Malvern at 40, and 30 Years On: One Last Bow for Profs. Boulton and Rayman, and a Long Road Ahead #Malvern40 #ActAgainstAmputation #DFCon #LimbPreservation @ALPSLimb

The Abbey Hotel is still covered in ivy. The hills behind it are still impossibly green. The water still runs cold and clear, the same water George Bernard Shaw, Charles Darwin, Charles Dickens, and Florence Nightingale all came here to take. Forty years after Andrew Boulton and Henry Connor started the Malvern Diabetic Foot Meeting in 1986, and thirty years after I first wrote a paper above a bank on the high street because I couldn’t afford to stay at the Abbey — Malvern is still Malvern. Somehow it gets better every year.

This one was different though. This was the fortieth meeting. And it was Andrew’s last in the chair.

The talk: From Nursing the Wound to Doctoring the Limb

My job this year was to draw the long arc — to put what we do now into the company of the people whose shoulders we stand on. The Ebers Papyrus, 1600 BCE. Honey and lint. The Benedictine monks of Malvern Priory in 1085. Semmelweis, Lister, and Halsted in the 19th century, washing their hands of the problem. Florence Nightingale in 1854, measuring what she managed. Elliott Joslin in 1928, hiring podiatrists and surgeons to work the same hallway in Boston — the first hospital foot team — and writing that “our Boston chiropodists are useful allies; they have contributed much to our reduction in gangrene.” Winter and DuoDerm in the 1960s and 80s. The first Malvern meeting in 1986. My first Malvern in 1996. DFCon in 2000 with George Andros. Joe Mills joining the cause at SALSA. The 2010 joint JVS/JAPMA special issue that formalized Toe and Flow. ALPS in 2020, born in the pandemic, now more than 2,000 members worldwide. And then — what comes next.

The hinge of the talk, the part I get more emotional about every time I show it, is two clips of the same ivy wall at the Abbey Hotel: George Bernard Shaw delivering his Doctor’s Dilemma line — “I marvel that society would pay a surgeon a large sum of money to remove a patient’s leg, but nothing to save it” — and Andrew Boulton, decades later, standing in front of the same wall. Same building. Same problem. A century in between, and the work is still the work.

The Lennon and McCartney bit

You can’t talk about Malvern without talking about the toasts. In 2008, in a hotel room a few floors up from where the dinner happens, Larry Lavery and I drafted four Beatles rewrites in honor of Andrew. We performed them at dinner that year and somehow it brought the house down. I rescued, remastered, and posted the whole archive last month — writers’ room, performance, applause, and Andrew at the Abbey walls. If you’ve never seen it, here it is:

Eighteen years between the original toast and this year’s last bow. Same teacher. Same hotel. Same ivy.

Look forward

Andrew is stepping out of the chair, not out of the work. And the work is broadening:

DFCon 26 — Anaheim, October 22–24. Twenty-six years on Hollywood Boulevard and now next door to the happiest place on earth. Co-chairing again with the family.
DFCon Singapore, DFCon India, DFCon SVS, DFCon at APMA — the franchise is going where the patients are.
DFUpdate — focused deep dives between the big meetings.
The ALPS Traveling Fellowship — sending the next generation to centers of excellence.
Student chapters — they’re already climbing the hill faster than we did.

The goal is the same one we’ve had since the very first DFCon in 2000, and frankly the same one Joslin had in 1928: eliminate preventable amputations over the next generation.

Blake’s Jerusalem, Malvern, the work

Blake wrote the words. Parry put them to music. Elgar orchestrated them from his home at the foot of these hills. We sing them now and we mean something specific by them — the dark Satanic mills are the preventable amputations. The bow and the arrows and the sword are the team, the tools, the data, the discipline. And the Jerusalem we’re building isn’t a place. It’s a clinic. It’s a hallway with a podiatric surgeon and a vascular surgeon in it. It’s a remote sensor on a foot in a home five thousand miles from here. It’s the next student walking through the door wanting to find their solemate.

To Andrew, to Larry, to Joe, to George, to everyone who built and is still building this thing — thank you. I will not cease from mental fight. None of us will. And we’ll see you next year, on Hollywood Boulevard at DFCon 26, and back on these hills the year after.

For the photos, the slides, the videos, and the rest — toeandflow.com.

#Malvern40 #ActAgainstAmputation #DFCon #LimbPreservation #DiabeticFoot #ToeAndFlow #ALPSLimb #DFCon26 @ABoultonMD @ALPSLimb @KeckSchool_USC @USC_Vascular