or other symptoms. So they really don’t need surgery, just because they have a torn meniscus, UNLESS they also have very specific mechanical findings or very specific pain, localized to the area where there is an identified torn meniscus. And yet, that is exactly what was happening, until recently.
 
I always got an MRI if my patient had persistent pain that failed to respond to conservative treatments, like those I describe in my newest healing program, HOW TO AVOID KNEE SURGERY, which you can see at  http://drbillsclinic.com/avoid_knee_surgery.html
But they only came to arthroscopic surgery if they had identified pathology AND specific symptoms and signs, consistent with the observed pathology.
 
I remember once, when I was much younger, I had a young man who had very specific joint line pain. He failed to get better with all the conservative treatments I prescribed–medications, local heat, physical therapy, the works. So, we got an MRI Scan. WOW! He apparently had an enormous tear of the posterior horn of his medial meniscus. Lit up like a Christmas tree! So obvious, even a lay person could see it from across the room.

Now, in a young person, job #1 is to preserve the articular cartilage at all costs: in other words, prevent arthritis, which is what happens if an untreated, unstable torn meniscus is allowed to remain, without treatment. So, with this as our goal, the patient, his parents and I were all of one mind: this kid needed surgery, pronto!
 
With all best intentions, I scoped the kid, expecting to see and repair or remove this enormous tear. Only…there WASN’T ANY TEAR. I looked and probed everywhere.  Nope.  Nada.  Well, I wasn’t about to fix what wasn’t broken, so I shaved away some inflamed synovium at the medial (inner) joint line, and got out.
 
He had what we call a “false positive” MRI Scan, a diagnostic image that appears for all the world to be a bona fide meniscus tear, only the tear doesn’t really exist. Imagine my embarrassment when I had to tell the family that I didn’t find the expected pathology, other than the inflamed synovitis (swollen, reddened lining membrane of the joint, which can get caught between the moving bones, just like a torn meniscus).  

The family was very grateful that he didn’t have a tear and all turned out well, because the patient’s preop pain was relieved, probably because I cut away that inflamed membranous tissue. But you could very easily argue that this was a completely unnecessary surgery–I was chasing the chimera of a false finding on a scan. It taught me a lesson, that’s for sure.
 
The fact is, MRI Scans are, at best, only 90-95% accurate on the medial (inner) compartment of the knee joint. This drops to only 60-70% accuracy on the outer or lateral compartment of the knee, because of the more complex anatomy of the lateral meniscus. Bottom line: MRI Scans and other diagnostic tests are NOT 100% accurate. They are just one part of the puzzle and have to be interpreted, based on the physical findings and a patient’s response to treatment. 
 
There are lots of reasons for knee pain. You can learn more about them, in layman’s English, in my best selling LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN (see here at http://drbillsclinic.com/eliminate_knee_pain.html )
 
Many, if not most of them, can be treated with effective nonsurgical treatments, including alternative and complementary methods. The trick is knowing when surgery is really warranted–and when it’s NOT. That’s why I wrote HOW TO AVOID KNEE SURGERY, which you can see here http://drbillsclinic.com/avoid_knee_surgery.html
 
Remember, the very best surgery is the one you avoid. Til next time, my friend, be well. 
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION

Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

When I was first building my joint replacement practice in Long Island in the early eighties, I focused on doing the most difficult revison procedures. Just so you know, a revision is a re-do operation of a prior joint replacement that failed, for whatever reason. What else you need to know is that these surgical procedures are at least four to five times the magnitude of an initial “virgin” joint replacement. 
 
The biggest revisions I’ve ever done have involved an entire body transfusion. That means transfusing the entire volume contained in a human body, over 12 units of packed red cells, together with platelets (that help to stop bleeding by forming “white clots”), FFP, or fresh frozen plasma (which contains clotting factors, to allow the bleeding surfaces to clot and stop intraoperative and postop bleeding), and additional fluids, containing electrolytes (charged ions, like sodium, potassium, chloride, etc. that let the heart beat and the nerves work, among other things).

Many times, the loosening of the initial implants results from resorption of the surrounding bone, a process called osteolysis. This occurs as a biological reaction to extremely tiny wear particles of polyethylene, from the plastic parts of a joint replacement–kind of like “brake dust” that accumulates on your car wheels from the wear of your brake pads. This often leaves weak or missing bone, which has to be replaced with bone graft, large pieces and ground up fragments of banked human bone, harvested from donors who have died. 
 
In addition, removing bone cement from the inside of the bones is time consuming, tedious and takes its own toll in damaging and removing native bone stock. Fashioning and fitting these bone grafts to reconstruct the patient’s bones is often the reason for long operative times in the OR. It ain’t easy.
 
And of course, these monster surgeries are fraught with potential complications and much higher risks than the virgin cases. So a failed joint replacement is not a small matter, but a pretty big deal to fix.
 
The longest total hip revision I ever performed took 15 hours, though most were in the three to six hour range. In other words, these are enormous surgeries, on a par with the biggest open heart surgery or excising and grafting an aortic aneurysm, in terms of magnitude and metabolic stress on the patient.
 
And for all these reasons, many surgeons who are comfortable doing primary (virgin) joint replacements are not so thrilled to do revisions. They often feel, many times quite correctly, that they’re out of their depth, way over their heads. 
 
So why in the world would I WANT to attract these cases?
 
My reasoning was multifactorial. I was the only one in the region really trained to do revisions. Most guys wanted someone to clean up their messes, and if I developed the reputation of being an expert in revisions, it would be a great indirect advertisement that I was an ideal choice for doing the simple, “virgin” total joints, too.
 
The problem was that most surgeons wanted to ship their disasters out of town, by referring the case to a big kahuna in The City, so they wouldn’t be embarrassed by the failure of their surgery and wouldn’t be tacitly admitting that someone else in town might be a better surgeon. So I had to attract these cases by going to the patients directly, by word of mouth. And once I got them, I had to handle these cases very diplomatically, so as not to embarrass the prior surgeon.
 
Even in the OR, where my pal and assistant Steve and I would scrub and come swaggering into the room to save the day, like “The Pros From Dover” in the movie M.A.S.H., we were careful not to badmouth the prior surgeon. After all, the failure was often NOT the fault of the surgeon, but caused by factors outside his control.
 
I always felt the guy did his best and “there, but for the Grace of God go I.” Other hotshot surgeons of my acquaintance were not so sanguine or understated in this regard. But I’ve always believed that the Universe has a way of punishing that sort of arrogance, eventually. In any case, my behavior did not go unnoticed.
 
Gradually, the other surgeons in town (and in the entire region) grew to trust that I wouldn’t throw them under the bus to the patient and family. I enjoyed the repuation of a gentleman, as well as an expert in this field. So they began to send me their grief, I would ask them to scrub with me, so they would become part of the solution, maintain their contact with the patient and family, and be able to bask in reflected glory, when the new surgery restored the patient and relieved the pain, which fortunately was most of the time.
 
The point of all this is that surgery is NOT without risks. And these risks are magnified and multiplied when an initial surgery fails and needs to be revised. So, it follows that you should NEVER undergo an UNNECESSARY SURGERY. 
 
If you have knee pain, for example, you may be able to relieve your pain and restore your function, by using the methods I’ve outlined in my newest healing program, HOW TO AVOID KNEE SURGERY. See how here at  http://drbillsclinic.com/avoid_knee_surgery.html 
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to   http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

Just a few minutes ago, while sitting in my study and reviewing my emails, I came across an article on one of the health care alerts about Tiger Woods. You may recall that Tiger has been out of the tournament circuit since his ACL reconstruction. As a result, we haven’t seen or heard much from him or about him in recent months. And the sport of Golf has been the poorer for it.
 
He made history by winning the Masters, against an outstanding opponent, while in constant pain from a double stress fracture of his tibia AND a chronically torn Anterior Cruciate Ligament. Despite wincing in obvious pain, he never gave up. He never considered quitting. He said he just put the pain aside and focused on his goal. No question but that he has the heart of a champion.
 
He was asked about whether or not he thought he’d be ready to compete this Spring. And, not surprisingly, he said he would be. He also reported how hard he was working on his rehabilitation. He obviously truly understands the necessity of doing the hard work of exercise, after a major joint reconstruction, in order to get an excellent postop result.
 
There are a number of lessons to be learned from Tiger’s behavior and his attitude. First, he accepts the reality of his situation and pays the freight up front. He pulled out of further competition this year, in order to give himself the best chance of a good long-term result with surgery he realized was unavoidable. 
 
His case is an excellent example of a truly necessary surgery. There are times when the mechanical problem demands the mechanical solution, especially when the patient is an athlete, making high level demands on the injured knee during his sport.
 
Next, he recognizes the need for HIS commitment to the aggressive postop rehabilitation program. Exercise is key to an excellent result. This is especially true after ACL surgery, where some of the most common complications include a stiff knee (arthrofibrosis), with loss of motion, recurrent instability and weakness. It’s only through range of motion exercises and strategic strengthening exercises that the potential created by the surgeon can be realized.
 
Finally, his attitude is exemplary. The man always focuses on his future goal. He never even considers not achieving it. In his mind, it’s not a question of IF he recovers and returns to his sport, but WHEN. There is little you can’t accomplish if you BELIEVE you CAN and WILL achieve your goal.
 
So don’t be surprised when he comes back, stronger than ever, next year. In his mind, he’s already SEEN it, he’s already DONE it.
 
Now, on the other hand, over the years, I’ve seen a number of patients who had a chronic ACL injury who were not athletes. They had no pain, no history of instability, like giving way or falling, and they were doing just fine with normal, everyday activities. In these people, although some surgeons would talk them into ACL surgery, I always tried them first on a strict regimen of exercises, like those in my PAIN-FREE PROGRAM, which you can see at  http://drbillsclinic.com/exercise_eliminate.html
 
You see, there are people who have alignment of their capsular tissues (meaning the direction the fibers run) that can compensate for an absent ACL. These combine with other factors, such as the position of the MCL attachment, and are collectively called “secondary restraints.” They provide another level of stability, even without the ACL. In these people, surgery may indeed be unnecessary. They may do just fine with a number of the non-surgical methods I present in HOW TO AVOID KNEE SURGERY, which you can get here at  http://drbillsclinic.com/avoid_knee_surgery.html
 
The key is that you need to distinguish between what is necessary and what is unnecessary surgery. And the way to do that is to see how you do with a conservative, non-surgical program, first. Hey, like a haircut, you can always cut more, but once cut, you can’t put it back. So, to relieve knee pain and restore knee function, go to   http://drbillsclinic.com/avoid_knee_surgery.html
 
And it should go without saying that you should get a professional evaluation, preferably by an orthopaedist, if you have persistent symptoms, especially buckling or giving way, or if you have snapping, catching or locking of the joint. Those are mechanical signs and may need further evaluation. Get your doctor involved early. And don’t be afraid–no one can operate on you, or make you do anything you don’t want to do. But that’s the best way to get all the facts. THEN, you can decide what you want to do.
 
That’s it for today, my friend. Til next time, be well.
 
Yours for a pain-free tomorrow, 
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

A good friend of mine emailed me today for advice.  He’s a doctor of chiropractic who’s developed severe pain in his hip joint. He saw an orthopaedist, who got an MRI, but it was inconclusive–could be edema, or it could be a more serious disease that could result in surgery. 
 
Trouble is, the picture doesn’t look like what you’d expect if he had the more serious disease. Typical of the problems one sees in clinical practice–cases often don’t follow the textbook presentation. So it makes it tough to know exactly what to do.
 
Seems the guy has asthma and he’s been taking steroids (prednisone) for some time to try to control the symptoms. But one of the potential and most dreaded side effects of longer term systemic steroid use, typically seen in asthmatics, rheumatics, or people with chronic allergies or skin diseases, is a bone disease called avascular necrosis.
 
Avascular necrosis is a kind of weird disease that no one’s ever heard of, until they get it, or know someone who did. It refers to the death of bone cells inside a bone. It’s variously called aseptic necrosis (meaning it is NOT caused by an infection), ischemic (meaning it’s due to oxygen deprivation) necrosis, or avascular (lack of blood supply) necrosis, or just plain old osteonecrosis (or “dead bone”) where “necrosis” means cell death. It commonly affects the hip, knee, shoulder, or ankle, in roughly that order.
 
For any number of reasons, this happens because there is a blockage of the blood supply to the bone of the affected joint. Think of it like a dam in a river. So everything “downstream” that is normally fed by the blood supply is suddenly cut off. The cells, deprived of oxygen, begin to die. The surrounding bone then begins to deteriorate. In the case of the hip, this area is recognized as “dead” by the body and special cells go to the site and begin eating away the dead bone area, so that new healing bone can be laid down.
 
The problem is that as that dead bone is removed, support for the overlying joint surface is is removed, too. The pressure across the joint surface causes the joint surface to collapse under the pressure. Think of a house that has its foundation eroded by an underground river, or a sink hole. What happens to the roof? Caves in, right? 
 
Same thing.
 
When the “roof” caves in, that segment collapses, the hip suddenly hurts like Hell and the resulting irregularity rapidly chews up the rest of the joint, causing rapid onset of arthritis. Very bad news, indeed.  Once that happens, nothing short of a hip replacement can relieve pain and restore function.
 
If you recognize the disease early enough, you can do a small surgery that can often save the joint from collapse. Through a tiny stab wound incision and under fluoroscopic control, a surgeon can drill a hole from the side of the hip bone into the femoral head, just like coring an apple. This relieves pressure inside the femoral head, which is believed to be responsible for cutting off the blood supply to the femoral head. Not as big a deal as total hip replacement, but, hey, it’s still surgery, right? You want to avoid it, if you can.
 
So the doctor’s dilemma is to get an accurate diagnosis quickly enough to do a lesser surgery and head off joint collapse, but not to do an unnecessary surgery, if it isn’t needed. And he has to try to relieve the hip pain, while all this is going on. Not always an easy thing to do. And made much more difficult when the picture isn’t typical. Tough to know what the right thing is to do…
 
Same thing occurs in the knee, but there, because the knee is a larger joint (in fact, the largest joint), it’s a lot more forgiving and less likely to collapse than the hip. So there, conservative non-surgical treatments make the most sense, like those I teach in my newest healing program, HOW TO AVOID KNEE SURGERY, which you can get at  http://drbillsclinic.com/avoid_knee_surgery.html
 
Meanwhile, I recommended my friend reduce the forces across his hip joint by using a cane. Same thing for a painful knee. Sometimes, the simplest things are the most effective. That, combined with a number of the alternative and conventional non-surgical treatments  to relieve pain, that I describe in detail at http://drbillsclinic.com/avoid_knee_surgery.html  may be very helpful to him. Even though the program was written for the knee, the methods I use are systemic, that is, they work for the whole body, hip included. And that program comes with a FREE Special Report on HOW TO RELIEVE HIP PAIN, too.
 
So, I wished him luck. Hopefully, he’ll recover soon, and avoid all those problems. We’ll just have to wait and see…
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow, 
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

For the past week or so, I’ve been trying to relieve your fears about surgery. Hey, you never know. One day you might NEED one of these procedures, and it would be a shame if you were terrified, due to misperceptions, misinformation, distortions and urban myths. It’s also a good idea to know just what your options are, so you can make an informed decision, should that day ever come.
 
So, I’ve attempted to give you the straight dope, tell you exactly what’s done, in each of the most common surgical procedures for the knee. As I’ve said before, when you KNOW the finite dimensions and the finite duration of an experience you fear, it helps a lot to put it in perspective, help you face it and help you handle it. 

Today, to round this all out, is the ultimate option: ARTHROPLASTY, more commonly called joint replacement. Though the term actually means “creation of a joint,” it’s come to be identified with joint replacment, and is now virtually synonymous. This was initially TOTAL knee replacement, but today, through many technical advancements, it encompasses PARTIAL or UNICOMPARTMENTAL joint replacement, as well. These options are explained in great detail, though in layman’s language, in my LITTLE GREEN BOOK at http://drbillsclinic.com/eliminate_knee_pain.html
 
This is really a misnomer, though. Unlike a total hip replacement, a total knee DOES NOT replace the entire joint, nor does it remove the bony segments of the joint. Instead, only the SURFACES are replaced with man-made shells of polished metal, articulating on very tough plastic. Technically, the operation is a joint resurfacing arthroplasty. If there’s severe arthritis on only one side of the joint, then only that side has its surfaces replaced. The so-called UNI (unicondylar knee replacement) can be done through a very small incision, sometimes even on an outpatient basis. The trick is for the surgeon to balance the ligaments and align the knee properly, so the kneecap tracks properly.
 
Small power saws are used, with special saw guides and alignment tools, to cut thin slivers off the ends of the bones, the femur and the tibia. This removes the arthritic surfaces and “opens up” the spongy (cancellous) bone, for acrylic cement intrusion, which holds the implants in place on the respective bones. The properly sized implants are then selected and implanted. 
 
A total knee replacement, like the name implies, resurfaces all three compartments, medial lateral and patellofemoral. It’s done for more extensive, or end stage disease, in two or all three compartments. It needs a larger incision, generally involves somewhat more pain, swelling and potential bleeding. It has a greater potential to develop adhesions, and limited motion, after surgery.
 
In both cases, weight bearing is initially limited by pain, and the use of crutches or a walker. Motion is started right away. Pain is controlled with medications, and physical therapy and rehabilitation are essential. Many of the exercises used are those I teach in my PAIN-FREE PROGRAM, at   http://drbillsclinic.com/exercise_eliminate.html
 
But here’s the thing. Although the success rate, in the right hands, is very good with joint replacement, you NEVER do this without the right indications. The truth is, nothing made by man is as good as what God gave you. Man-made parts can wear out, can get loose, even get infected…and there’s always the chance of a technical problem or human error, even in the best of hands. 
 
So you need to be SURE that if TKR or a UNI is recommended, it’s NECESSARY. And if you can get relief from ANY more conservative methods, conventional, alternative, or complementary, provided you don’t have a lot of bone loss in the joint or severe deformity, then it’s an UNNECESSARY SURGERY and should be delayed, or avoided. And it was to help you do just that, that I wrote my new healing program, HOW TO AVOID KNEE SURGERY   http://drbillsclinic.com/avoid_knee_surgery.html
 
Well, I hope that this series on knee surgeries has been informative for you and that I accomplished my goal: to tell you exactly what goes on in the O.R., give you some perspective and relieve your anxiety and fears about surgery. If you NEED surgery, by all means, accept the risks and get the benefits.  Odds are, you’ll do great. But if you’re not sure, or if all non-surgical measures have NOT been exhausted, then there’s at least the possibility that you may be headed for an UNNECESSARY SURGERY.
 
In that case, get my program and be prepared. Don’t guess, when you can KNOW. Click on the link and get HOW TO AVOID KNEE SURGERY today, right NOW, at   http://drbillsclinic.com/avoid_knee_surgery.html   to relieve your pain, restore your function and do it WITHOUT SURGERY.
 
Til next time, my friend, be well and have a great weekend.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved