Sunrises, sunsets

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Matula Thoughts June 4, 2021

2883 words

SUNRISES AND SUNSETS

One.

Sunrise, sunset. Nearing the halfway point of the calendar year, a favorite yearly milestone is approaching – the summer solstice and the first day of astronomical summer. As a resident years ago I didn’t much notice this longest day of sunlight but, now getting on in life, it has gained greater attention. You don’t have to go to Stonehenge to understand the Earth’s shape and tilt (23.5 degrees from orbital plane), seeing how the “easterly” position of sunrise changes from winter to summer. The sun rises in true east and sets exactly in true west only on two days each year – the equinoxes on March 21 and September 21.

The 17-year cicadas are back. I saw and heard them on this past Memorial Day weekend. Sunrise and sunset for them span 17 years, a rather unusual existence.

Gray Michigan winters often obscure the daytime sun and we relish it when dominates in the spring. In northern Michigan summer sunsets after 10 in the evening are worth staying up to see. On Sunday June 20 summer solstice will happen at 11:31 PM EST [Below: summer sunset, Empire, Michigan.] 

Most people believe this is true: the earth is round and it revolves around the sun. These ideas seemed counter-intuitive to pre-scientific people and even recently have been contested, but Copernican evidence for heliocentricity and Hubble Space Station observations are good enough for most people, even though some doubters still exist. They may doubt because they truly haven’t figured it out – or they hang on to the belief because it is expedient to their interests, perhaps in the sense that Jaume Plensa’s figure, Behind the Walls, suggests in front of the UM Museum of Art.

Another point to celebrate in the June calendar is the 19th, a date I’ve just learned about from a book called On Juneteenth by Annette Gordon-Reed. This was a significant moment in time, when the actuality of the Civil War concluded in Texas, thatapp had continued to fight on months after Appomattox. There is reason to think that this date may grow into a full national holiday in recognition of the still-lingering conflict over the opening of the second paragraph of the Declaration of Independence. 

Two

Words cannot express … Pandemics don’t fit into calendar years neatly and it turns out that any expectations that Covid-19 would last only a year were naïve, now that we are well into a second year. Yet, incredibly in this relatively short time, have developed vaccines and better skills at managing the active disease. Few of us have not seen covid up front in friends, family, patients, and neighbors – whether in acute disease, long-haulers, or death. While covid death has largely spared the UM urology family, mortality at-large has not. [Above: Eclipse, Alma Thomas, 1970. SAAM.]

In this past year of social submergence we have lost Ed Tank, Clair Cox, Dick Dorr, Ed McGuire, Bob Moyad, John Hall, Joe Cerny, and Bill Belville (shown in rows from top left, above) amidst other personal and patient losses, and certainly there will be more. Each loss creates a unique reconciliation for each of us, and when writing condolence notes the phrase “words cannot express …” often comes to mind, even if left unwritten. Some words, particularly those of poets, however, do come closer to the mark of replicating feelings. 

A recent web-based reading and discussion with two great American poets, Edward Hirsch and our UM colleague Linda Gregerson, was particularly rich in meaning. It was sponsored last month by The Book Stall in Winnetka, IL, to plug Hirsch’s new book, 100 poems to Break Your Heart, and it included a piece by Linda, For the Taking, that she read. She had sent me a link to the event and any chance to hear her perform a reading is worth the price of admission. Hirsch’s title is far from inviting, but the book contains much that gets close to the mark in expressing grief in words, authentically. The introduction offers a framework for an enabling understanding of grief. 

“Implicit in poetry is the notion that we are deepened by heartbreaks, by the recognition and understanding of suffering – not just our own suffering but also the suffering of others. We are not so much diminished as enlarged by grief, by our refusal to vanish, or let others vanish, without leaving a verbal record. The poet is one who will not be reconciled, who is determined to leave a trace in words, to transform oceanic depths of feeling into faithful nuances of art.”

This paragraph rings true, the process of dealing with grief, Hirsch says, not only reconciles but also painfully enlarges us. This point extends beyond personal needs to console ourselves with personal losses and express condolences to others for their personal losses – we also need to develop the vocabulary and nonverbal skills in our medical students and residents because dealing with grief is a life skill that physicians need and cannot be delegated to our few palliative colleagues. Maybe some of us know this implicitly, but I for one really didn’t fully comprehend this idea until Hirsch’s book.

Three. 

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Heliocentricity was believed a factual truth by some people in classical antiquity, ancient India, the medieval Islamic world, and Renaissance thinkers (da Vinci: “The Sun does not move.”) but it was Copernicus in 1543 who largely settled the question, or so it seemed. Galileo’s observations and calculations made him a champion of Copernican heliocentricity although leaving the Italian astronomer at odds with the Roman Church. An Inquisition in 1615 supported the Church’s defense of faith against science, but Galileo continued to challenge authority.  His book in 1632, Dialogue Concerning the Two Chief World Systemscompared the Copernican system with the traditional Ptolemaic system and was construed as a challenge to the Pope the final straw to bring the Church down on Galileo. An Inquisition in 1633 confined Galileo to house arrest for the last years of his life. [Above: Andreas Cellarius (1596-1665) illustration of the Copernican system, from the Harmonia Macrocosmica.]

Even after the Church gave up the fight against heliocentrism, others took up the ignoble battle. In 1859 Commander A.J. Morison published a book The New Principia; or True System of Astronomy, in which Earth is proved to be the Stationary center of the Solar System … while the Sun travels yearly in an ellipse around the Earth. He wasn’t the last to hold this retrograde notion, an author with the curious pseudonym Parallax in 1873 published Zetetic Astronomy, Earth is not a globe. An Experimental Inquiry into the true figure of the Earth, proving it a plane … and the only known material world. The 20th century began in 1901 with more support for these enduring memes, with Wardlaw S. Scott’s, Terra Firma: The Earth is Not a Planet, proved from Scripture, reason and fact.

False claims of Morison, Parallax, and Scott – whether delusional beliefs or blatent commercial propoganda – were out of step with the accumulated world view and evidence of science. Yet, as testimonies to free speech, they were offered fairly to the public that in turn rendered public opinion and scientific evidence that deemed the Flat Earth claims ludicrous then, a century past  –  and even more so in this day and age. Nevertheless, as the human population nears eight billion it is no surprise that some small minority will embrace these ancient delusions as a startling reality. Autocracies protected from free speech can demand such delusions for its nation.

            The recent phenomenon of instantaneous global social media clouds the issue, allowing deliberate false claims of rumors, conspiracy theories, or alternate realities to infect huge swaths of the population within minutes, imperiling truth. The matter of free speech, held so dearly until now by liberal democracy, is in question today as never before – yet, as always, some limits to free speech have always been recognized, such as “yelling fire in a crowded theater,” an example hard to come by in Covid times. 

Four.

Politics – local and larger. The Covid Pandemic of 2020 continues to diffuse into 2021, further disrupting lives, businesses, economies, education, health care, and so on but just as any crisis this one brings some old problems into focus with new clarity. Health care disparities, in the grossest sense of greatly increased death rates in disadvantaged communities, is one salient example. Less glaring, but no less concerning, is the rampant spread of misinformation (whether imagined or malign) and the inability of wide swaths of the population to comprehend a proper and reasonable scientific argument. These two matters (among others) are serious threats to the human future. 

If a democracy is to reflect the corporate beliefs and aspirations of a populace in maintaining its rules and regulations, it stands to reason that the populace must be reasonably literate – holding, forming, and reforming beliefs that are reasonable, drive toward truth, and promote the civilized behaviors upon which civilization depends. In past centuries when civilization was primarily a local phenomenon and information was finite, autocratic governance worked well enough, until it didn’t and was replaced by new authorities. When enough of the population was fed up, or not fed enough, change happened as after Marie Antoinette said to her hungry subjects, “Let them eat cake.” The will of the people tipped her off the throne. Some sort of quorum-sensing formula, driven by hunger, inequity, abuses, or other outrages turns a compliant population into an angry one that demands change. This biological behavior transcends the animal kingdom.

It’s gotten more complicated for human civilization that has progressed from a three-dimensional world to a world with a fourth dimension of information that accelerated after Gutenberg and jumped into warp speed with the digital revolution and the internet.  – information, and that information is infinite. The Shannon number comes to mind, a calculation by Claude Shannon indicating the number of possibilities of the game of chess. This number far exceeds the number of number of atoms estimated in the observable universe, an enormously huge number itself, and yet the Shannon calculation represents only a single game in the incalculable pantheon of human knowledge.

Civilization today is largely experienced globally, with a mix of inter-connected governmental systems, although all governments ultimately, in one way or another, depend on some corporate consensus of belief in them, whether the ruling authorities are autocratic, sectarian, democratic, military, “divinely ordained” royalty, or otherwise in the position of authority. Nevertheless, regardless of the fourth dimensionality and globalization, the basic biologic determinants prevail and quorum sensing of pain and outrage continue to tip the scales of political equilibrium, but with more destructive consequences than machetes, guillotines, or guns.

Five.

Literacy. This idea relates to two papers sent to me – one by our colleague Cliff Craig, UM Professor of Orthopedics and the other from his 1965 UMMS classmate Mike Johns, now in Atlanta after stints at Johns Hopkins, Emory, and back at UM as interim EVPMA. 

The first, a JAMA paper by neurologist at Indiana University Bruce Miller, discussed false responses to the Covid pandemic. [B.L. Miller. “Mechanisms and Possible Responses.” JAMA. 2020;324 (22): 2255-2256.] Miller rightly stresses the importance of Science Literacy, but as I read the story that term Science Literacy jumped out at me. It’s not a new term, having been around for a century in various forms, but it became prominent in conversation and literature after around 1970, when it was viewed as an extraordinary form of literacy. Paul de Kruif, a UM Ph.D. and assistant professor in microbiology, in microbiology was one of the early “science writers” for general audiences.

            At the most basic level, literacy is the ability to read and write, uniquely human skill sets and arguably the product or cause of civilization. Very quickly in the course of civilization literacy came to mean three things, the “three Rs,” reading, writing, and arithmetic.  St. Augustine of Hippo , writing in Latin around AD 400 confessed the importance of  “legere et scribere et numerare discitur” (learning to read, and write, and do arithmetic). Now, 1700 years after St. Augustine, it is no less appropriate to exclude Scientific Literacy from the core properties of literacy than it would have been to exclude “numerare discitur” from “reading and ‘riting’”.

            Our Western educational systems have largely failed, making scientific literacy a deliberate exclusion from the vast majority of educational products. We graduate students from universities with literacy in literature, performance, art history, accounting, business, law, world history, music, marketing, packaging, political science, languages, and even in engineering, scientific, and health care professions without a firm basis in scientific literacy in its largest sense: how do we hold, form, and reform beliefs based on science and general human values. 

The second paper was more complex and required deeper reading. In fact, that’s what it was about – deep reading. This paper by Adam Garfinkle in National Affairs, in fact required a couple of runs through it myself and while it dealt with literacy, it approached the topic through a consideration of neural pathways.   [National Affairs, Spring, 2020.] Deep literacy, Garfinkle claims, builds capacity for abstract thought, analysis of difficult questions, imagination, creativity, clarity, and empathy. Language is at the core of this phenomenon of deep literacy, that goes far beyond its basic platform of the “three Rs.”  The author ties this into biology, culture, and political systems.

“Deep reading has in large part informed our development as humans, in ways both physiological and cultural. And it is what ultimately allowed Americans to become ‘We the People,’ capable of self-government. If we are losing the capacity for deep reading, we must also be prepared to lose other, perhaps even more precious parts of what deep reading has helped to build.”

            The risk to deep literacy seems to come from the loss of quality attention –  some call this “cognitive patience.” The digital revolution is blamed for this, but it may be a larger 20thcentury phenomenon tied in with its faster pace of culture, manifested in work, entertainment, news cycles, and travel. The search engines have increased the pace, and with smart phones, tablets, and computers by our sides we may not need to teach memorization of multiplication tables or speeches such as the Gettysburg Address. Yet something happens in the human brain when the tables are learned and when the speech is memorized – internalized, as it is. By off-loading or sub-contracting the mental work of processing facts, ideas, and narratives, we may lose the ability to synthesize from them. 

            Musical literacy and that of visual art differ from the art of numbers and narratives. Knowing the multiplication tables and Gettysburg Address, for example and for most people, require mental work – the brain must expend calories to accomplish those tasks. Somehow it takes less work to internalize a tune or recall a picture. American Pie and Mona Lisa are carried around by most people of my vintage and in my region of space. A musician or painter can build upon them, consciously or subconsciously, when they create something new. The same is true for someone who really knows the Gettysburg Address, but it’s one thing to really know all 172 words and another thing to call it up from Wikipedia or Alexa.

Postscript.

Sunrise, Sunset was the wedding song written in 1964 by composer Jerry Bock and lyricist Sheldon Harnick for the musical play, Fiddler on the Roof. It hit close to the mark as Harnick recalled at age 90 in an NPR interview April 30, 2014.

“I do remember when we wrote “Sunrise Sunset,” the first person we played it for was Jerry Bock’s wife. And when I perform a song for someone I try not to look at them. It makes me a little upset if they’re not paying attention. So I look above them or to the side of them.

Anyway, I sang “Sunrise Sunset” and when I finished, then I looked at Jerry’s wife Patti and I was startled to see that she was crying. And I thought my goodness; this song must be more effective than we even know. And the same thing happened – I am not a pianist but the music to “Sunrise Sunset” is easy enough so that I could learn the piano part – and I played it for my sister.

And when I finished I looked and she had tears in her eyes. And that was a very unusual experience.” 

The song still rings true. [Below: Summer sunset, Empire, Michigan.]

Matula Thoughts began about 20 years ago in the form of a monthly email What’s New from the Medical School Dean’s Office of Faculty Affairs and transitioned to a Urology Department monthly communication around 2007. In 2013 the personal essay took the form of Matula Thoughts, on a web site called Word Press, and this essay is around the hundredth in that form. There is a time for all seasons and this seems the right time to “sunset’ this public effort, but with great appreciation to the readership that motivated me for the past two decades. The monthly discipline of producing Matula Thoughts has been invigorating but this seems the right time to let it go.

Thank you if you’ve been following Matula Thoughts over these years.

David A. Bloom, June 4, 2021

I know this much is true

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Matula Thoughts May 7, 2021

2,986 words

May2021

plensa-2-copy

One.

People are out and about this spring in sharp contrast to last year when Ann Arbor’s sidewalks, streets, and parking lots were virtually empty. If you happen to walk on State Street near the UM Art Museum you may see a large-scale sculpture by Jaume Plensa called Behind the Walls. This made its debut at Rockefeller Center in 2018 and then had a stay in Mexico City, before settling here at UM. [Above: Plensa’s Behind the Walls.]

I first noticed the monumental face during a “covid walk” last spring – actually, a friend pointed it out to me. The sculptor’s intent of updating the “see no evil” meme of the three wise monkeys seemed clear but, as I returned to Behind the Walls on other walks, deeper nuances of the self-blinded face expanded. After a year of sightings and casual thoughts regarding Behind the Walls, I was prepared for the documentary about Jaume Plensa shown by the UM Penny Stamps School of Art Series in collaboration with the UM Art Museum and its director Tina Olsen. Plensa had this to say, using the metaphor of “a message in a bottle”:

“In a world full of injustice, disasters and suffering, it seems banal to speak of beauty, frivolous even. I am convinced that beauty has an extraordinary force, an extraordinary capacity for regeneration. It has an obligation to illuminate us.” [Approximately 56 minutes into the film.]

 “I’ve spent my whole life trying to construct a language, an alphabet, an ideology, a … thought that would help me understand others better. I suppose there is also a search that is related to the message and the bottle, my message. I try to write it with more precision but especially I also try to make even stronger bottles, more stable so they can get as far as possible.”

“The things around us, the people, the objects, are sleeping like children who suddenly fall asleep in a car. Sculpture, creation, has this enormous capacity for waking us up again.”

“I believe that in my case there has been a thorough search for something I haven’t found yet, which is to understand how I relate to the outside, my relationship with the world, the community, others, especially my relationship with myself. Me myself, towards myself, because I know if I reach that distant point in myself, I will understand it in others.” [1:16]

Behind the Walls goes beyond the cynical monkeys who chose not to observe anything that they expected to be unpleasant or “evil.”  Plensa says something more. The hands over the face – disconnected from the arms, shoulders, and torso –  are naturally assumed to be self-directed to cover the eyes, although it is just as easily imagined that external forces – culture, society, peer pressures, politics, or sectarianism –  as likely to be the levers positioning the hands.

Ty Seidule’s book, Robert E. Lee and Me (mentioned on these pages in March), is a case in point of how personal world views are built by the cultures that raise, educate, and sustain us. Col. Seidule, whose childhood and education were framed by the monumental legacy of Lee, became a career officer in the U.S. Army and completed his service with a Ph.D. in history from Ohio State University and position as chair of the history department at West Point. At the Military Academy he noticed a striking absence of confederate memorials on the campus (in stark contrast to the rest of the country) and his life-long adulation of Lee vaporized as he came to understand the myth of the “lost cause of the south” and the sad painful fact that Lee betrayed his country.  (Thanks to Professor Victor Garcia, University of Cincinnati College of Medicine, who sent me the book.)

Two.

Empty places. Just as Ann Arbor streets were empty last May, so too were its classrooms from pre-school through graduate school. A second school year has now begun under the Covid cloud and the fighting over “open vs. virtual” schooling continues. [Below: Ann Arbor parking lot at West Huron and North Ashley on Saturday May 2, 2020 at mid-day, normally full at this time of year, but startlingly empty in the second month of the pandemic.]

May 2 parking

School closures for infectious diseases are nothing new, we recently uncovered a similar situation more that 100 years earlier – even before the previous great pandemic. Reed Youmans, grandson of Reed Nesbit, recently sent us a box of clippings, photos, and notes retained by the family, and one newspaper clipping referred to Reed Nesbit’s uncle, Dr. Otis Nesbit of Valparaiso, Indiana. One October night in 1913 the Superintendent of Gary Indiana Schools visited the general practitioner at home and asked him to “come over to Gary and help me keep my schools open” because of “a regrettable situation common to most school communities of the day.”

“People then had the fanciful idea that if they locked up their schools, they’d have no infantile paralysis, no diphtheria, no scarlet fever, or smallpox or whatever, Dr. Nesbit said on occasion of his retirement last week, following nearly 28 years as head of the Gary Schools Medical Department.” [“School chief voices praise of Nesbit,” The Gary Post – Tribune. Tuesday, August 5, 1941.]

Even then the idea of closures to mitigate communicable diseases was contested. Nesbit’s uncle turns up in the UM Urology story and will be explored in our second book, A Century of Urology at the University of Michigan. The first book, The Origin Story of Urology at UM, is available electronically and we expect hard copies soon. The open access link:

https://doi.org/10.3998/mpub.11693324

Recurrent infectious diseases plagued schools and communities a century ago, even though the principles of vaccination had been well-established for more than a century. Furthermore, the germ theory, recognized then for five decades, wasn’t understood well enough to apply to the finer details of respiratory droplet contamination, although many sensible people understood the value of wearing masks in surgical situations and epidemics. The big Influenza Pandemic would begin only four years after Otis Nesbit was recruited to the Gary schools and the story continues to repeat – as the past year has shown.

Three.

1932. The microcosm of UM urology can be claimed to have begun in 1919 when Hugh Cabot arrived in Ann Arbor. Urology residency training began in Ann Arbor in 1924 when Charles Huggins followed Cabot from Boston and Reed Nesbit came from California the next year as Cabot’s second trainee to become a urologist. Cabot was fired by the regents in 1930 and his virtually unknown protege Reed Nesbit became the head of the tiny urology section.

Nesbit quickly began making a name for himself and for Michigan Urology. By 1932, he had published papers (Annals of Surgery, Archives of Surgery, JAMA, J. Mich. Med Soc.) and that year joined the American College of Surgeons (ACS), a younger organization than the AUA, and one that would bring him to a high point of his career three and a half decades later.

Yet in 1932, two years after Cabot’s dismissal, the Medical School was still adrift without a dean. The nation too was adrift – the Depression and Dust Bowl were torturing millions of Americans. Millions more worldwide were suffering from worsening geopolitical and economic conditions. The Dow Jones Industrial average reached its post-Depression nadir of 41.22 in 1932. Brave New World by George Orwell was published. Motion pictures were a pleasant distraction from the dreary times; the film Arrowsmith, based on the Sinclair Lewis Novel (centered around a fictional version of UM Medical School) tied with The Champ for most nominations at the fifth Academy Awards but lost out to Grand Hotel for best picture.

Jack Lapides, a studious young man from Rochester, NY, came to the Ann Arbor campus in 1932 as an undergraduate. So too did Arthur Miller, an aspiring writer from New York City. Each travelled different paths to success with their UM educations, although they must have passed each other on campus, we found no evidence that they interacted.

In 1932 the federal role in health care was directed to public health, rather than individual health care. The U.S. Public Health Service Syphilis Study of Untreated Syphilis in the African American Male at Tuskegee was initiated this year in Alabama to study the natural history of untreated syphilis and the study continued until 1972, attracting little national attention, particularly in its early years. A decade later effective antimicrobial therapy became available (penicillin) in the U.S. however the study failed to offer that possibility to its subjects – a terrible mistake. [Below; Doctor injects subject with placebo. Tuskegee Syphilis Study, administrative records (1929-1972), National Archive. Wikipedia.]

Tuskegee-syphilis-study_doctor_injects_subject_with_placebo

The gratuitous Nazi human experimentations around that time were becoming public and would show the darkest side of humanity. Few people then recognized the parallels of the two programs; even though the motivations were different, it is a slippery slope from one to the other. Ethical concerns over Tuskegee were raised within the Public Health Service (PHS) in 1955 and over the next decade, but it took a whistleblower within the PHS, Peter Buxtun, to bring the national attention that ended the experiment in 1972.

Four.

Prescientific vs. scientific medicine. Clinical experimentation has been part of medical practice for much of human history; trial and error is at the root of the observation and learning that underlies the scientific process – trying to find out what’s true. Just as our clinical analytical sense has sharpened over time, so has our ethical analytical sense – trying to do what’s fair.

Systematic and statistical analysis of clinical trials with groups of people entered the mainstream of medical education and practice in Paris with the clinimetric approach of professor Pierre Charles Alexander Louis (1787-1872) (see Origins p. 30, 30n) who debunked the use of bloodletting in pulmonary tuberculosis, culminating in his 1836 book and the Society for Clinical Observation of his students, including Bostonians Samuel Cabot III and Oliver Wendell Homes. [P.C.A. Louis, Researches on the Effects of Bloodletting in Some Inflammatory Diseases, Boston Hilliard, Gray, 1836.]   [D. McCullough, The Greater Journey, Simon and Schuster, NY, 2011.]

Holmes, back in Boston in 1843, proposed the idea that another infectious disease, childbed fever, was transmissible from patient to patient.

In 1847 Ignaz Semmelweis (1818-1865) utilized a clinical trial in a Vienna Hospital – “randomized” by assignment (according to hospital admission on an odd or even numbered day) to one of two public maternity clinics – to study childbirth fever. The two clinics historically had marked disparities in death rates, that was widely attributed to the fact that the First Clinic was the teaching service for medical students whereas the Second Clinic was the teaching service for midwives. [Below: Puerperal fever death rate by years, Vienna General Hospital 1841-1846, Wikipedia, Ignaz Semmelweis.].

Yearly_mortality_rates_1841-1846_two_clinics

The medical students divided their days between the autopsy room and the First Service, while the midwives mainly spent their time on the Second Service. Semmelweis postulated that the medical students were transferring some sort of “cadaverous material” to their patients and he instituted a policy of hand rinsing in calcium hypochlorite solution between the autopsy room and examination of patients.

The experimental work of Semmelweis showed that “cadaverous poisoning” via uncleansed hands not only caused the higher mortality in the First Clinic but could be downgraded significantly by hand-cleansing between patients. His work was mocked, his ideas were unpublished at the time, and he was dismissed from his job. His career and life went downhill and he died of unclear reasons after forced hospitalization and mistreatment in a mental hospital at age 47 in 1865.

In contrast, Lister’s clinical experiments, just around the time of Semmelweis’s death were widely published, showing that sepsis (of another origin) could be prevented using carbolic acid to prevent limb gangrene and generalized sepsis after open fractures, applied on a patient-by-patient basis.

Five.

Bush_signs_in_ADA_of_1990

Disabilities constitute a disparity in health care just as in most other public goods of society. The documentary Crip Camp mentioned last month on these pages centers around a camper who became a writer, producer, and director of the film. James LeBrecht was born with spina bifida. His disability prevented ambulation and his parents told him he would need to be very outgoing to be accepted in life by “normal” people, explaining that he had to approach other people because “they are not going to come up to you.”  He become an extrovert in his neighborhood, but attendance at Camp Jened in the Catskill region of New York in 1971 offered LeBrecht his first chance to live and play without embarrassment among other (also disabled) kids. A nucleus of those campers later became major participants in the Disability Revolution that led to the American Disability Act (ADA) of 1990. [Above: George H.W. Bush signs ADA June 26, 1990 on White House South Lawn. Pictured (left to right): Evan Kemp, Rev. Harold Wilke, Pres. Bush, Sandra Parrino, Justin Dart.]

LeBrecht unabashedly recalled how urinary incontinence forced him to contend with diapers until a urinary diversion freed him from them, although still left him dependent on stomal supplies and vulnerability to leakage mishaps. Four medical advances were changing the lives of spina bifida children around that time LeBrecht went to camp:

a.) Safe and effective post-natal repair of open spinal cord and cutaneous defect by pediatric neurosurgeons became routine after the midpoint of the 20th century;

b.) The Holter Shunt for hydrocephalus;

c.) Urinary diversion, most specifically the Bricker ileal conduit diversion that came into major use in the 1950’s in conjuncture with extirpative cancer surgery but within a decade found routine application to spina bifida children to prevent urinary incontinence, infections with sepsis, and upper tract damage;

d.) The work of Jack Lapides in Ann Arbor.

In 1971 the American Academy of Pediatrics recommendations for infants and children with spina bifida recommend “after urinary diversion” followed by intravenous pyelograms to keep track of the upper urinary tracks. Routine urinary diversion, the standard of care, was life-changing for LeBrecht and thousands of other spina bifida children.

A major change coming into play in 1971 changed life even more greatly for spina bifida folks and many other people. The Jack Lapides methodology of clean intermittent catheterization was first publicized then, initially for adults with lower urinary tract dysfunction but within a few years extended into the spina bifida cohort. Papers with Diokno and Kass, eliminated the need for surgical urinary diversion and gave spina bifida children a better and safer way to manage their urinary tracts.  [A.C. Diokno, J. Lapides et al, “New approach to myelodysplasia,” J Urol 116.6 (1976): 771-772.]   [E. Kass, J. Lapides, “The significance of bacilluria in children on long-term intermittent catheterization,” J Urol 126.2 (1981): 223-225.]

Crip Camp was one of the five nominees for best documentary film last month, but My Octopus Teacher won the Oscar.

Postscript

I know this much is true is the name of a book (Wally Lamb, 1998) and an extraordinary motion picture miniseries (HBO, 2020) depicting two brothers, one with terribly disabling mental illness although both boys were tortured by their perceptions and misperceptions of reality.

What we each know to be true is limited by what we are taught, what we chose to see, and what we chose to evaluate. Just as science and medicine depend on truth, the imaginative worlds of art, literature, and motion pictures at their best and most enduring seek to portray the veracities of life and society. A recent PBS documentary on the writer Flannery O’Connor quoted her as refuting the idea that fiction was an escape from reality, saying that good fiction was “a plunge into reality.”

It should be no surprise that households of scientists and healthcare workers may yield artists of one sort or another – or vice versa. These pages last month noted that the TV series House (2004-2012) portrayed a brilliant Sherlockian diagnostician, counter-intuitively misanthropic and dependent on pain medication. Dr. House was played by actor Hugh Laurie, son of a well-known English physician, Ran Lurie. The actor later said he felt guilty for being paid more money to present a fake version of a physician than his father ever earned as a doctor.

The classic urologic example of this is Katharine Hepburn (1907-2003), daughter of a Connecticut urologist, Thomas Norval Hepburn (1879-1962) for whom an endowed lectureship exists in Hartford. Her career spanned 60 years on stage and screen, achieving 12 Best Actress Nominations and four Oscars. [S. Berg, Kate Remembers, 2003.] The next Hepburn lecturer is set to be our Nesbit alumna Ann Gormley (1993 fellowship with Ed. McGuire).

Hugh Bonneville, son of legendary British urologist J. P. Williams (1926-2020), allegedly took the surname of a favored automobile model to spare his well-known father any notoriety. Bonneville’s Earl of Grantham in Downton Abbey certainly reached many more people than the skilled hands of Mr. Williams, even if less viscerally. J.P. Williams was a respected consultant at the Institute of Urology in London, an acclaimed Harley Street practitioner, and author with John Blandy (an important teacher in Ed McGuire’s training) of the History of the British Association of Urological Surgeons. J.P., as he was known, founded the Chrysalis Club, an informal monthly forum for trainees in urology.

Vanessa Kirby was brilliant in the recent film, Pieces of a Woman. She is the daughter of prominent London urologist Roger Kirby (b. 1950), an early pioneer of robotic prostatectomy, founding editor of several journals, and director of the Prostate Center on London’s Wimpole Street. Vanessa just missed out on a best actress Oscar award last week to Frances McDormand of Nomadland – both works being keen observations on human pain and suffering.

These coincidences remind me of my friend and colleague, Ian Thompson, Jr., who once hoped write a book called, How Urology Changed the World. Thomas Hepburn, J.P. Williams, and Roger Kirby (and surely others) would figure strongly in it, as their children in entertaining us through theater help us understand it.

state-st.

Behind the Wall, tucked away between the old and new portions of the UM Museum of Art, is ironically obscured by a large red figure as well as the busy pedestrian and vehicle activity of State Street. But you will see it if you look.

Thanks for reading Matula Thoughts this May 7, 2021.

David A. Bloom

Showers and Shows

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WN/Matula Thoughts April 2, 2021

Showers and shows, corvids and covids

2,765 words

One.

April showers are annoying when they catch you unprepared but these heavenly shows can be enchanting and do bring May flowers. Spring rains entertain and sometimes astonish with their beauty, intensity, and lightning spectacles. Most importantly April showers are essential to the planting seasons that we humans have relied upon for 7,000 years.

Painted the same year as Hiroshige’s Sudden Shower (above) is Millet’s The Gleaners, showing three women gleaning a field for stray stalks of wheat (below) on a cloudy day before crows and other animals picked them off. [Two paintings from 1857. Above: Utagawa Hiroshige’s Sudden shower over Shin-Ohashi Bridge and Atake in the One Hundred Famous Views of Edo series. Brooklyn Museum.  Below: Jean-Francois Millet’s The Gleaners, Musée d’Orsay.]

Agriculture, the invention essential for human success, also expanded opportunities for the adjacent success of predators of both our foodstuffs and increased populations. Modern society, interconnected and mobile, in turn offers easy opportunity for global distribution of viral predators by aerosols and droplets to 7 billion human incubators that further disseminate and revise the predator.

Inventions have kept us ahead of extinction so far and scarecrows were one of the better early inventions, arguably our first robotic impersonators, animated by the wind as they waved off corvids and other winged diners.

The Covid pandemic (declared last spring on March 11) reminded that our food supply remains tenuous – whether threatened at the source by predators or by supply chain breakdown – with bare shelves in the aisles of food stores a year ago. Food security now more than ever is at risk because of the intricate supply chains of modern society – contingent on geopolitical, economic, and biological stability. Just now, the inventions essential to survival are vaccines.

Human cooperation using masks and prudent distancing and the incredible ingenuity of vaccines – their amazing creation, mass production, and deployment in less than a year – may lead us out of this crisis and give time to prepare for the next one. Whether the next challenge will come from the likes of corvids or covids remains to be seen, but challenges are to be expected.

All nations stumbled in terms of pandemic response, some more than others. We debate which political party or political system will best protect us from the next disasters, but it is more likely that a balanced portfolio of domestic political parties and international political systems in relative harmony will offer the best chance. No single ideology – libertarian, democratic, republican, socialist, parliamentarian, monarchy, corporatocracy, etc. – is likely to offer the best hope for mankind, although representative democracies with fair open societies are more likely to bring innovation to the forefront and extract the optimal wisdom of crowds than other systems.

 

Two. 

April hosts other celestial shows, notably the Lyrid meteor showers (April 16-26) with an average count of 10 meteors per hour, providing spectacular night-time shows at this time of year (above). Rainstorms and meteor showers, as parts of nature’s pageantry, entertained humanity long before we learned to create our own shows, through stories, visual art, song, and playacting. [Image credit: Astrophotographer Mark Lissick. Lyrid meteors and the Milky Way, taken on April 22, 2013, in Hope Valley, California (near Lake Tahoe).  Mark Lissick/Wildlight Nature Photography.]

Modern life, especially during these days of Covid, has pushed much of our entertainment indoors to the small screens of households and personal devices. News, commentary, biography, history, and drama – and various mixtures of these – provide more than enough “content” to entertain and educate us when leisure time crops up between the moments of getting our daily bread and preparing it.

One year ago, Covid-19 was exhausting hospital and mortuary capacities around the world, schools and restaurants closed, and unemployment exploded, although large chunks of the population refused to believe those facts and reports. Social isolation forced new approaches to work, education, and entertainment. Fear and the paradoxical echo-chamber news of social media magnified primitive challenges to social cohesion, public safety, and science. These challenges are to be expected in a free society – mask doubters, vaccine refusers, and violent extremists have been around since the last major pandemic – but it seemed worse with this pandemic. The contrarian support from political leaders, however, was not only a low moment for this democracy, but it was consequential in terms of exacerbation of lives lost from unnecessary congregation and virus dissemination but also humiliated this nation in the view of other nations.

 

Three.

Small screens. Social isolation forced most of us indoors for work and entertainment while the internet and innovative software allowed immediate access to workplaces, education, news, and recreation around the clock and throughout the week. People and families worldwide who were lucky to have home televisions or devices with internet capability, self-entertained at an unimagined scale. Motion pictures were already in the process of transitioning from public theaters to mobile devices, but the pandemic accelerated the transition. [Below: Peepa Pig © and her family watching TV.]

Medical topics have entertained people throughout the history of modern literature and early in the 20th century. Plays such as Shaw’s The Doctor’s Dilemma (1906) and novels such as Arrowsmith by Sinclair Lewis (1925) remain relevant today, reflecting cultural attitudes and issues of their times and ours. After written plays and novels translated to motion picture shows the genre burgeoned in the later 20th century and expanded to this century, admixing entertainment with social commentary on cultural attitudes, personal crises, ethics, and injustices reflecting myriad facets of the human condition. To me, the greatest medical story in print, from the perspectives of authenticity, plots, and style, is Cutting for Stone, by physician Abraham Verghese (2009). It leaves most others far in the dust.

A complete examination of the medical stories in print, on stage, and on screen would be a larger project than would be suitable here, but a cursory view of health care shows for personal entertainment at home, is entertaining in itself.

 

Four.

The first popular TV medical shows featured characterizations of generalist physician Dr. Kildare (1961-1966, five seasons, 191 episodes) and a brilliant and thoughtful neurosurgeon Ben Casey, MD (1961-1966, five seasons, 153 episodes). They are long gone but the soap opera General Hospital endures (1963 – present, 47 years over 14,000 episodes), with a brief disruption for Covid, offering romance, marriages, mistresses, mayhem, crime, and episodic murders broadcast in an afternoon time-slot. Medical shows have burgeoned and this list is hardly comprehensive, but illustrates the spectrum and chronology. [Below: BBC image from 1966.]

Marcus Welby, M.D. (1969-1976) returned to the theme of a kind family doctor solving common physical and emotional problems in a small town over a gentle range of social issues while dealing with his own family’s dramas. This was the first ABC show to become #1 on TV (in its second season 1970-71), lasting for seven seasons with 169 episodes.

Realism mixed with comedy in M.A.S.H. (Mobile Army Surgical Hospital) as a medical team in a combat zone (actually Korea and watched in the context of Vietnam) lightened its daily load of tragedy and pathos by comedy. Based on a 1968 novel by Richard Hooker and a 1970 feature film, M.A.S.H. was translated into a half hour television series on CBS that lasted 11 seasons with 256 episodes from 1972 -1983. The dark comedy brought gallows-like humor to the serious business of the operating theater.

St. Elsewhere (1982 -1988) also carried realism into living room TVs with dramas of a medical team in an underserved community for six seasons with 137 one-hour episodes that earned critical acclaim and concluded with a brilliant ending.

Doogie Houser, M.D. (1989 -1993) mixed the challenges of hospital-based medical practice by a boy-genius leukemia survivor who, at age 14 had become the youngest licensed physician in the U.S. The show begins with him at age 16 as a surgery resident in LA, living at home with his parents and follows him for 97 episodes dealing not only with his obvious precocity (he can prescribe drugs but can’t buy beer) as well as inner city gang trauma, racism, AIDS, homophobia, etc.  Created by Steven Bochco and David E. Kelley. Doogie Houser was an unlikely successor to Steven Bochco and David Milch’s Hill Street Blues (1981-1985).

Dr. Quinn, Medicine Woman (1993-1998) offered a new take on medical dramas, featuring a woman physician placed in the American west, spun out into six seasons, 149 episodes, and two television movies.

E.R. (1994-2009) incorporated the dramas and personalities at play in a large city Emergency Department. Created by physician Michael Crichton the long-running show established the careers of some notable actors and the idea of this new subspecialty of medicine as a lifelong career path in the eyes of the public, for until recent times Emergency Rooms were usually staffed by rotating trainees, generalists, and on-call specialists. This lasted 15 seasons with 331 episodes.

Bramwell set in late Victorian England follows Dr. Eleanor Bramwell, challenging men and stereotypes as she runs a hospital for the indigent she calls The Thrift, in the East End of London beginning in 1895. This British show lasted for four seasons with 27 shows between 1995 and 1998, and still holds up well to modern viewing. [Below: Sony “flat screen” TV from 2000.]

Twenty-first century small-screen shows revised reliable old themes but also ventured deeper into less complimentary and comforting themes of medical practice including commercialism and more nuances of human behavior and social context.

City of Angels (2000-2002) ran for two seasons with 24 episodes on CBS. It was the first main network medical drama with a predominantly African-American cast.

SCRUBS (2001-2010) was a heroic diary of a young physician, produced by Disney, lasting for nine seasons with 182 episodes.

Nip/Tuck (2003-2010) dramatized the business of cosmetic surgery with comedy and drama, lasting for six seasons and 100 episodes.

House (2004-2012) portrayed a brilliant Sherlockian diagnostician with his own problems. He was a notorious rule breaker but solver of medical mysteries that confounded others. Counter-intuitively misanthropic and dependent on pain medication, the lead figure Dr. House was played by actor Hugh Laurie, son of a well-known English physician, Ran Laurie. The actor later said he felt guilty for being paid more money to portray a fake version of a physician, than his father ever earned as a real physician. This highly acclaimed show lasted eight seasons with 177 episodes. [Wikipedia.]

Doc Martin (2004-2021) tells the story of a quirky vascular surgeon at Imperial College London who develops hemophobia and relocates to a small Cornish village, where his uncle and aunt own a farm. Doc Martin readjusts his career to become a general practitioner although the antithesis of the kindly Marcus Welby phenotype. Dr. Martin lacks any bedside manner – lacking social skills he is rude, abrupt, and generally unkind for nine seasons and 70 episodes usually of 50 minutes.

Grey’s Anatomy (2005 –  ),  produced by Shonda Rhimes, centered around a young woman physician named Meredith Grey, punning on the classic anatomy textbook of Henry Gray of 1858. Meredith’s dramas began with her as a surgical resident in Seattle and the prime-time show lasted for 17 seasons with 370 episodes up to the pause for Covid.

Nurse Jackie (2009-2015) ran for seven seasons and 80 episodes, featuring an emergency department nurse in a NYC hospital. The show explored difficult issues including drug addiction and The New York State Nurses Association protested perceived “unethical behaviors” of the main character in bending rules to best serve patients.

The Knick (2014-2015) ran only for two seasons with 20 episodes in a fictional Knickerbocker Hospital in NYC around 1900. The protagonist, Dr. John Thackery, was the chief of surgery modeled on William Halsted balancing his own drug addiction with ambitions for innovation and excellence. Economic stability of The Knick, racism, and ethical issues contend in the plot of this historically realistic show, which was deeply informed by Dr. Stanley Burns and the Burns Archive.

It would take a larger essay to encompass all the other medical television shows, especially the new ones that are proliferating with melodrama, excitement of the operating room and emergency department, stereotypes noble and vile, including: Chicago Med, The Resident, Transplant, Virgin River, Trauma, 9-1-1, Valkyrien, Nightshift, New Amsterdam, and others. Historical themes returned with The Knick and a truly bizarre show, Ratched, imagined a prequel to the notorious psychiatric Nurse Ratched from the great film One Flew Over the Cuckoo’s Nest. All these shows leave little doubt that the genre will continue, portraying a broad swath of the human condition through healthcare lenses.  If another global quarantine comes by, these shows offer 2,436 episodes to binge – even before turning to the enduring soap opera, General Hospital, with its more than 14,000 stories.

The bottom line is that the medical shows have specialized into as many different versions of the profession and its professionals as the public has experienced or can imagine – from the finest to the basest. Many shows inspired countless young people towards health professions from Dr. Kildare, to M.A.S.H. to Nurse Jackie. [Below M.A.S.H. season six cast.]

M.A.S.H. more than most other medical shows revealed the systems behind the personal dramas of each episode, and the imperfect and often contradicting systems of the U.S. Army added to the complications of each day. Military medicine is a vast set of services and supply chains that may need to be mobilized and moved across the planet at a moment’s notice. Yet this is but one part of the national “health care system” at play on a 24/7 basis.

 

Five.

Documentaries. Of all types of shows, documentaries are the most compelling for me, showing the world and ourselves (in the larger sense) to ourselves in the personal sense, with the good, bad, ugly, and beautiful of life. Health care documentaries are a rich genre and a good place to start is Crip Camp. Camp Jened was a summer camp for children with disabilities that began in 1951 and was recently explored in a film by James LeBrecht and Nichole Newnham that won the Audience Award at the Sundance Film Festival in 2020 and an Oscar nomination (available on Netflix). LeBrecht began Camp Jened himself in 1971 and his film, with archival footage, tells how a cohort of campers came together in their later lives to join in social actions that informed broader social understanding of what George H.W. Bush would call “the shameful wall of exclusion.” Bush used that phrase when he signed the American Disabilities Act in 1990. The role of the Crip Campers was essential to that story and the film will broaden your understanding of the idea that human freedom – encompassing life, liberty, and the pursuit of happiness – is intrinsically tied to personal health with mobility and access to fair inclusion in the world.

Health and healthcare, equitable and excellent, are great aspirations of human civilization – just as are clean air, good water, and food, along with shelter, public safety, and human liberty. No deity, divinely authorized authority, or algorithm provides these things. Multiple nations, regions, local authorities, and organizations must provide these things for their stakeholders. The public complaint that “the health care system is broken” implies an expectation that an actual system should exist, whereas in fact multiple systems are at play often at cross purposes nationally and internationally. Expecting a government or political party or algorithm to create a perfect system (or “fix” a “broken” one) is a fool’s errand. The solution will be to optimize performance and coordination of the myriad organizations through wise legislation, robust and fair safety nets, responsible corporations and unions, honest professions that serve the public, and an educated public.

Professions have been at the heart of health care, notably the early profession of healing or medicine documented since Hippocrates and the more recent profession of nursing, so well codified by Florence Nightingale. The corporatization and industrialization of health care, while necessary and inevitable at some levels, have eroded the professions that have humane aspirations rather than economic and metric motivations. Retention of a balance between profession and industrialization in the delivery of health care may be the best hope in constructing a set of health care systems for the future.

 

Postscript.

Truth and fiction. Journalism, personal memoir, factual narratives, and documentaries declare themselves to tell truth but is the marketplace of the readership that validates the claim. Fictional stories as works of imagination are  rooted in actual human experience and, at their best, tell truths. These narratives of imagined stories may achieve realism through their art, uncovering truths and sometimes displaying them with astonishing clarity – the truth of a moment in life, a scene, a person, or a story. For these works too, the marketplace of readership validates the authenticity. In fiction or factual narrative, health, disability, and disease will always be compelling parts of our stories, however they are told, illuminating for better or worse the human condition, as it is called.

Thanks for reading Matula Thoughts this April, 2021.

David A. Bloom

University of Michigan

Politics, as usual?

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Matula Thoughts March 5, 2021

2987 words

Politics, as usual?

One.

Last month was Lincoln’s birthday and a new biography, Abe by David Reynolds, merits comment. Fundamental issues of Lincoln’s times remain fundamental issues today and Reynold’s book permits you to be a “fly on the wall” in the rooms where consequential things happened. You need not be historian, constitutional lawyer, or elected politician to weigh in on these issues – literacy in today’s complex world is an existential necessity, political literacy for health care professionals in particular. 

Lincoln took office at an extraordinary moment of bitter partisanship and threat to the nation. His first inauguration was preceded by ugly political fighting amidst divisive and turbulent social conditions that Lincoln navigated deftly, although sometimes uncertainly. Many ideologies, “isms” and factions created a toxic climate that divided the nation into uncompromising strongholds of opinions as to which way the country should go. Lincoln was the consensus choice of the voters, but his perceived ideology was contentious to a vocal minority.

A recent article by historian Ted Widmer tells how on February 13, 1860 (a day after Lincoln’s 51st birthday) a mob tried to enter the Capital to disrupt the confirmation of the election. The mob, lacking passes to enter the Capital (and ignoring how American democracy was intended to work with peaceful transfer of presidency), was blocked by soldiers and protested loudly outside the building. Tempers also flared inside House and Senate chambers but American democracy and Lincoln won that day at the Capital. [T. Widmer, NYT, Jan 10, 2021.]

Reynolds argues convincingly that Lincoln distilled the toxic climate of opinions and centered his political course on the central defining idea of the nation as he saw it,

“.. Slavery, he declared in August 1856, ‘should be not only the greatest question, but very nearly the sole question.’ Noting the diversionary tactics of the proslavery side, he stated, ‘Our opponents, however, prefer that this should not be the case.’ He again drove home his main point: ‘The question is simply this – should slavery be spread into the new territories or not? This is the naked question.

Along with the naked question went a central idea. ‘Our government rests in public opinion … Public opinion, on any subject, always has a central idea, from which all its minor thoughts radiate. That central idea in our political public opinion, at the beginning was, and until recently has continued to be, the equality of men.” [D. S. Reynolds, Abe, Penguin Press, 2020, p. 434-435.]

This was a historically sound and prescient argument. Lincoln boiled down the entire national acrimony to the single organizing (and aspirational) principle of the Declaration of Independence – human equality.

Inasmuch as the Declaration was the primary justification for the new nation, it was an obvious corollary for Lincoln that the nation could not be divided, leading him to the famous biblical reference in his House Divided speech of June 1858. 

“ ‘A house divided against itself cannot stand.’

I believe this government cannot endure, permanently half slave and half free.

I do not expect the Union to be dissolved – I do not believe the house to fall – but I do believe it will cease to be divided. It will become all one thing, or all another.” D.H. Donald, Lincoln. Simon & Shuster, NY 1995. p.206.]

For all the subsequent debate over the conflict between the aspirations of the Founders and the ugly facts of “state’s rights” to hold human beings as “property,” the reality is that neither the Declaration nor the Constitution provided for such personal rights to own property in human beings – a concept totally dissonant from the foundational mandate and words of the Declaration.

Both documents had required consensus among all 13 colonies. Three provisions of the Constitution reflected the wills of slave-holding states, yet the document deftly steered clear of asserting any claim to the noxious idea of human slavery itself – “property in man.”

The first Constitutional provision (Article I, Section 2) allowed for congressional representation and apportionment of taxes for the states based on their “respective Numbers” of “free Persons” (these were assumed to be white men only, although that was never explicitly stated) plus:

“…those bound to Service for a Term of Years, and excluding Indians not taxed, three fifths of all other Persons.”

This cynical inclusion gave the slaveholding states the extra edge of additional votes and tax reapportionment for three-fifths of all enslaved persons. Ultimately these provisions were obliterated by the Thirteenth and Fourteen Amendments.

The second provision, another bone thrown to the slaveholding states, came in Article 1, Section 9 but it was time-limited.

“The migration of Importation of such Persons as any of the States now existing shall think proper to admit, shall not be prohibited by the Congress prior to the Year one thousand eight hundred and eight, but a tax or duty may be imposed on such Importation, not exceeding ten dollars for each Person.”

The final provision is in Article IV Section 2:

“No person held to service or labor in one state, under the laws thereof, escaping into another, shall, in consequence of any law or regulation therein, be discharged from such service or labor, but shall be delivered up on claim of the party to whom such service or labor may be due.” 

The framers of the Constitution clearly expected “property in man” to wither away, little expecting the Missouri Compromise of 1820 would allow the inclusion of a new slaveholding state and the Kansas-Nebraska Act of 1854 would allow the “popular sovereignty” of new states to make their own decisions on the matter. Rather than withering away slaveholding was resurgent in the days leading up to Lincoln’s first term and civil war was inevitable.

Lincoln set a course for the war with principle and perseverance, although as it ground on undecidedly, the Union will flagged and Lincoln feared for his reelection. By July 1863 the tide turned, in spite of draft riots in NYC, and Union victories in Vicksburg and Gettysburg fueled optimism. In August the president decided to sit for a picture.

Photographs in those days required long exposures, lasting many seconds or minutes and, as Lincoln sat for a glass plate portrait in August 1863 at Alexander Gardner’s studio in Washington, a fly alighted on the president’s trouser leg below his right knee. Lincoln was unperturbed and continued to sit still for the photograph, without troubling the insect. [Above: Gardner’s photo. Below: detail of the famous fly under Lincoln’s knee on the posterior crease.] 

 

Two.

Health care in Lincoln’s time hardly compares to health care today, but the matters of human inequality in terms of life, liberty, and the pursuit of happiness underpin our modern acrimony just as they underpinned the great national dilemma in 1860, especially so today in matters of health care. [Above: Harper Hospital, original hospital complex in an 1884 drawing  710 of The history of Detroit and Michigan or, the metropolis illustrated …, by Silas Farmer p. 710. British Library.]

In Lincoln’s lifetime it was unusual for a person anywhere in the world to go into a hospital. Medical care was delivered in doctor’s offices, people’s homes, or on battlefields. Hospitals offered very little to their unfortunate patients, aside from a bed. Lincoln died just when the germ theory emerged from Ignaz Semmelweis, Louis Pasteur, and Joseph Lister. The medical world was starting to change. During the Lincoln presidency, Ann Arbor had no hospitals, while Detroit had several, the newest being Harper Hospital, built in 1863, largely to attend to soldiers injured during the Civil War. 

Health care reflects the values and aspirations of economic and political systems of any given community and society. Modern nations seem to be see-sawing between democratic rule and authoritarian/central rule. Yet this is not a simple bipolar contest. Democratic rule provides elected representatives to express “the will of the people” but requires significant central/federal authority that may verge toward authoritarian leadership (as was claimed during FDR’s presidency on numerous occasions). Authoritarian control of a society responds poorly to the needs of the people, stifling education, inquiry, and innovation but is ultimately (and ironically) contingent on acceptance of that authority by enough people in the society (as revolutions have proven again and again). As Lincoln said, our government rests on public opinion. And public opinion should be informed by basic Constitutional literacy. 

A scathing critique of modern hospital care is recounted in the recent small book by noted historian Timothy Snyder, Our Malady. Lessons in Liberty from a Hospital Diary. He offers the provocative opinion that liberty in the political sense and health care in personal terms are directly linked, gleaning that perspective from his near-fatal illnesses and suboptimal hospital care.

“America is supposed to be about freedom, but illness and fear render us less free. To be free is to become ourselves, to move through the world following our values and desires. Freedom is impossible when we are too ill to conceive of happiness and too weak to pursue it. The word freedom is hypocritical when spoken by the people who create the conditions that leave us sick and powerless. If our federal government and our commercial medicine make us unhealthy, they are making us unfree.”

 

Three.

Freedom of enterprise and thought have brought great accomplishments in medicine and science but not a unified system of heath care. We often are told “Our health care system is broken” but the  complaint is not quite right. No purposeful system exists, rather a variety of organizations and systems that have evolved in response to the myriad needs and challenges of healthcare. Each system may work well enough for its purposes and stakeholders, but they function independently, often in competition with other systems and their stakeholders. The common good of the public, individually and at-large, tends to be a secondary concern. The “broken system” complaint, although misconstrued, is relevant and global. The individual patient is the ultimate stakeholder, but gets lost in the systems. 

Health care should be many things – accessible, equitable, effective, efficient, timely, safe, kind, and universal. But it usually falls short. This is obvious to 7 billion people –  advantaged and disadvantaged populations alike. Local, regional, and global inequities are visible every day on public streets or in countless newsfeeds. Even if your individual health care seems secure, it is precarious – predicated on a job, a bank account, health status, social status or caste, location, family member, public safety, and other particularities.

The frameworks of healthcare organizations reflect the values that underpin them in each locality and their nations. Most perform adequately in terms of their business success, some excellently, but few do well in the matters of personal care, coordination, excellence, equity, and value. Business success (revenue optimization) is not the primary purpose of non-profit healthcare organizations. That’s not why society grants them no-for-profit status.

The State of California recently sued Sutter Health for anticompetitive practices that raised the cost of health care in northern California for little reason beyond increase in revenue. 

We, the public, should care about this. Most large health care organizations enjoy the benefit of “non profit” status. The public gives these organizations tax breaks that are not given to “for profit” organizations like Amazon, Exxon, or Johnson and Johnson, that have a central defining objective of maximizing shareholder value. “For profit” organizations of course have other protections carved out by the public, notably limited liability status, that enhance their abilities to succeed in the business world, but “not-for-profits” serve larger public values.

 

Four. 

Management by accounting uses performance metrics and these have spread into the non-profit sector, health care in particular. Metric domination tends to deform missions. When governing boards use performance incentives to inspire a CEO, CFO, or CMO to cut nursing positions, eliminate overtime, or decrease benefits, then those things are likely to happen even if they damage the quality of products, the performance of employees down the ladder, or the culture of organizations. The entire brand of any organization is at risk, not-for-profits especially. Governing boards optimally should govern and not manage (and micromanage) their organizations. They need wise management leaders with holistic (and accountable) reign over their domains in the organization to best advance the mission of the enterprise, which naturally involves financial responsibility but not to the detriment of mission or brand. [Above: bean counting. Illustration from Margarita philosophica, 1503, by Gregor Reisch (d. 1525). Houghton Library, Harvard University.] 

Financial responsibility in health care, essential as it is, cannot not be constrained to the next quarter’s balance between revenue and expenses. Immediate “financial margin” is important, but no less essential are quality, value, stakeholder satisfaction, financial liquidity, investment in enterprise strategy, investment in research and innovation, health care education, debt leverage, leadership succession, community responsibility, workforce health-retention-recruitment, organizational culture, policy development, public health, etc.

Health care is a huge and complex bucket of obligation in the modern world, far too complex for any of its myriad organizations to be primarily managed by key performance indicators or incentive directives.

 

Five.

Presidential inaugurations used to occur at this time of year because slow communications and clumsy political processes of this nation in its earlier history required at least four months from national elections to the peaceful transition of power that distinguished the American experiment in democracy.

The first inauguration, that of George Washington, took place on April 30, 1789, but subsequent ones occurred in March until March 4, 1933, the last March presidential inauguration, when Franklin Roosevelt replaced Herbert Hoover (above) – after a contentious election in the dark days of the Great Depression, but the two statesmen executed a graceful transfer of power in the finest tradition of American Democracy.

New technologies of communication and shortened news cycle in Roosevelt terms allowed inaugurations to be moved to January –  the second inauguration of Roosevelt was the first of these after the Twentieth Amendment to the U.S. Constitution moved the beginning and ending of presidential, vice presidential, and congressional terms from March 4 to January 20.

The past presidential election degenerated into fraudulent claims of voting irregularity, dozens of dismissed lawsuits to overturn results, and efforts to block the transition of power by congressional mischief or threat of armed force. The election results were counted, recounted, inspected, certified, and ligated over two months, but cynics may seek to restore that original prolonged interval between actual election and inauguration to allow more time for shenanigans.

Unfortunately, something so important as political leadership falls into the hands of all sorts of men and women called politicians, whom history proves again and again cannot be uniformly trusted to “do the right thing.”

This ultimately comes down to personal assessment, but what are the right things? Are they the right things for politicians, their constituencies, or the right things for society at large? The answers comes back to the Declaration and Constitution: life, liberty, and pursuit of happiness with Constitutional fidelity. This means fair and equitable education, justice, public health and safety, and opportunity.  Much of this is measurable with public health and safety data, poverty statistics, crime rates, equity in housing and education, and “happiness” ratings such as Likert score surveys.

Roosevelt’s four terms derived from democratic elections and he functioned with a strong hand, discovering new essential federal roles in rebuilding a nation from economic collapse and then guiding it successfully (along with much of the rest of the world’s nations) through a massive war. Hitler, in contrast,  manipulated his appointed position as chancellor into authoritarian rule that precipitated and lost that war, incurring unimaginable devastation in his 12 years as dictator.

Political systems, transcending individual leaders and terms, are essential to carry out the “will of the people” and protect them from threats whether they be human threats, economic threats, biologic threats, or environmental threats. Political literacy is an existential necessity. 

 

Postscript.

On the walls.

Metaphoric elevation of lowly and annoying houseflies (Musca domestica) to miniature sentient journalists imagines the precarious nature of the invertebrate, in imminent danger of destruction by authoritarian swat. [Above: Housefly, Wikipedia.] 

A related metaphor, the bugging of a room, came to life in the real world and literary genres of crime and spy stories. 

After President Obama successfully eliminated an annoying fly during a CNBC interview in June 2009 a number of journalists recalled Lincoln’s greater tolerance in August 1863. The organization People for the Ethical Treatment of Animals (PETA) chastised Obama mildly and sent him a “handy-dandy bug catcher” according to its newsletter Animals Are Not Ours. [Alisa Mullins, “Obama and the fly,” June 17, 2009.] 

This was not President Obama’s last public brush with the unruly insect order, it happened again in January 2013 during a White House briefing when he announced his selections to head the Securities and Exchange Commission and the Consumer Financial Protection Bureau. An emboldened fly briefly alighted on Obama’s forehead, but escaped to buzz another day, although journalists were quick to record the event. Vice President Pence, among countless others, also had his historic moment with Musca domestica, at the October 2020 Vice Presidential debate, once again showing that politicians sometimes tolerate flies on the walls and bugs in the rooms where things happen.

American re-enlightenment. The George Floyd moment of 2020 illuminated much of the American condition from its original sins to present disparities that so impact the aspirations of life, liberty, and the pursuit of happiness.

My friend and Army colleague, pediatric surgeon Victor Garcia, recently sent me a book by a teacher at his alma mater, West Point, Ty Seidule. Robert E. Lee and Me. A Southerner’s Reckoning with the Myth of the Lost Cause. This timely book, explains how attitudes are formed in cultures, how they persist, and how or why they can change. [T. Seidule, St, Martin’s Press, NY. 2021.]

The difficulty of changing beliefs and myths – through rational argument, historical analysis, and scientific process – is an existential challenge that our species seems to be failing. Flies on the walls watch and invertebrates may yet win the day on this planet, even though Homo sapiens is capable of doing so much better. 

Thanks for looking at Matula Thoughts, March 5, 2021.

David A. Bloom

University of Michigan, Department of Urology

 

 

February makes us shiver

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Matula Thoughts 

February 5, 2021

2311 words

 

One.

One. 

February made me shiver…  Of all the songs and phrases that accompany most months, this timely phrase from Don McLean’s 1971 song American Pie echoes especially strongly in the minds of many of us who lived through that era of American political unrest and the Vietnam War. I was a surgery intern in Los Angeles back then when the song was making its rounds and even though I didn’t fully understand all of its imagery, the lyrics and music struck a responsive chord. In fact, I wasn’t clear if it was a musical poem rich in metaphor or a pleasing musical jabberwocky of nonsense.

At eight minutes and 36 seconds, it was a long song but the words were authentic for my generation. McLean was only 26 years old at the time, but nostalgia dominated the first paragraph, celebrating the music of “A long, long time ago” before the cold snap mentioned in the second paragraph, “But February made me shiver,” referring to the plane crash that killed legendary singer Buddy Holly on February 3, 1959. McLean’s phrases and tune come back to me every year at this time. [Above: Don McLean singer. Below: Donald Maclean surgeon, UM Bentley Library.]

 

Two.

Another Donald Maclean (1839-1897), a surgeon unrelated directly to the singer, played an important part in the story of Michigan Medicine. Born in Canada to Scottish parents, this Maclean attended Kingston College in Ontario. He studied medicine in Edinburgh, Scotland and fell under the spell of the great surgeon and teacher, James Syme, who had earlier taught Joseph Lister (Syme’s daughter Agnes married young trainee Lister). Maclean returned to Kingston as professor of surgery but came to Ann Arbor in 1872 as fifth sequential replacement for the founder of UM surgery, Moses Gunn. Unlike the previous short-term intermediaries, Maclean had staying power in Ann Arbor, lasting until 1889 and teaching a generation of UM medical students in the Pavilion Hospital, including William Mayo (UMMS 1883). Just as his predecessors in the Ann Arbor Surgery Chair, Maclean managed his private practice in Detroit and commuted by train to Ann Ann Arbor for classes and teaching demonstrations. Accordingly, Maclean was one of the strong voices who wanted to move the clinical teaching programs and professional practices of the UM medical faculty to Detroit with its larger population and relative abundance of hospitals.

Dean Vaughan, university president James Angell, and the UM regents had a contrary vision of retaining the medical school, clinical practice, and hospital in Ann Arbor, so when the issue came to a head, Maclean and the other “exiteers” were no longer welcome on the faculty. It was at that point that UM established a “full-time” faculty position and university clinical practice for its next chair of the Surgery Department, Charles de Nancrede, who would serve from 1889 to 1917. The university also recognized the need for a more modern hospital facility, and that opened on Catherine Street in 1891, although it quickly proved inadequate for the needs of the times. After de Nancrede retired in 1917 Cyrenus Darling provided a weak interim period of leadership until 1919 when the next chair would be the celebrity urologist Hugh Cabot.  

 

Three.

A paradigm shift occurred between the eras of surgeons Donald Maclean and Hugh Cabot in Ann Arbor. It actually wasn’t such a terribly long long time ago in the grand scheme of things although, to contemporary medical students and trainees, Maclean’s era certainly must seem to be the distant past. Actually, that was the time of my great-great-grandparents. 

Horace Davenport, UM’s great physiologist and historian of the Medical School, uncovered representative surgical cases of Maclean at UH in 1881-1882, that were published in Physician Surgeon by Maclean. The range of procedures is remarkable considering that Maclean was the sole surgeon and the surgical facilities in the Medical School and Pavilion Hospital were rudimentary. Maclean’s attention to reporting of results, although also rudimentary by today’s standards, was laudatory for his times. [D. Maclean, “A tabular statement of the surgical work done in the Department of After Maclean 1881 and 1882,” Physician Surgeon, 5 (1883): 387-396.] [H. Davenport, Not Just Any Medical School, p. 20.]

The astonishing paradigm shift that followed Maclean delivered surgical (and medical) specialization to mankind and the first steps of minimally invasive surgery – most widely and effectively evidenced in the urology arena.

Hospitals that were once dormitories for the sick became complex healthcare factories with a multiplicity of diagnostic and therapeutic capabilities. Costs escalated greatly and new parties eagerly began to divide up the monetary pie of health care. Research embedded in medical schools and hospitals generated new knowledge and tools. Medical education expanded from four years of medical school to internships and residency training programs equivalent in length of time or greater than that of medical school. Teams replaced individuals as health care providers. Public health joined with individual health care as responsibilities of modern societies and myriad systems (small practices, community health centers, medical centers, and large healthcare networks) self-assembled to create the modern and postmodern meta-systems of health care in the U.S., Canada, and other nations of the world.

 

Four.

Hospitalization today is a commonplace phenomenon. In Maclean’s time hospitalization was unlikely for an individual in their lifetime. In modern times, however, most people in industrialized nations are likely to undergo hospitalization at some point in their lives for childbirth, surgery, trauma, cardiopulmonary conditions, infectious diseases, or a wide variety of other conditions.

A friend endured a difficult (non-Covid) hospitalization this winter, emerging successfully but not without much suffering, a number of failed communications, fumbled hand-offs, and errors. All that that provoked another friend to make the common observation that “the system is broken, and broken beyond repair.” Happily, our first friend (the patient) made it home, even as the concomitant covid syndemic exploded, driving UM and St. Joe’s daily inpatient Covid patients above 100 each for the first time since spring. 

I feel responsible for our organizational imperfections my friend endured, even though I’m no longer in a position of organizational responsibility. When our Faculty Group Practice (FGP) evolved in the early 2000s I believed that our new UM clinical leadership structure could provide the best hope for aligning the complexities of modern health care to the triple academic mission while taking into account the harsh economic marketplace and changing public policies. Now, as our FGP has become the UM Medical Group (UMMG) under the banner of Michigan Medicine, I still believe this is true, although we have a long way to go, as evidenced by my hospitalized friend. 

After I apologized for our systemic imperfections of fumbled “hand-offs” and glitches in processes of care to my friend and his family, I reflected on the common phrase that “the system is broken.”  The sad familiar phrase is nonspecific and unhelpful – what actual system was being referenced as broken? It’s almost like observing that the planetary environment “system” is broken, which may well be true, but doesn’t offer much help in solving the universally recognized problem. More accurately, many systems actually work very well, but mainly in serving their own particular needs rather than needs of individual patients and the public at large. 

The vast array of enterprises and systems in national health care are variably interconnected, but not united operationally to produce the purposeful and elastic system that we crave. The idea of a single centralized (governmental) system to fulfill the myriad needs of a nation’s health care is not easily imaginable when it comes down to specific functions, in fact that experiment has been tried and failed in 20th century China and Soviet Russia. It doesn’t seem reasonable to think we could build (even with Artificial Intelligence) a systemic set of rules, laws, and organizations to deploy the myriad aspects of personal and public health care, accounting for the needs of workforce education, research, innovation, public policy, crisis preparedness, safety nets, private sector, and professional organizations. 

We presently witness the astonishing multinational development of multiple effective vaccines in response to the global pandemic, decelerate in the implementation phase with clumsy national and local policies, supply chain issues, political rhetoric, false narratives, vaccine deniers, and worldwide healthcare disparities resulting from poverty and racism. A tiny virus has thrown every national and health care system into states of confusion and exacerbated the known inadequacies and disparities.

 

Five.

Making health care work. The charge that “our system is broken” is aimed most acutely at the fundamental parts of health care – the delivery of individual ambulatory and inpatient care, while supporting the public health of a population. It is a certainty that any given integrated organization, such as Michigan Medicine, can go a long way toward making health care work better and more fairly for their individual patients, workforces, and regional stakeholders. 

The operation of a large regional health care system such as Michigan Medicine is not amenable to any algorithms known to mankind.  Expectation that artificial intelligence might provide efficient and humane central management will likely be disappointed, just as other exclusive central systems failed to provide societies the full range of health care in its particular clinical, public, educational, investigative, and innovative dimensions. It’s difficult to identify any society that has pulled off this pent-fecta, although it’s not for lack of trying. For now, the best hope is management by teams that distill content expertise of specialties and stakeholders, to aligning them to the needs of the individual patient, the public health, and the larger aspirations of society. 

It was big news at UM in Ann Arbor in mid-month when David Miller was named as President of Michigan Medicine, taking over from David Spahlinger, who had done great service in the role of President of UMHS and Executive Vice Dean for Clinical Affairs, a position he held in its various names through two decades of astonishing change and growth. [In modern health care camouflage: above David Spahlinger and below David Miller and Justin Dimick.]

 

Postscripts. 

Another Donald Maclean (1913-1983) evokes the spirit of the late David Cornwall. This Maclean was a member of a Cambridge spy ring that passed British and American secrets to the Soviet Union in WWII and during the cold war. The Gaelic surname in its various spellings means alternatively ‘son of Gillean’ referring to Gillean of the Battle Axe of Ireland around 1200 or ‘servant of St. John.’ The Scottish Clan MacLean has been powerful throughout the history of Scotland and all the MacLeans, Macleans, McLeans, McCleans, McLaines, and McClains may well derive from a single mitochondrial mother “Eve.”  [Below: Donald Maclean the spy, Wikipedia.]

Maclean made headlines in 1951 when he exfiltrated to the Soviet Union, along with fellow conspirator Guy Burgess, and they would be followed in 1963 by Kim Philby. Maclean’s family accompanied him to Moscow but after an affair with Philby, Mrs. Maclean returned to the West 1979, dying in NYC in 2010. The three Maclean children each married Russians, but all subsequently also returned to the West, leaving their father behind, working as a foreign policy analyst at Moscow’s Institute of World Economy and International Affairs. He died, reportedly of cancer at age 69, and was cremated and honored in Moscow in 1983.

A Fourth Man, fellow spy Sir Anthony Blount and art historian and Surveyor of the Queen’s Paintings, stuck it out in England and was unmasked in 1979, but lost only his knighthood. The Cambridge Four later turned out to have been the Cambridge Five, after John Cairncross (code-named Liszt) was confirmed by KGB defector Oleg Gordievsky in a 1991 interview as the Fifth Man. Cairncross, a literary scholar from Cambridge had previously been known as an atomic secrets spy, confessing partially in 1951 and losing his civil service job. He moved to the U.S. as a lecturer at Northwestern and Case Western Reserve, where he confessed more completely in 1964 to British investigators who had opened his case after Philby’s defection. Cairncross moved to Rome in 1967 to work for the U.N. and then in 1970 to Provence, France. He died in England in 1995. 

These convoluted truths may seem stranger than fiction, but made for great stories from the late great spy novelist John le Carré, the pen name of David Cornwall (19 October 1931 – 12 December 2020) in the enduring tales of George Smiley and other memorable protagonists.  

 

February each year manages to get the work of a month accomplished in fewer days than the other longer months. This, of course, is a hyperbolic thought, as if a month is a purposeful agency instead of an arbitrary block of time. Yet, this playful conjecture is an inverse run of Parkinson’s Law by which work expands to fill the time or other resources available for its completion.

Parkinson, a British naval historian and academic in Malaya, in his later career, wrote a short piece in the Economist in 1955 that he expanded into a book in 1957. He thus fulfilled his own law –  expanding words rather than more vaguely defined work – to explain the same idea of Parkinson’s Law, laid out in the brief Economist article, later in his book.

Like most rules of organizational theory, Parkinson’s Law needs to be taken with the proverbial grain of salt, although Parkinson took it pretty far, mathematically modeling it out based on an analysis of the British Admiralty staff from 1914-1954. He considered how the administrative staff grew inexorably, unrelated to number of commissioned ships, wars, or other obvious factors: more personnel, but no additional work. His formula predicted that management staffing increased annually on an average of 5.75% (with a modeling range of 5.17 to 6.5%) regardless that the amount of work was static, without annual increase, but factoring in ages of appointment and retirement, and man-hours required for communication among personnel.

Parkinson’s self-styled rule, was greatly (but not entirely) satirical, much like Willie Sutton’s rule for success (go where the money is) or Robert Sutton’s organizational No Asshole Rule (don’t retain “jerks” in the organization) for successful teams.

 

Thanks for reading Matula Thoughts, this February 2021.

David A. Bloom, University of Michigan, Ann Arbor

Expectations and epistolaries

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Matula Thoughts
January 1, 2021
Expectations and Epistolaries

2941 words

One.

Calendar reset. After all the hoopla, brouhaha, and general ruckus, today’s customary greeting “Happy New Year” looks ahead with optimism. Human nature, on the other hand, nudges us to also look backward with caution, Janus-like. One year ago, few people expected 2020 would be dominated by a tiny RNA virus. Clues were present but, even without those signals and others soon following, common sense alone should have kept us, vulnerable species that we are, on guard for recurring global pandemics, the last massive one having been only a century ago. [Above: Janus, Wikipedia, source Vatican.]

Some argue that the present pandemic is more accurately described as a syndemic: an unfortunate coincidence of a global infectious disease and a range of noncontagious comorbidities. The term came from medical anthropologist Merrill Singer in the 1990s, referring specifically to the interactions among substance abuse, violence, and AIDS (SAVA). Syndemic now denotes occurrences of multiple categories of disease interacting in specific populations. The Lancet expanded the concept for a new series in the journal beginning in 2017. [The Lancet, 389:881, 2017.] A Lancet article this autumn discussed the syndemic nature of COVID-19 in India and the dangers of false optimism as restrictions were lifted there in June. [The Lancet, 396:867, 2020.] In syndemic terms the COVID-19 situation is an acute respiratory viral condition interacting with an array of noncommunicable diseases (NCDs) that tend to cluster within social groups. The key operative words here are respiratory viral infection and social groups (social translates to behavioral, economic and caste). DOI:https://doi.org/10.1016/S0140-6736(20)32000-6

It is beyond ironic that, when the worldwide COVID deaths reached one million by the end of September last year, the United States accounted for 20% of fatalities although representing only 4.25% of the world’s population and arguably possessing much of the world’s best resources to contain the virus. Lacking in this country were national leadership, public trust, and the good will and sense of its people to take sensible measures to minimize spread of a somewhat fragile and moderately contagious virus, SARS-CoV-2.

 

Two.

Expectations. History shows that uncertainty about what a new year will bring is nothing new. New years bring gains, losses, and some recoveries as I’ve seen while researching the story of Michigan Urology with far more discovered than two books and Matula Thoughts could contain. One letter found in the Bentley Library fits this January essay nicely: a note sent by UM Medical School Dean Victor Vaughan to his friend Dr. Arnold Lorand in Karlsbad, Czecho-Slovackia, written January 12, 1920. The two friends had lost touch during the terrible war that disrupted their lives, as it had millions of others. They were lucky to reconnect. 

“Dear Doctor:-
Mrs. Vaughan and I were much pleased to receive your Christmas card. We have often wondered what had become of you, and we have often expressed the wish that we might look down upon Karlsbad, its splendid mountains, and its beautiful walks, many of which awaken in us pleasant memories. We have gone through the dreadful cycline [‘cyclone’], I and my five sons were in the Army, and my oldest son now rests in French soil. I often wonder whether I will ever desire to visit Europe again. However this may be, we remember you with the greatest pleasure, and we send you best wishes, not only for the coming year, but as we hope, for the many years to come. Yours truly, V.C. Vaughan.”

Lorand (1865-1943) was a physician at the Carlsbad Spa, longevity researcher, and pioneer of modern geriatric medicine. His 1911 book, Old Age Deferred, was popular in America and went through a number of printings. [New England Med Gazette, 47:845, 1912.] He was one of many academic friends gained and visited by the Vaughans during their lives, and epistolaries such as Vaughan’s were the common way people kept in touch, taking more time and crafting than today’s phone calls, emails, or texts. [Below: Lorand and 1913 edition of his book.] 

In 1919, with the end of WWI in sight, the Vaughans looked forward to better times as they returned from military duty in Washington, DC to Ann Arbor, but grief followed that summer when their son “Clarence” drowned accidentally while swimming in a river in France, just as troops were drawing down near the end of the war. Dean Vaughan had gotten the news while at the American Medical Association national meeting in Atlantic City in mid-June 1919, just as he was to chair a session. After a few moments to collect himself he stepped onto the stage and took the chair. It was also during this meeting that Vaughan first met Hugh Cabot who had recently returned from more than two years on the Western Front in France serving with the British Expeditionary Forces. Allied Powers and Germany ended their conflict and signed the Treaty of Versailles on June 28, 1919, but within the next 20 years, Germany would break its postwar agreements, subsume Czechoslovakia, and initiate another world war.

After a difficult 1919, the Vaughans hoped for a happier 1920 and the Christmas Card from the Lorands was a happy signal.

 

Three.

Little things, unnoticed by most people at this first moment of 2021, may become consequential to us in the near future, just as they did last year and every previous new year. The little things may be microorganisms, memes, or people. For example, few in Ann Arbor noticed in January 1933 when Adolph Hitler became chancellor of Germany, although the world soon took note. Many people admired his German patriotism in the dark days after the Treaty of Versailles with his ability to energize domestic industry and get railroads to run on time, but autocratic governance and tyranny never serve a people well and end badly.

In contrast, the 1933 presidential inauguration of Franklin Delano Roosevelt on March 4 was universally noticed throughout Ann Arbor and beyond, marking a turning point in the Depression, although his new administration disturbed many conservative citizens. Where Reed Nesbit stood on this issue can only be imagined as he was not as public with his political beliefs as had been his mentor, Hugh Cabot. Nesbit, however, seemed always to favor the common man.

Roosevelt may not have been a “common man”  but his disability brought him close to the myriad daily struggles of common people. Few Americans knew, at this time, that FDR needed assistance to stand and walk, due to polio, it had been believed, incurred in 1921 although a modern view suggests that Guillain-Barré was the more likely cause. [Below: a scene unimaginable in 2021 – Herbert Hoover and Roosevelt together enroute to 1933 inauguration. Library of Congress.]

In retrospect those 1933 transitions began a new chapter in the recurring contest between democratic rule and authoritarian rule, in this instance precipitated largely by the residue of WWI and the Great Depression. Which system best solves a nation’s problems and improves the lives of its people? Hitler exploited his nation with coercion and physical force, while Roosevelt deployed a lucky mix of democratic process, capitalistic enterprise, “New Deal” big government, and moral authority. The public, the press, and academia took far too little notice of this contest until it spilled over into another world war that would give democratic ideas and humanity another reprieve. Cats have a finite number of lives, but we hope democracies have more. 

 

Four.

Annus mirabilis. In January 1971 Jack Lapides began his second year as Section Head of Urology and it was an extraordinary one. As someone who had grown up in Depression times, served in the Pacific in WWII, and seen university and national politics up close, Jack was no “Polly Anna.” Yet, while cautious of threats ahead politically, economically, and globally he relished the opportunities of his new position and robust ideas. 

Now, a half century later, it is tempting to try to understand his thoughts as 1971 opened up. Just like today, that New Year began on a Friday. This would be the year Lapides broadcast his ideas on clean intermittent catheterization (CIC) that at the time contradicted medical convention, initially bringing him more ridicule than praise. Nonetheless the concept proved worthy, opening the door to a new era of surgical urinary tract reconstruction and improving the lives of hundreds of thousands of people with urinary tract dysfunction globally.  A generation later, leaders like Bernie Churchill in Toronto equated Lapides’s retrograde idea to the most “Nobel Prize worthy concept” in urology.
https://doi.org/10.1016/j.juro.2016.10.080

Lapides (above) published nine papers in 1971 and was appearing on the national center stages of urology regularly just as his predecessors at UM, Hugh Cabot and Reed Nesbit had in their times. At the American Urological Association (AUA) annual meeting in Chicago, May 16, 1971, Lapides moderated a panel called “What Constitutes a Good Urological Residency,” consisting of Peter L. Scardino of Savannah (father of our friend Peter T. Scardino), Clarence Hodges of Portland Oregon (trainee of actual Nobel Prize winner Charles Huggins of UM and then the University of Chicago; later mentor of John Barry), Ralph A. Straffon of Cleveland Clinic (trainee of Reed Nesbit), W.V. Tynes of Norfolk, J.J. Buchierre of Rochester MN, and John Hall of Ann Arbor (chief resident at UM). 

The UM urology brand was in wide display at the 1971 AUA in Chicago. Notably, the chairman of the Society of Pediatric Urology that year was Ian M. Thompson, formerly from Ann Arbor, but currently chair in Columbia, Missouri. The 1971 AUA Meredith Campbell lecturer, Willard E. Goodwin of UCLA (a friend and supporter of Lapides) spoke on “Some hermaphrodites, pseudohermaphrodites, ambisexuals, and other ambiguous types I have known.” An “Ask the professor” session featured Goodwin and John J. Murphy urology chief at the University of Pennsylvania. Murphy was a 1952 graduate of the Nesbit program. Residents on the podium “grilled” the professors about their training and absorption into the field of urology, and “seemed to have the feeling somehow that they had been misguided in a urologic career.” [AUA Centennial History Vol. 1 p. 58.]

That oddly negative view of those residents was not repeated the following years nor did it seem to indicate a trend. Lapides’s trainees in Ann Arbor harbored nothing less than great respect and admiration for their chief and experiences in Ann Arbor, as based on my recent conversations with many of them. In the summer of 1971 Charles Adams, Sahir Cittan, John Gambee, and the late Ed Tank completed their urology training at UM while Robert Barnett, Thomas Kub, Thomas Newman, Lee Underwood, and Robert Vinson began their three years of residency under Lapides. I began my training at UCLA that summer, falling under Goodwin’s spell and far from ever feeling misguided considered myself lucky to be there. Sadly 1971 was the year that Jack’s wife, Alice, passed away.

 

Five.

Ups and downs. A half century ago, 1971, was a great year for an ascending Jack Lapides, but it was a tipping point into despair for another UM alumnus who lost faith in his own future, and indeed the future of our species. This individual dropped out of the conventional world and stepped off the so-called grid to a hermit-like existence in a cabin he built in rural Lincoln, Montana, much in the manner of Henry David Thoreau, or so it seemed at first. The modern-day recluse, however, had far darker thoughts, believing that industrial society could not control its own future and would destroy not only our species, but all others and the planet around us. These ideas took over his brain like a virus and led him to believe that the only recourse was to mail bombs to people targeted as symbolic in industrial society. He anonymously delivered at least 16 bombs that maimed and killed a number of people between 1978 and 1995, becoming known and feared as The Unabomber. In 1995 he sent the New York Times a letter promising to suspend his campaign of terrorism if it printed a rambling essay he included, “Industrial Society and its Future.” Meanwhile, a large FBI team at work since 1978 had failed to identify this “Mad Bomber,” until his brother became suspicious enough to supply the critical tip that led to arrest in 1996 and current imprisonment.

That incoherent essay of Ted Kaczynski (UM Mathematics Ph.D. 1967) has been reformulated to a book, Technological Slavery, available on Amazon where it is described blandly.

“Logical, lucid and direct, Technological Slavery is more than an expansion on the ideas set forth by Theodore Kaczynski in Industrial Society and its Future (aka ‘The Manifesto’). It radically reinvigorates and reforms the intellectual foundations of an age-old and resurgent world view: ‘Progress is a myth. Wild nature and humanity (including human freedom, dignity, and autonomy) are fundamentally incompatible with technological growth.”

Kaczynski is now incarcerated at Federal Prison ADX in Florence, Colorado, serving a life sentence for his murderous campaign, and receives no remuneration for the book. 

Considering our ineptitude as a species and society in dealing with many existential crises  – pandemics, terrorism, extreme weather, earthquakes, environmental deterioration, poverty, food insecurity, economic and social inequality, ongoing regional warfare and destructive geopolitical conflict – it is no huge surprise that a small subset of our 7 billion people become unhinged by reality. To be so certain of belief and driven to terrorize others by mayhem and murder as Kaczynski, however, is clearly far beyond the pale. And others follow, notably Anthony Warner, last week in Nashville. [Below: Pales of settlement; Ireland 1488 and 1901 Poland and Russia. Wikipedia.]


Surely there are myriad constructive ways to build better futures for ourselves and the planet, although we’d better find them more quickly as the opportunities are slipping away.

No one can fully know what 2021 will bring, but we can predict some things will be lost this year: for a start – certainly much glacial ice and rain forest, and likely some essential species. Whatever other critical events we ignore at our peril – time will tell.

 

Postscripts.

Letters to self. We sent What’s New by email for 20 years and continue to publish the web version, Matula Thoughts, on the internet (maulathoughts.org) on the first Friday of each month.

What’s New, the communication, began in Allen Lichter’s Dean’s Office of UM Medical School in 2001. Some in the office then believed that “we can’t communicate too much” whereas others felt burned-out from the daily barrage of “Too Much Information” on physical and electronic desktops. The idea of producing something predictable but not too frequent, while interesting (one hoped) and reasonably concise, seemed preferable to random uncurated attachments and messages. We began What’s New then at predictable monthly intervals (first Fridays) to provide a finite “weekend read,” of around 15 minutes. The essay transitioned to the Urology Department in 2007 with the web version (easier to access and manage if “followed” on the website) in 2013 as matulathoughts.org making this number 95. 

The Dean’s Office of Faculty Affairs, now in the capable hands of Brian Zink, and the Department of Urology, under the excellent stewardship of Ganesh Palapattu, are creating their own modes of communication to fit their new times. Matula Thoughts continues a monthly cadence of essays relating loosely to medicine, Michigan, urology, biology, or other matters in the cabinet of curiosities, from a professor making the final round of bases in the game of academic medicine. This year seems a good time to free up people’s email and liberate many from an unwanted monthly weekend assignment, so we will discontinue the email distribution of What’s New. We will, however, continue the web format Matula Thoughts, that can be accessed by the click of a button on the web site, providing a monthly email and link to matulathoughts.org.

Trees fall in forests. 

Why write these essays? The essayist Michel de Montaigne (1533-1592) was an initial inspiration and exemplary modern expressions of the urge to communicate in writing are flourishing. Even if few people in the forest witness the falling tree of an essay, it serves a primal purpose. [Above: Hartwick Pines State Park, Grayling, Michigan, September 2020.]

Comparing the essay form to the nearly-obsolete hand-written letter, the author Claire Messud commented:

“The review and the essay remain a more public, yet ideally still intimate, version of the epistolary. Not a place to share one’s private details, to be sure, but certainly to try to communicate, as precisely and with as much complexity as possible, one’s experience of a work of art, or the evolution of one’s thought….” [C. Messud, Kant’s Little Prussian Head & Other Reasons Why I Write. W.W. Norton, NY, 2020, p. xx.]

A letter assumes an audience, usually of one, although not necessarily of anyone. The act of writing provides a measure of satisfaction and deliverance (of an observation) even if it is simply a “note to self.” Messud’s book is both “an autobiography in essays,” as it’s self-described, followed by a collection of 16 literary and visual art contemplations, but most importantly, one suspects, it is an extraordinary series of personal notes-to-self that bring clarity to the writer. 

Metrics
Nothing is beyond the pale on the internet and much of it is measurable. Matula Thoughts took a small dip when the author ceased to be departmental chair of urology at UM in 2019 but readership is back with a rise this year with views at 3458, 3357, and 3929 (31 Dec.) for 2018, 2019, and 2020. This past year 16 countries produced 10 or more “views’ and another 55 countries had “single digit visitors” – enough observers in the cyber forest to justify continuing Matula Thoughts for 2021. Of course, “a view” or “a visitor” is not necessarily a thoughtful reader, but merely a measure of notice within the forest and, happily in terms of forest sustainability, Matula Thoughts doesn’t require many falling trees. Nonetheless, after nearly 20 years of this essay, it remains primarily a “letter-to-self,” if only an affirmation of self that sometimes resonates with someone else. [Below: Word Press readership for Matula Thoughts 2020.]

Thanks for reading Matula Thoughts this January 2021.
David A. Bloom

 

December

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Matula Thoughts

December 4, 2020

Change and hope

2810 words

One.

Hope. Change and uncertainty are inevitable, but hope is the part of the human tool kit that helps people navigate life’s turbulence. Change may bring hope or horror, as imagined in the fictitious scenario (shown above) of audience response to the novelty of moving pictures in 1895 when the magic of film was an expectation beyond reasonable hope. [Above: “Panic in the Audience when Lumiere Shows his first Film.” Figure from Suddenly this Overview. Peter Fischli and Davis Weiss, Exhibit, Guggenheim Museum, April 2016.]

It is rational to hope that things will return to a semblance of normal after this “final wave” of Covid-19 disrupts workplaces and education, prolongs social isolation, and disturbs belief in science and reason. Humans rebound after bad times and new forms of creativity emerge from calamities, as seen with RNA vaccines. Still, we would do better to remember those bad times and plan for their inevitable return. [Below: Michigan Theater – mostly closed in Covid times and its big screen moving pictures sorely missed.]

Last year just around this time, our department hosted its annual Holiday Party, an event inaugurated by Jim Montie after the Urology Department emerged from a Department of Surgery division 20 years ago. As the department expanded, the get-togethers outgrew Ann Arbor venues and moved to Fox Hills Golf & Banquet Center with the help and generosity of Kathy and Mike Aznavorian. Further growth and blurred administrative boundaries over the years stretched even Fox Hills’s capacity for the UM Urology family, their children, and guests to mingle, see Santa, dine, and dance. A few of our staff put their hearts and souls into planning and deploying the event, with food, avionics for Santa, and gifts for children. When the financial uncertainty of 2008 struck, we hesitated but continued the party.  Little did we anticipate an emergent virus from the other side of the planet would break our annual run of holiday parties. Covid not only brings the monetary concern, but also precludes the social interaction and reminds us how much we miss gathering. 

[Above: Santa, Holiday Party 2013. Below: Keller and Osawa families, Holiday Party 2015.]

UM Urology has gotten so large and far-flung that hardly any of us knows everyone else – a far cry from my first days here in Ed McGuire’s Section of Urology.  With clinical and research activities of our department in at least 15 geographic locations, the challenges of communication and cultural identity are great. Families, organizations, and nations tend to grow far from their roots, straining integrity of the whole. Periodic gatherings can be forms of thanksgivings to recall roots and purpose, restore connectivity, and celebrate diversity. We hope and expect to gather again. 

 

Two.

Origins. With December here, a new year just around the corner, and the second century of urology at UM ahead, thoughts turn to the origin stories that ground our views of the world. Personal origin stories as well as organizational ones are idiosyncratic and complex – and all are rich in certainty, invention, and selective memories. The UM urology narrative, is assembling on our website. [Above: Cropsey painting of early UMMS.]

https://medicine.umich.edu/dept/urology/about-us/our-history/origin-story

Origins are never perfectly clear. The past can never be fully ascertained or known as completely as it actually happened. It can, however, be illuminated and investigated not merely out of curiosity but also to understand options for today, reinforce essential values, and prepare for the future. Our origin stories are lean in the details of the original peoples of the Americas who were displaced by explorers and colonists. Examination of origins forces us to see what’s missing, what’s right, and what’s wrong, thus giving opportunity to improve what’s lacking and what’s incorrect with ourselves and our organizations.  

Historians elicit facts, create narratives of the past, and measure it all according to values then and now so as to understand the meanings of those stories. This expansive evaluation is, at first glance, contrary to that of scientists who generally take reductionist approaches that render observations to the simplest explanations. Through methodological analysis   scientists may hope to find grander truths in general rules, laws, and theories. Health care providers, ideally, combine the story of a patient (the larger narrative of their past and present) with the facts of observation and clinical investigation.

 

Three.

Urology is a small detail in history’s medical narrative and its roots at the University of Michigan are uncertain. [Above: medieval uroscopy – man with a matula.] We have no practice logs from UM’s first genitourinary surgeons, Cyrenus Darling and Ira Loree, nor reminiscences to know what they thought of the 1902 “urology” neologism, although they chose not to adopt it. Their recollections of WWI and the Influenza Pandemic can be assumed unpleasant, but how those large events affected their daily lives, families and friends, and political responses can only be vaguely imagined. Who in their time would have thought that the “war-to-end-all-wars” would be followed so quickly by another one and who knew that the 1917 pandemic would end after a third wave in 1920? Who could have doubted that other pandemics wouldn’t follow? Most astonishingly who would dispute, today a century later, that face masks, social distancing, and rudimentary hygiene limit the spread of respiratory infections? 

The thoughts of Darling and Loree concerning their replacement in 1919 by  “Modern Urologist” Hugh Cabot were not positive and those impressions were exacerbated by his brusque manner, causing their swift departure to the welcoming St. Joseph Mercy Hospital a block away. From this disruptive transition, the UM Section of Urology was born.

No less disruptively ten years later Hugh Cabot, Medical School dean by then, was fired by the regents after losing confidence of the faculty. Reed Nesbit, Cabot’s second trainee, built the Section of Urology from 1930 through 1967, when he retired to Sacramento. Then, after an uncertain six months, Nesbit’s trainee Jack Lapides, was named successor and continued the clinical, educational, and research missions of the Section of Urology from 1968 to 1983. Like Nesbit, Lapides trained a great cohort of urologists of all types, including a great string of pediatric urologists: Norm Hodgson (Nesbit 1958), Tomohiko Koyanagi (N’70 – see Postscript), Ed Tank (N’71), Steve Koff (N’75), Evan Kass (N’76), and Barry Kogan (N’81). Still under the administrative management of the Surgery Department, UM Urology gained Ed McGuire (trained at Yale by Bernie Lytton) as Section Head.  This transition, too, caused disruption, with the loss of Ananias Diokno to the Beaumont system. 

The five-person Section of Urology under Ed McGuire (above) welcomed me and my family to Ann Arbor in the summer of 1984. The small section of five is now the large Department of Urology of 50 full-time faculty led by Ganesh Palapattu. Our academic space, initially on the fifth floor bridge between the old Mott and old Main University Hospital, moved to the second floor Taubman Building when it opened in 1986, and then the third floor of Taubman in Jim Montie’s early years as Urology Chief. That space underwent a well-needed facelift this autumn. Although this is the administrative hub of the department, our faculty have offices in the Cancer Center, North Ingalls Building (the old St. Joes Hospital), North Campus Research Complex (our Dow Division of Health Services Research in the old Pfizer Research campus), Muskegon’s West Shore Urology, and clinical and surgical activities at more than a dozen other sites.

 

[Above: Taubman Administrative Urology. Sept. 15, 2020. Below: September 30, 2020.]

The challenges of this Covid year are not over, as we yearn for a return to social proximity and in-person conferences. The postponement of the yearly Nesbit Alumni Meeting, along with other regular medical and scientific sessions was disappointing, but not unprecedented. The AUA, for example, also cancelled this year as well as in 1918, 1919, 1943, and 1945.

Academic routines are changing into new normals, such as our zoom visiting professor lecture in mid-November from Jim Hu at Cornell, shown below in one of his slides. Still, we miss our conference rooms.

 

Four.  

Narratives. The writing process for the UM urology story has strengthened my admiration of others far better at that art. My career, not primarily one of writing, was directed to what Hippocrates narrowly considered “the art of lithotomy,” but grew into its surgical cousins of orchidopexy, hypospadias repair, pyeloplasty, bladder reconstruction, and other needs of modern urology.  Turning facts into authentic narratives is a different occupation and certain writers stand out: John McPhee and E.O. Wilson for nonfiction, or Kazuo Ishiguro and David Mitchell for fictional story-telling. McPhee at age 89 continues to weave artful narratives of fact and people, while Wilson at 91 explains science with clarity and grace. Mitchell at 51 creates tapestries of fact and imagination, crossing fictional genres. Nobelist Ishiguro, at 65, writes novels that explore the uncertainty of memory and its deceptions. The authenticity of great fiction is a mirror to reality; as the Good Lord Bird miniseries proclaims: “All of this is true, most of it happened.” 

Our parochial story, The First Century of Urology at UM, is an accounting of real people and events that built a small specialty in a great public university amidst the contexts of its times, providing and creating state-of-the-art clinical care (such as it was), generating new ideas, educating successors, and leading colleagues.

We were fairly certain of the sequence of Nesbit’s early trainees and associates in our Origin Story of Urology at UM, but new information kept popping up. For example, Susan Dorr Goold, daughter of our recently deceased colleague Dick Dorr (Nesbit 1968), gave me pictures from her dad’s office but the identity of one drew a blank. Skip Campbell and Mac Whitehouse identified the photo as Rigdon “Rod” Ratliff, (Transylvania College A.B. 1924, UMMS 1929) who practiced urology at St. Joe’s. In medical school Ratliff became interested in surgery and urology under Cabot and Coller, and was likely influenced by Huggins and Nesbit – trainees and later junior staff under Cabot. With his MD in hand, Ratliff went across the street for internship at St. Joe’s and fell under the influence of Ira D. Loree, the UM genitourinary surgeon displaced nearly a decade earlier by Cabot. The cataclysmic stock market crash a few months into internship undoubtedly shaped Ratliff’s career plans and he remained at St. Joe’s in practice with Loree, the early years serving as a de facto residency in urology.  

By 1935 Ratliff was considered a legitimate urologist and Nesbit appointed him “Instructor in Urology” without salary. Loree died on August 11, 1936 and Ratliff took over his practice, revising his UM title in 1938 to “Part-time Instructor,” allowing more time for St. Joe’s practice. Ratliff maintained this title until 1946. Curiously, Ratliff didn’t join the AUA until 1946, his application endorsed by Nesbit and Robert Breakey, a Lansing urologist.  Ratliff continued to teach students and interns, and one of them, Tom Newman (Nesbit alumnus 1974 – now retired in Tucson), recalls Ratliff teaching him the “Water sink window test.”

Ratliff (above) collected urine samples in clear specimen bottles (modern matulas) before cystoscopy, holding them up to the window by the sink in the cystoscopy suite and if clear to daylight he poured the urine into the sink and completed the cystoscopy. Only if turbid, would he send the specimen for urinalysis, culture, and sensitivity.  At University Hospital, however, Newman discovered a very different approach; Lapides insisted on routinely spinning the urine and staining it with methylene blue before examination under the microscope and then dipstick urinalysis, with culture and sensitivity, if necessary. One approach was practical and cost effective, the other was richly academic. Newman fondly recalls Rigdon as a quiet gentleman. Clearly, Dick Dorr shared that admiration. Ratliff retired in December, 1973, according to the AUA files (found for us by Tupper Stevens) transitioning his AUA status from active member at $75 per year to senior member at $15. At home on 231 Corrie Road in Barton Hills, Ratliff died of a heart attack January 29, 1977. He was the last link between Hugh Cabot’s era and ours. 

 

Five.

The uncertainty of history. This turbulent political season, a friend referred me to the recent book, American Dialogue, by American historian, Joseph Ellis, who explained a central irony in his field.

“There is an inconvenient truth that most historians acknowledge under their breath, admitting that objectivity, in the sense that mathematicians or physicists, use the term, is not a realistic goal for historians. The best they can strive for is some measure of detachment, which serves the useful purpose of stigmatizing the most flagrant forms of ideological prejudice (i.e. cherry-picking the evidence to claim that Thomas Jefferson was an ideological Christian or Andrew Jackson was a New Deal Democrat). But as you believe that the study of history is an ongoing conversation between past and present, detachment itself is delusional. In his Style in History (1974) Peter Gay put the point succinctly: ‘History is always unfinished in the sense that the future always uses the past in new ways.’ In fact, the past is not history, but a much vaster region of the dead, gone, unknowable or forgotten. History is what we choose to remember, and we have no alternative but to do our choosing now.”  [Ellis, American Dialogue, 1918. p. 7.] 

Certitude, whether moral, intellectual, or political, is a tricky matter as reflected in this column last month when we tried to make a case for an enlightened Certainty 2.0 that allows one to retain some degree of uncertainty to allow for “I’m not so sure” and keep asking questions. Perhaps H.L. Mencken overstated the matter when he claimed that moral certainty should occupy a low rung in the ladder of human intellect, but he had a fair point.  

The moral certitude of John Brown, in song, epic poem, or current Showtime series, The Good Lord Bird, epitomizes the smugness of Certainty 1.0.  Timothy McVeigh’s ideological certainty terrorized Oklahoma City in 1995, striking against the Federal government by bombing a federal building, killing 168 people and injuring more than 680 others. Similarly, Ted Kaczynski (UM Mathematics Ph.D. 1967), certain that industrial-technological society was subjugating mankind and destroying the planet, responded by sending bombs to university faculty and airlines in 1978, to “get back at the system.” He wreaked havoc on the lives of random people who represented modern society or happened to be in the way of the bomb.  This campaign precipitated a long FBI investigation that ended with arrest in 1996 (see Wikipedia). Religious certitude (perhaps a form of ideological certainty) fueled the destruction of the World Trade Center on September 11, 2001. 

Self-serving certitude, another broad form of certainty, is that of psychopaths who justify their actions by personal convenience, often framed by occupation or paycheck, as mentioned here last month, with attribution to H.L. Mencken, Lewis Sinclair, C.E. M. Joad, and others: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Closely related is political certitude, as in recent seasons has tested the flexibility of the American Experiment.

Immaculate Misconceptions, the title of a section of the Law chapter in Ellis’s book  includes two extraordinary quotes relevant to certitude and to stimulate your uncertainty as a reader we defer their sources to the postscript.

Source A. “When a case comes to me, I don’t do whatever I feel like doing, I have a standard. That standard is what would the people at the time the Constitution was enacted have said.”   

Source B. “Some men look at constitutions with sanctimonious reverence, and deem them, like the ark of the covenant, too sacred to be touched. … We might as well require a man to wear still the coat which fitted him when a boy, as civilized society to remain under the regimen of their barbarous ancestors.”  

These ideas relate to the question of the role of originalism or textualism in law. Adjudication of today’s uncertainties according to the exact words of a set of historic bylaws might be considered a cop-out, relieving decision-makers of consideration of contemporary complexities and values. One expects that was not Scalia’s intent in his heart of hearts, but rather his starting point to consideration of legal questions. We surely hope our judges and wise leaders struggle intellectually with uncertainty to arrive at a Certainty 2.0 in their consequential decisions.  

 

Postscript.

Sources. A. Antonin Scalia, speech at the University of Fribourg, March 8, 2008.  B. Thomas Jefferson to Simon Kercheval, July 12, 1816.  [J. Ellis, American Dialogue, The Founders and Us. Vintage Press, NY, 2018. p. 151.]

The Good Lord Bird, is a 2014 book by James McBride on John Brown and its Showtime dramatic series offers an ironic introductory quote, “All of this is true, most of it happened.” This complements Don Coffey’s enduring admonition to his research students to try to understand the difference between facts and true facts, reminding how certainty is tenuous but some things are deeply true to us.

Congratulations. The Japanese Government recently awarded Tomohiko Koyanagi The Order of the Sacred Treasure, Gold Rays with Neck Ribbon in recognition of outstanding contributions to medical education and research. https://en.wikipedia.org/wiki/Order_of_the_Sacred_Treasure

[Above: Tom Koyanagi. Below: Order of Sacred Treasure.]

Thanks for reading Matula Thoughts this December, 2020.

David A. Bloom, University of Michigan Department of Urology

 

Autumn leaves and certitude

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Matula Thoughts 6 November 2020
4129 words



One.

Autumn leaves and Nobel Prizes normally highlight this season, although Covid, climate, and a consequential national election dominated our attention this year. The award in Medicine or Physiology last month, however, went for discoveries relating to the hepatitis C virus.

That curious terminology of medicine or physiology is a historic reminder how science was disrupting health care when the Nobel awards began in 1901. A new certainty of physiology and other scientific disciplines, explaining the basis of normal biological function and disease back then, is now widely accepted in the 21st century, although we realize that the optimal practice of medicine in addition to its scientific basis also requires art and humanism. [Above: autumn leaves, Ann Arbor westside, 2020. Below: Nobel Prize medal.]

Politics are also in the air this month, even more unpleasantly than usual, and the Nobel awards are no less political than other human enterprises. Conflicts over these prizes have involved nearly all fields including that of Medicine or Physiology. The 1923 prize to Frederick Banting and John Macleod for the discovery of insulin outrageously excluded Charles Best and James Collip. Honorably, the two named prizewinners independently split their monetary shares with Best and Collip. No award was presented in 1925; the two main contenders, Johannes Fibiger and Katsusaburo Yamagiwa, had been proposed separately as the first to induce cancer in laboratory animals, but both were branded “undeserving” with great certainty by a key member of the award committee. Fibiger had used a roundworm he called Spiroptera carcinoma (Gongylonema neoplasticum) to cause stomach cancer in rats and Yamagiwa used coal tar to create cancer on rabbit ears. After further deliberation the following year, the prize went to Fibiger, although in durable fact Yamagiwa’s work was by far the better proof of principle of chemical carcinogenesis. Nonetheless, Fibiger was the first to get this Nobel Prize for work related to cancer. The second time this happened was in 1966 when Reed Nesbit’s first urology trainee, Charles Huggins, shared the award with Peyton Rous.

The Nobel Foundation offended Adolf Hitler when it awarded the Peace Prize in 1935 to Carl von Ossietzky, the journalist who exposed the clandestine German rearmament, illegal according to the Treaty of Versailles. von Ossietzky, a Roman Catholic, had been detained and beaten in German prisons and concentration camps since February, 1933, and was hospitalized with tuberculosis when the award was announced. Hermann Göring ordered von Ossietzky to refuse the award and the Nazi regime prevented travel to Stockholm but, in an act of civil disobedience, von Ossietzky issued a note accepting the Peace Prize. The ugly politics caused two committee members to resign and Norwegian King Haakon VII dodged the ceremony, even though the recipient could not attend. von Ossietzky died in 1938 while hospitalized under Gestapo surveillance.

In February 1953 Watson and Crick assembled an accurate model of the structure of deoxyribonucleic acid (DNA). Rosalind Franklin’s x-ray diffraction images, shown to Watson by Wilkins, provided the “eureka moment” in which the double helix configuration was realized. Watson and Crick were recognized for this with a Nobel Prize in 1962, that they shared with Wilkins. Franklin, however, having died of ovarian cancer in 1958, never learned of her role in the breakthrough and, by virtue of the rules of the Nobel Prize, was ineligible because she was no longer living.


Two.

[Above: Newton, by William Blake, 1805. Tate Museum.]

Certainty 1.0. Craving certainty, we derived it for most of human history from personal observations, beliefs, and the authorities of the times. A Matula Thoughts correspondent from Georgia raised the matter of moral certainty last month, quoting H.L. Mencken on the issue:

“Moral certainty is always a matter of cultural inferiority. The more uncivilized the man, the surer he is that he knows precisely what is right and what is wrong. All human progress, even in morals, has been the work of men who have doubted the current moral values, not of men who have whooped them up and tried to enforce them. The truly civilized man is always skeptical and tolerant, in this field as in all others. His culture is based on ‘I am not too sure.’” [Minority Report: H.L. Mencken’s Notebooks (1956).]

Morality and certainty, historically, were inseparable for most of humanity, hardwired in cultures and written into laws of churches, states, and organizations. Morality, as a topic, is far beyond scholarly consideration of this set of essays, but certainty is a matter of keen concern in health care. Philosophers, religious leaders, royalty, politicians, have offered their versions of certainty over millennia, but certitude challenges easy universal agreement, as one’s certainty on an issue is based on one’s origin, belief system, willingness to reason, and livelihood. Mencken, Lewis Sinclair, C.E.M. Joad, and others have variably said: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

From a practical perspective as a physician, certainty means belief without rational grounds for distrust. Medical practice demands that conclusions must be drawn with certainty, for example, from urine specimens whether in matulas, under microscopes, via chemical strips, or on culture plates. Urologists, as all practitioners, depend upon certainty in diagnosis and therapy, yet we cannot be absolutely certain about everything that passes under our visage. Relative certainty is a practical and essential qualification. [Below: Constantine examines urine in matulas. 11th c. Wikipedia.]

Mencken (1880-1956), influential journalist and social critic known as the Sage of Baltimore, could turn a phrase well, but he represented a peculiar elitism and exceptionalism of the first half of the American 20th century. Self-assured in his certainty, he often was acerbic and dismissive to those he perceived as lesser intellect or “lower caste,” although he didn’t use that terminology. Mencken was contemptuous of Franklin Roosevelt, argued against the New Deal, objected to U.S. participation in WWII, and harbored admiration for the Nazi regime. Ayn Rand was one of his great admirers, but other influential voices were critical. Christopher Hitchens later offered a scathing opinion of Mencken in a book review.

“How did one of America’s seemingly great rationalists and modernists come to regard Roosevelt as more worthy of condemnation than Hitler? The answer, on the evidence of this and other studies, is that Mencken was a German nationalist, an insecure small-town petit-bourgeois, a childless hypochondriac with what seems on the evidence of these pages to have been a room temperature libido, an anti humanist as much as an atheist, a man prone to hyperbole and sensationalism he distrusted in others and not as easy with the modern world and its many temptations and diversions as he liked it to be supposed.”

Hitchens also turned his phrases well, but when he hit, he struck hard and unsparingly. [Hitchens, “A Smart Set of One,” The New York Times (17 November 2002), book review of The Skeptic: A Life of H. L. Mencken (2002) by Terry Teachout.]

Certainty, although personally comforting, closes the mind to new ideas and leads to smugness. It is irrational to expect 7 billion people to share the same certainties about all matters, short of a limited number of generally-accepted facts, such as that days follow nights, the moon has phases, eclipses occur occasionally, kindness and civility are nice, and some things such as infanticide and cannibalism are grotesque. The first rule of certainty, however, is that change is inevitable and accordingly, uncertainty rules above all.


Three.

Uncertainty. Werner Heisenberg made uncertainty respectable when his concept of indeterminacy (on a very small scale) in 1927 garnered him the 1932 Nobel Prize. Erwin Schrödinger carried the idea to the visible world in 1935 with his famous thought-experiment and paradoxical cat. [Above: Heisenberg c. 1901; Below: Schrödinger c. 1933. Wikipedia.]




[Above: Movable silhouette of Schrödinger’s fictional cat in the garden at Huttenstrasse 9, in Zurich where he once lived; visitors outside the walls cannot know the cat’s position or its direction, at any moment. Wikipedia.]

Uncertainty entered the moral dimension and popular culture, it could be argued, with Bryan Cranston’s fictional character Walter White in the Vince Gilligan television series of 2008. White, a modern-day high school chemistry teacher, is followed over five television seasons “breaking bad” into a dark world of the manufacture and distribution of 96% “pure” methamphetamine. White’s nickname Heisenberg initially conveyed his good state as a brilliant chemistry teacher, but the full irony came out when Walter turned to his dark side as a meth kingpin. [Below: Breaking Bad publicity still, Walter White.]

Mencken’s caution of self-certainty and promotion of “I’m not too sure” belied a number of other outrageous statements, defaulting to intemperate self-certainty, and forgetting his own restraint of “I’m not too sure.” Some Menckenisms reflected primal certainty that trumped morality and civility, such as “Every normal man must be tempted, at times, to spit upon his hands, hoist the black flag, and begin slitting throats.” [Mencken, The New Poetry Movement, Chapter 6.] [Below: Jolly Roger Flag.]

Momentary reversion to the primitive pirate in everyman – casting off the morality and mores of humanity, whether in thought-experiment or actuality – can’t be blamed on Mencken. He articulated the idea well, but it hardly originated or ended with him, and homicide remains widely evident in fact and fiction; even if we do not choose to be murderous outlaws, we relish them in our entertainment.

It comes as a surprise, now, 20 years into the 21st century, to find widespread craving for authoritarian rule. Possibly, this is propelled by a growing sense of nihilism where too many people prefer the certainty of “I don’t really care except for what’s good for me” over the uncertainty of “I’m not too sure.”


Four.

Independent thought. Modern society seemed to be gravitating toward the intellectual relativism of “I’m not too sure,” although maybe that was my wishful thinking.

It is reasonable to believe that throughout human history most people prayed for relief from authoritarian subjugation by clan leaders, priests, pharaohs, princes, kings, queens, and dictators. Those few leaders dictated their personal certainties to everyone else, claiming authority derived from physical strength, bullying, divine authorization, bloodline, caste, national exceptionalism, political sectarianism, or other “isms.” Physical intimidation in authoritarian societies suppresses expression of uncertainty and even more effectively, the memes of sectarian “isms” act as ideological viruses replicating the certainty of patterned thoughts in individual minds and crowds, precluding reasoning and doubt.

People, perhaps most, chafe under authoritarian rule, although they may do so silently. The contrary meme of the pirate, openly rebuking authority of the establishment, always finds sympathy in regulated societies, even those not authoritarian and repressive. An interesting example is the island of Corsica, variably contested by many authoritarian nations over the centuries and now French, proudly displays its counter-cultural pirate symbol on flag and coat of arms. [Below: Corsican symbols of independence.]


Mental acrobatics that lead to certainty are sometimes called heuristics and, aside from crude mapping by functional MRI, the neural gymnastics at play defy our best imagination and science. It is more convenient to be told what things are certain than to be figuring them out in every step of life’s way. Our historic predecessors – early humans lacking today’s sharpened tools of logic, science, and debate – must have found comfort to be given explanations for solar eclipses, earthquakes, or monsoons by tribal leaders or village priests, rather than tremble at the uncertainty of it all.

The problem with human thinking nowadays seems to be the matter of how people deal with their sense of “I’m not too sure.” Methodological thinking, analysis of information, and fair discussion can help people understand what to be sure of, what to question, and how to decide. However, these instruments of education, science and free speech are only effective when we step outside the comfort of our particular certainties and open our minds to other opinions, information, rational debate, and experiments of thought and science. Too often, we revert to the easier dogma of our sects and certainty our leaders.

The Good Doctor, a new book by our Georgian colleague, examines the importance of uncertainty in medical practice; no good physician can be a know-it-all. On the other hand, nobody wants an ambivalent doctor who offers a list of ten possible diagnoses and ten potential remedies and tells us to choose what we prefer. [K. Brigham, M.M.E. Johns, The Good Doctor, Why Medical Uncertainty Matters. Seven Stories Press, NY, 2020.]

A relevant thought comes from professor Sarah Buss here in the UM Philosophy Department who explains to her students that they can’t gain a deeper understanding of issues they consider in class without becoming less certain where they stand on those issues: “I aim to help them gain clarity, knowing that the result will often be a loss of certainty.” Professor Buss, in turn, quotes colleague Kieran Setiya:

“The patience to ask and to keep asking questions, without the assurance of agreement or the availability of methods apt to elicit it, is the philosopher’s gift. It is an expression of intellectual hope, and the repudiation of philosophy is a counsel of despair.”

[K. Setiya. Monk Justice. London Review of Books. 42 (16), 30 Aug. 2018.]

For everyday events on the human scale, in space and time, things are usually one way or another. We are used to uncertainty in life, but we prefer predictability, whether in elections, horseracing, or surgical outcomes. In fact, we depend on some degree of certainty, even if it is the probability of knowing the odds of a specific throw of dice or hand of cards, assuming fairness of the event. Statistics for a condition or certain state within a group, however, doesn’t translate well to a particular person for whom having the condition or state is a personal possibility of “yes” or “no,” that is a 50% probably in their mental calculus.

Adjectives and numbers help arbitrate uncertainty. Even simple adjectives, as in the world of genetic diseases, may offer precision. For example, “rare” conditions are said to affect less than 62/100,000 people while “ultrarare” has come to mean fewer than 2/100,000. [J.M. Friedman et al, “Exome sequencing and clinical diagnosis,” JAMA, 324:627, 2020.] By this terminology hypospadias is not so rare (2 in 500 male births), while cloacal exstrophy is ultrarare (1 in 250,000 births). A recent zoom visiting professorship to our pediatric urology division from Katherine Hubert Chan of Riley Children’s Hospital, offered a lesson on graphics in surgical decision-making, utilizing icon arrays to demonstrate frequency of a given condition. Pictographs nicely convey a sense of likelihood or unlikelihood without the abstruse jargon of high-voltage statistical tools. [Below: an icon array.]

Five.

Certainty 2.0. At some point we humans admitted a new form of certainty into our minds, basing belief on rational argument, verifiable evidence, and experiment, rather than anecdote and authority. Paradoxically, this new certainty is based on acceptance of some uncertainty that facts and models change as we interrogate them. Nonetheless this should not allow a lazy retreat to anarchy and nihilism where nothing is held true.

Certainty is desirable in surgical practice; when treating stones, congenital malformations, or malignancies, specific identification of a problem is closely linked to beneficial solution. Yet knowledge and technologies change and yesterday’s certainty becomes today’s uncertainty, thereby reintroducing the questions, how do we know what is correct and how should we act today?

Hugh Cabot, founder of urology at Michigan and man of great certainty, took wide interest in medicine, often crossing epistemological boundaries to study and collaborate outside of his field. Working with pathologists on a paper on gastric cancer in the era of the Nobel controversy, Cabot and fellow faculty member George Adie had published their thoughts on its etiology in 1925, quoting views of their colleague, Aldred Warthin. [H. Cabot and G. C. Adie, “Etiology of Cancer of the Stomach,” Annals of Surgery 82 (1925): 86–108.] William Mayo, another physician with an Ann Arbor connection (UMMS, 1883), was also interested in the topic, writing a lead article in Surgery, Gynecology and Obstetrics in 1912 that discussed treatment from his point of view: “Cancer of the stomach: its surgical cure.” [SG&O, 14 (2): 115-119.] Mayo criticized lengthy diagnostic interludes that allow the disease to progress from “week to week” until by the time a practitioner has absolute certainty of the diagnosis before referring to patient to Rochester, “This is not a case for the surgeon, but for the undertaker.” Mayo concluded: “Cancer of the stomach is the most frequent and most hopeless form of cancer in the human body. Early operation affords the victim the only chance of a cure.” Time and discovery have altered the certainty of those conclusions. Ironically, gastric cancer took Mayo’s life at age 78.

The rapidly changing conditions, information, and misinformation surrounding Covid-19 have challenged medical certainty and public certainty. Political iniquity and social media mischief accelerate the uncertainty and miscertainty. Rather than dwell on this here, we offer two essential articles from NEJM, both accessible at no charge on the internet.
One editorial says it all. “Dying in a leadership vacuum,” [NEJM, 2020; 383:1479-1480.] A perspective by J.N. Rosenquist, “The stress of Bayesian medicine – uncomfortable uncertainty in the face of Covid-19.” [https://www.nejm.org/doi/pdf/10.1056/NEJMp2018857?articleTools=true]

Postscript.

Frank Legacki, legendary Michigan Swim Team Captain of the Class of 1961, successful businessman, and friend of the University of Michigan Musical Society and Department of Urology, passed away last month on 10/16/2020, leaving his wife, Alicia Torres. [Above: Frank at Steve’s Deli, September 23, 2020.]

Born 9/28/1939, Frank grew up in a tough Philadelphia neighborhood, the oldest of eight children – six boys and two girls. His parents, of modest means, believed in education and raised the children firmly and proud of their background and opportunities. Dad, a Polish immigrant, was a carpenter. Mom, daughter of Irish immigrants, deftly managed the large family. Frank attended Father Judge High School, where by luck and hard work, joined the rudimentary swimming team his freshman year. Lacking a pool at the school, Frank and teammates trained at pools as much as 1.5 hours away. Swimming was the glue that kept him focused in high school and he became a National Catholic High School Champion and a Scholastic All-American, earning athletic scholarships at several universities. Narrowing his choices to the University of Michigan and Ohio State University, both with top Collegiate Swimming programs, Frank asked his high school coach which school to attend. The coach answered, “Probably Ohio State, Michigan is far more difficult academically and you may have problems getting through at Michigan.” Frank decided on the spot to go to Michigan. 

Education and swimming at UM shaped his life. Eligible for the team in his sophomore year, 1959, Frank became NCAA Champion in the 100-yard freestyle and anchored the winning 400-yard freestyle relay. Two weeks later at the US Open Championship (later called the National AAU Championships) he set the American record in the butterfly. Michigan’s score of 95.5 at that competition was a new record and solidified the UM 1959 Swim Team as the greatest in NCAA history. Frank and his team continued to win and set records, and he was elected captain in his senior year, receiving other honors and leadership positions outside of athletics. Frank married after graduation in 1961 and stayed in Ann Arbor for an additional year to get an M.B.A. The couple would have four daughters, divorcing after 23 years.

A business career took Frank to New York City at Ogilvy & Mather Advertising. He went on to executive positions as: Managing Director of the Strategic Consulting Group of Marketing Corporation of America; VP of Marketing for Converse Athletic Footwear; Founder and President of the Andover Consulting Group; and President of Kaepa Athletic Footwear. Frank led a buy-out of this last company and eventually sold Kaepa to Umbro Sports Apparel. During these years he returned to UM for an M.B.A., graduating in the top quarter of the class.

In the business world Frank met Alicia Torres in San Antonio in the autumn of 1993 and they became business friends and then partners. Organizing a leveraged buyout of software products, and they formed Rosebud Solutions, generating outside investments, building a skilled team, and growing the business. Their partnership became personal and they grew close, marrying in Philadelphia on August 8, 1998, and then relocating in Ann Arbor. Rosebud was acquired by McKesson, Inc. (NYSE: MCK) in 2008. Frank went on to work part-time with Fletcher Spaght, Inc., a Boston venture capital firm, eventually retiring fully.

Frank, always loyal and grateful to UM, often said: “I was born at the University of Michigan; it was here I learned how to think.” In Ann Arbor, Frank and Alicia immersed themselves deeply in university matters and the community, enlarging their network of friends and interests. Frank was recognized for his achievements by induction into the University of Michigan Hall of Honor and The Pennsylvania Sports Hall of Fame. He stayed active with the University as President of the Grey Whales (Swim Boosters); Board of M Club Letter winners; UM Alumni Association Board; UM Urology Department Board; and Chair of the Marketing Committee of the University Musical Society. Frank was also President of the Barton Hills Maintenance Corporation. Frank and Alicia regularly attended over 20 UMS performances annually as well as School of Music Theater and Dance events. They generously supported Michigan Theater and were regular presences at UM athletic events, with season tickets for Football, Basketball, Hockey, Wrestling, Softball, and Swimming meets. Active fishermen, they cast lines in Florida and exotic locations around the world. Frank loved his time with grandchildren, Sam, Sophia, and Noah, taking them fishing, to UM events, and cooking together. The kids loved “GP Frank.”

Frank shared his rich and full years generously with friends, family, neighbors, and the University of Michigan. Alicia recounts:

“Frank had an amazing life. He gave much more than was given to him, and celebrated life like very few. He loved keeping in touch with elementary, high school, and college friends and those he met during his career and travels. Frank asked strangers about their life, where they were from and then, they too became Frank’s friends. Through his travels, Frank always carried an extra U of M cap, which he would give to people who captured his heart. When Frank entered a room, he owned it, you knew he was there, in a good way.”

Paul Legacki from Sacramento, Frank’s last living brother, was a frequent visitor to Ann Arbor in Frank’s final year. Frank anticipated his final days gracefully and with good humor, requesting his epitaph be borrowed from the last lines in Edmond Rostand’s great play, Cyrano de Bergerac. In the final scene Cyrano lies in Roxanne’s arms, mortally wounded and weakening, as he looks at Roxanne and says his final words; “They have taken my life, but they have not taken my panache.” Frank lived an active and interesting life, with extraordinary panache.

In one of the sweet coincidences of life, the lovely home of Frank and Alicia is situated exactly between those of Ananias Diokno (Nesbit 1970) and Kate Kraft (Nesbit faculty 2011), and across the street from the former home of Ed McGuire who succeeded Nesbit’s direct successor as Urology Section Chief in 1983, Jack Lapides (Nesbit 1950). Ananias and Kate’s family looked over Frank in his last days. Many of us lost an extraordinary friend when Frank died. His passing, at a young and robust 81 years of age of metastatic prostate cancer, reminds us painfully that we still have a long way to go in our work in urology.


Additional Postscripts.

The Lasker Awards were held back this year due to the Covid-19 pandemic. These are awarded annually since 1945 to living persons who have made major contributions to medical science or performed public service on behalf of medicine. This year the Foundation instead highlighted the 29 awards given in the past that recognized advances in infectious diseases, the first of those going to John F. Mahoney in 1946 for treatment of syphilis with penicillin and the most recent to Douglas Lowy and John Schiller for vaccination to prevent HPV in 2017. [J.L. Goldstein, JAMA September 25, 2020.]. My bet for a 2021 Lasker Award will be on Anthony Fauci for his tireless and courageous representation of scientific truth in the public interest in turbulent times.

Apocryphal Keynes quotations: “When the facts change, I change my mind. What do you do sir?” or “When someone persuades me that I am wrong, I change my mind. What do you do?” Variants of these have been attributed to redoubtable British economist John Maynard Keynes (1883 -1946), but no direct sourcing has been found. Nobel laureate Paul Samuelson and others alluded to versions of the remark, long after Keynes died. Whatever actual the source, it is an enlightened human idea.

True fact. Face masks diminish respiratory germ transmission by respiratory droplets. This is certain and has been clear to every surgeon, nurse, and OR worker on the planet for well over a century. Argument on this point is futile and malintented.

[Above: Justin Dimick and Hari Nathan, UM Surgery Department. Below: Aditya Pandey & Paul Park UM Neurosurgery Department.]

Thanks for looking at Matula Thoughts this November, 2020.
David A. Bloom
Department of Urology, University of Michigan

Quilting bees and blues

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WN/MT October 2, 2020
Quilting bees and blues
2392 words

One.

 

 

 

October Blues. Historically at this time of year, the blues came from regret over the loss of summer and the expected hunkering-down for winter ahead in the northern hemisphere. October 2020, however, finds most of the world already hunkered down for Covid-19. Students had another cause for October Blues, after the emotional rush of new school terms in September gave way to the “boring” routines of schoolwork, boredom that is now a matter of fond nostalgia.

No one can reasonably deny that schooling is essential to pass along skills and knowledge to successive generations. The processes and environments of schooling, in all its forms, also provide opportunities to improve the actual knowledge and skills, as well as forge community values. The present pandemic reaffirms that schools are a cornerstone of society at K-12 levels for socialization of students and for liberation of parents to do their daytime work. Higher education and the myriad forms of schooling beyond traditional schools are no less essential, but sharply compromised by pandemics that, recurring as we know well, should not take us so completely by surprise.

The Quilting Bee (above) shows a community passing along skills, knowledge, and values through an organized tradition. The painter, Anna Mary Robertson “Grandma” Moses (1860-1961), started to paint seriously at age 78, completing The Quilting Bee in 1950. Quiltmaking and quilting bees, also called quilting frolics, were good ways for communities to dispel their situational blues. Quiltmakers have transcended cultures from the earliest known quilts around 3400 BCE in the Egyptian First Dynasty to more recent times in this country. Enslaved Africans, New England Quakers, Hawaiian natives (shown below), and Amish communities in Pennsylvania, Ohio, and Indiana, among countless others, developed quilting expertise, passing along methodologies, and improving the art across generations. [Niihauan quiltmakers, photograph by Francis Sinclair, 1885, Wikipedia.]

 

Stephen and Faith Brown, UM alumni and friends of the Urology Department, followed their serendipitous interest to become expert collectors of Amish quilts, exhibiting their quilts at the UM Art Museum, the Renwick Gallery, the University of Kansas, the Denver Art Museum, and the de Young Museum. The unexpected bold colors and patterns of those quilts contradicts the restrained lifestyle of the artisans and surely must have dispelled their blues while enhancing their sense of community. [Exhibit at Renwick. Copyright Faith and Stephen Brown.]

 

 

 

Two.

 

Succession and success. Skills, arts, and knowledge of quiltmakers, soldiers, archeologists, urologists, and other workers of all sorts survive only through their successors. Virtually every discipline ensures its succession through role-modeling, education, and training, prospering when the processes of succession are deliberate.

At this time of year, medical students are anxiously sorting out their career paths and seniors are taking specialty rotations and applying to training programs. Last year’s seniors are now residents-in-training at Michigan Medicine in the fourth month of what was once called “internship,” currently labeled postgraduate year one (PGY 1) in the jargon and long line of continuing medical education (CME). [Above: Terra Cotta Soldiers of Qin Shi Huang, first Emperor of China, c. 210 BCE. Below: successive UMMS class pictures in UH corridor.]

 

The Department of Urology, as any recruiting discipline, has the double duty of selling itself to applicants while also appraising them for abilities to succeed in training and practice. Equally important, we want to build our team in urology while enhancing its diversity. We have a strong track record in this work from the days of Program Directors Gary Faerber and Khaled Hafez, and currently Kate Kraft and Sapan Ambani (all shown below).

Gary Faerber (Nesbit alumnus 1989 – now a professor at Duke.)

 


Khaled Hafez (Nesbit alum 2004)

 


Kate Kraft (Nesbit faculty 2011)

 


Sapan Ambani (Nesbit alum 2014)

 


We had no idea, last year at this time, that interview days wouldn’t take place as usual this season, when digital surfaces will reduce the full human dimensionality day-long experience to constrained transactional computer sessions. Zoom will dominate until society-at-large equilibrates with Covid-19 so we can resume a more human interview process.


Three.

Hopes and dreams. What do residency applicants want? Overall, they want a five-year learning and living experience that will bring them happiness and success, although each individual defines these conditions uniquely.

What do the faculty, current residents and fellows, and staff want? They want bright, industrious, and dependable learners and workers who will be successful in their training and in their careers. From its start in the 1920s, UM Urology has trained people to advance the discipline through care of patients, creation of new knowledge, and teaching of sequential generations. Shared values of integrity, kindness, leadership, and citizenship have been modeled and reinforced in our community of work and learning for nearly 100 years.

For the many applicants to UM Urology, we can offer only a few positions. Selection is necessary, but identification and ranking of top applicants is painfully imprecise. Applicants similarly need to assess the training programs in the national match process and for them as well, no ideal formula, algorithm, set of experiences, or scores, predicts success. Guidance from “experts” at gauging successful outcome is a forlorn hope and appraisal by each party comes down to personal holistic consideration, that is gestalt. During recruiting seasons as department chair, I wished we could have taken many more applicants, as I saw potential for success in training and in life within most candidates. While the matching process is currently an embarrassment of riches for training programs, it is a matter of life-altering consequence for each applicant.

 

A painting in 1886 called Hope by George Frederic Watts (1817-1904), captures the complexity of the predicament: a blindfolded woman sitting on a globe plays a lyre with only a single string remaining. Possibly she retains optimism in spite of obvious handicaps. Perhaps she is content but realistic. We can only guess the artist’s intent, but regardless of the nature of her thinking and sense of hope, the scene certainly is suffused with the blues. [Above: Tate Museum].


Four.

Prediction. The UM Bentley Library contains great riches – we have seen this in our study of the UM Urology history. One exchange of letters between UMMS Dean Victor Vaughan and a physician in Marion Ohio, named Fillmore Young, in July 1919, centered on the question of “Why some succeed, while others fail” in medicine. Young intended to give a paper on the topic and wrote to Vaughan, as “one of about fifteen of the prominent men of our profession who have succeeded,” asking for three indicators of success. As an example, Young quoted three predictors from the prominent American surgeon, Nicholas Senn (1844-1908).
“First: He knew his business.
Second: He asked no outside advice.
Third: He demanded his position.”

Senn’s dogmatic, inflexible, and self-assured advice was ridiculous, largely the antithesis of any responsible advice for success. Vaughan’s reply (shown below) revealed a greater mind and kinder person.
“Dear Sir;
In my opinion, there are three qualifications essential to success. The first of these is intelligence; the second is industry and the third is integrity. Fortunately most men are born into the world with a good degree of potential intelligence. They are furnished with a normal brain and they only need to work it right and with sufficient industry. Intelligence and industry, however, in order to lead to real success must be controlled by integrity,
Yours truly, Victor C. Vaughan.”

 

Dean Vaughan wrote this just a month after learning of the death of his oldest son, in France at the conclusion of WWI. This was also when Vaughan first considered Hugh Cabot for the chairmanship of the UMMS surgery department, and in whom the qualities of intelligence, industry, and integrity seemed to be in full display.


Five.

Opportunity. One year after this exchange of letters, when the only gender qualified for success in medicine seemed to be male, the 19th Amendment to the Constitution legislated voting rights to women. This doubled the American voting denominator and helped open up the national talent pool for work, ideas, and leadership necessary for society.

While the University of Michigan and its Medical School had been educating women since 1870 and 1871, the numbers of women in the classes, never at parity from the start, sharply dropped off in the first half of the 20th century and only reached parity in the early 21st century. The inclusion of women in medicine doubled the talent pool for medical progress.

More recently, one hopes, the George Floyd tipping point signals a groundswell of sentiment to deconstruct widespread structural racial impediments to equal opportunity for all people to pursue success.
In case you missed Randy Vince’s article, “A piece of my mind: Eradicating racial injustice in medicine,” in JAMA last month, it’s well worth reading. [JAMA, 324:451, 2020.]

 

Randy, our senior uro-oncology fellow, offers a personal perspective, referring to stages of learning in the transition from ignorance to mastery of a subject. He suggests personal steps to ameliorating social injustice, and the final one, implementation of widespread culturally-aware mentorship training, is predicated on the idea of building pipelines of opportunity for as wide a swath of the human talent pool as possible. This is a matter of widely seeking and extending mentorship throughout all communities of our potential successors. Of course, no single health care provider can mentor every possible community, but a robust team such as UM Urology can probably cover most. [Above: Vince at a socially-distanced coffee break, September 2020.]



Postscript.

Purposes and cross purposes. Higher education is in the news this month, as never before and institutions that figure out how to bring students and teachers together in safe proximity will be highly prized. Hand hygiene, face masks, and social distancing work well. It shouldn’t be rocket science to outfit some classrooms and lecture halls as “test kitchens” with vertical laminar air flow. The reversed air flow need not be “ICU grade,” but just enough to give gravity a little help with respiratory droplets. It would be money well-spent, for this will not be the last pandemic to interrupt educational routines.

Students come to colleges, universities and medical schools for a number of purposes, sometimes cross-purposes. Some want to learn who they are and understand their place in the world. Others seek knowledge and skills, or merely a ticket, to a particular occupation. Many students are deeply curious about a particular subject. No small few simply want liberation from home and opportunities for socialization. Schools, for most students, are a means to some end. G.K. Chesterton, mentioned in these columns last month, once wrote:
“ … in logic a wise man will always put the cart before the horse. That is to say, he will always put the end before the means; when he is considering the question as a whole. He does not construct a cart in order to exercise a horse. He employs a horse to draw a cart, and whatever is in the cart. In all modern reasoning there is a tendency to make the mere political beast of burden more important than the chariot of man it is meant to draw.” (Irish Impressions, 1919)

When the “end-game” is improvement of the human condition, no institution has been more durable than that of higher education in pursuing that object. From times of Socratic and Hippocratic schools to the more formalized educational center of al-Qarawiyyin in Fez (Morocco) in 859 and then Bologna’s “first” university in 1088, and present-day colleges and universities, higher education has aspired to create the citizens, ideas, occupations, and technologies of the future. In a Darwinian sense this is why they endure and grow, yet even complex multiversities, such as UM, remain imperfect in extending their opportunities fully.

We educate medical students and residents to become tomorrow’s urologists, anticipating they will be the leaders and best of urologists. The founder of UM Urology, Hugh Cabot had an even larger view as Medical School Dean, explaining this in 1925 at the 36th annual meeting of the Association of American Medical Colleges in Charleston at the Fort Sumter Hotel October 26-28. His talk “Should medical education be importantly recast?” concluded with this paragraph.
“Finally, but perhaps most important, throughout the whole period of education the goal must be kept in sight, that goal being not the successful practice of medicine but the successful service to the community. If at any point either teacher or student loses sight of service as the paramount object of the practice of medicine, then medicine will fall from its high estate and be classified, and deserve to be classified, as a trade rather than a profession.”

Those remarks anticipated comments made 35 years later on the steps of the Michigan Union by another Bostonian, Senator John F. Kennedy, in a presidential campaign speech on October 14, 1960.
“Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign. I come here tonight asking your support for this country over the next decade. Thank you.”

Hope is tempered by the blues throughout this global village in October 2020, besieged by pathogens, tribalism, extremism of all sorts, authoritarianism, economic challenges, kleptocracy, and environmental deterioration.

 

Yet, October is still a time for optimism with belief in human ingenuity to fairly share the harvest bounty and solve the problems of our times. When the talent pool for human invention is maximized by including all people, the likelihood of good solutions is increased. The short burst of autumn colors, soon ahead, is one of nature’s best antidotes to the blues before we put on winter clothes, accommodate to the gray skies of Michigan winters, and pull up comforters and quilts at night. [Above: Autumn streets, Ann Arbor 2020. Below: Halloween by Grandma Moses, 1956.]

 


Thanks for reading Matula Thoughts, October, 2020

David A. Bloom, Department of Urology, University of Michigan

 

 

 

 

     

    Seasons change

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    WN/MT September 4, 2020
    Truths & mousetraps.
    2450 words



    One.

    This September feels different. It’s no longer just a matter of seasonal daylight contraction, but also a fact of social shrinkage and much more. Summer 2020 was unlike any before and academics this autumn, from pre-school through medical school, will also be totally different. Innovation is in demand to navigate the crises in business, education, medical practice, public policy, sports, and much of everything else in daily life. The good news is that humans are good at creating new and better mousetraps, although not so good at escaping the mental mousetraps of their own follies. [Above: September ground litter, Scio Township 2018.]



    Hunkering down in the first weeks of this 2020 Covid pandemic, I reread Howard Markel’s book, When Germs Travel: Six Major Epidemics That Have Invaded America and the Fears They Have Unleashed. Written in 2004 it holds up very well now, 16 years later, offering pandemic perspective. Howard, shown above, has frequent pieces on Public Broadcasting Service (PBS), maintains the 1918 Influenza Epidemic Encyclopedia in a UM Digital Archive (chm.med.umich.edu), has a recent Medical Dispatch in the on-line New Yorker Newsletter (August 6, 2020), and a new book on genetics, called Helix, in the works.

    Lessons learned from past infectious disasters tend to be forgotten. Face-masks, hygienic measures, social distancing, and validated vaccines unquestionably mitigate transmission and acquisition of germs – medical scientists and the informed public know this much is true, but why doesn’t everyone else?

    Weaponization of those protections, particularly the ridiculously easy solutions of face masks and social distancing, as political gestures is sadly bizarre. Whether it’s a matter of ludditism, partisan ideology, or mere ignorance will be sorted out by future social critics. As a person who wore face masks in operating rooms for nearly 50 years – alongside uncounted colleagues, nurses, and scrub techs – the claims of “medical reasons” why some people “can’t wear a mask” are incredulous – as unconvincing as claims of pet snakes or birds as “medically-necessary” travel companions on airplanes. The parallel contention that the duty to wear masks violates personal freedom is certainly a far cry from anything reasonably derived from common sense or the American Constitution. It’s not surprising that similar skirmishes sprung up with the Great Influenza epidemic in 1918, when education and science had not quite universally settled the germ theory in minds, but it is astonishing to find such shenanigans a full century later. [Below: mask-wearers at University Hospitals, senior medical student Annie Minns and professors Cosmas Van De Ven and David Spahlinger – social distancing briefly waived for the photo op, Aug. 2020.]


    Two.

    Basic truths. Mousetraps for infectious diseases have come and gone, but routine hygiene and simple impediments to germ transmission (face masks & distancing) seem to be basic truths.

    Historical medical relics were facts once true for their times. The iron lung for the respiratory failure of polio was a “better mousetrap” in the 1930s through the 1950s. The original iron lung used two vacuum cleaners to change pressure in an iron chamber, compressing and inflating chests and lungs of children lying within them. Philip Drinker (1894-1972), teacher of industrial illumination and ventilation at Harvard Medical School (alongside famed UMMS graduate Alice Hamilton), came up with a popular design, the “Drinker Lung.” Haven Emerson (1906-1997), son of NYC Health Commissioner, improved the device by placing the patient in a bellows within the chamber. Emerson’s Iron Lung was quieter, lighter and only $1,000, half the price of others. It remained in production until 1970, when polio largely had disappeared from much of the planet due to vaccination. Coincidentally this is a good opportunity to refer to Markel again. [H. Markel. “The genesis of the iron lung,” Arch Pediatr Adolesc Med, 1994; 148 (11): 1174-1180.]

    Polio outbreaks were dreaded in the summer. As a child, I noticed post-polio limps in many people and heard about iron lungs, seemingly ubiquitous in every hospital. The July newsletter, Matula Thoughts, referred to our friend and colleague Skip Campbell who was hospitalized at “old” University Hospital as a youngster to treat his polio. That was just around the time polio began to disappear when field trails of Salk’s vaccine, directed from UM by Thomas Francis, proved it “safe, effective, and potent” in 1955. The Sabin vaccine soon proved better. Oddly, U.S. authorities supported only the Salk clinical trial, and Sabin had to prove his vaccine in field trials in the Soviet Union. This was no small feat in the political theater and Cold War of the 1950s, but Sabin, against the grain, organized the trials and the world ran to his better vaccine. Even now, however, global polio eradication is incomplete. [L. Roberts, Science, 367:14, 2020.]

    Situational necessity, inspiration, and competition fuel better medical mousetraps, but innovations happen best in open societies. Iron lungs were useful in their times but gave way to better innovations. Modern respiratory physiology knowledge and more sophisticated ventilatory technology sprang from other responses to polio. [J. West. “The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology,” J. Appl Physiol (2005); 99:424-432.] So once again, let’s celebrate democracy and free speech: innovation -with its validation, dissemination, and improvement – thrive best in the fertile social soil of personal freedom and open expression.


    Three.

    Mousetraps.  “If you build a better mousetrap the world will beat a path to your door.” Such is the power of “the market” at large, whether the market is commercial or intellectual. Flat Earth maps may lead some mousetrap-seekers astray, but most people find their ways to better ideas and technologies. [Above: Conventional Victor Mousetraps at Barnes Ace Hardware two for $1.69 vs. Intruder’s Better Mousetrap two for $5.99.]

    Ralph Waldo Emerson (above), the source of the phrase, actually wrote:

    “If a man has good corn or wood, or boards, or pigs, to sell, or can make better chairs or knives, crucibles or church organs, than anybody else, you will find a broad hard-beaten road to his house though it be in the woods.”

    Emerson knew something about paths in woods, not only living among them, but also hiring Henry David Thoreau as his property caretaker when the journalist of Walden Pond needed a paying job. A future tenuous connection between Emerson and Ann Arbor materialized after James Elliott Cabot (below), Emerson’s friend, executor, and biographer, fathered Hugh Cabot, who instigated the first century of Michigan Urology in 1919. “Elliott” Cabot (1821-1903, shown below), as he was known, was a brother of Dr. Samuel Cabot III and shares facial physiognomy with at least three of his sons: Michigan’s first urologist Hugh Cabot, twin brother Philip, and internist brother Richard Clark Cabot.



    Four.

    Medicine has had its share of mousetraps. Enduring diagnostic tools from antiquity  – the medical history, physical examination, rudimentary vital signs, and uroscopy (body fluid observation) – have been tested and refined in medical marketplaces over millennia. For urine inspection, pottery gave way to glass matulas, microscopes extended visual inspection into the microscopic world, chemical analysis opened up molecular composition of urine, and bacteriology led to identification of pathogens. Innovation similarly propelled stethoscopes (1816), x-rays (1896), electrocardiograms (1920s), CAT scans (1970s), and MRIs (in wide use after 2000) into the clinical marketplace. The technology of modern urology is too rich a topic for further mention here, except to take note of Nesbit’s transurethral resection of the prostate, Lapides’s clean intermittent catheterization, and McGuire’s leak point pressure.

    Amidst high-tech mousetraps of today, the simple face mask used in ORs around the world is clearly effective against dust and infectious droplets (liquid dust). A recent JAMA article by Brooks, Butler, and Redfield, suggests we implement universal masking for all healthcare workers and patients in clinical situations, affording both personal protection and source control. Aerosol particles range from sub micrometers (0.0001) to a full ten micrometers (microns) in diameter. By the way, 1000 microns equals 1 millimeter. Even simple cloth face coverings substantially limit forward dispersion of exhaled respirations in the 1-10 microgram range. [JAMA 324:635, 2020.]   [Above: ORs & face masks in Mainz, Germany. Below: airborne particles, source – Wikipedia, Particles. Horizontal axis in micrometers, or microns.] 

    A higher level of filtration than routine face masks, the N95 mask, was designed to meet the U.S. National Institute for Occupational Safety and Health (NIOSH) specification of filtering at least 95% of airborne particles. To be fully effective, it requires “fit-testing,” an annual ritual at Michigan Medicine along with the TB testing, that few knew would become so useful in these Covid times. [Below: N95 mask.]



    Some people, mainly constitutional textualists and originalists, claim that governmental agencies such as NIOSH were not “intended” by the Founding Fathers, who could hardly have known about aerosols, viruses, or the Internet. Yet the Founders surely knew that knowledge, technology, and monetary systems were changing the world and would continue to do so – Franklin, Jefferson, and Hamilton most certainly among them. Enough Founders anticipated that American governmental regulation and American free enterprise would need to work in tandem to support the foundational principles of life, liberty, pursuit of happiness, and First Amendment protections. The NIOSH agency derives from any reasonable interpretation of the Declaration of Independence and the Constitution.

    The global nature of human challenges, even for a matter so small as dust particles, is stunning. Airborne dust, solid or liquid, has no national boundaries. A NASA global simulation of aerosol transportation in the troposphere over 12 months beginning 17 August 2006, takes about two minutes to watch and will expunge any notions of national exceptionalism. This video clip shows that the recent African dust storm this year was no anomaly.
    [Title: Atmospheric Aerosol Eddies and Flows – NASA GSFC S.ogv
    Author: NASA. Date: 1 January 2008, 23:17:03]

    On the other hand, the Covid component of respiratory aerosols is fortunately not very durable in time or distance. Infectivity seems to drop off after 6 feet or some number of hours. Otherwise, the above NASA animation would be very alarming in the face of this pandemic. Furthermore, the best evidence indicates that long-range transmission of small-particle aerosols (<5 micrometers) is not the dominant mode of Covid infection. Close-range respiratory droplets (large aerosol particles >5 micrometers) is the far more likely threat, easily thwarted by face masks and a little distance. [M. Klompas et al, JAMA, 324:441, 2020.] 


    Five.

    Thermometry, a mainstay in the armamentarium of medical mousetraps, is a hot topic these days. Curiously, the fact of “normal human temperature” is not clear and some authorities believe that “normal” has been dropping. One wonders if normal temperature for communities of Inuit people living near the Arctic Circle is the same as “normal” of equatorial people, or could normal in infants be the same as for octogenarians? We don’t treat pulse or blood pressure with the same strict exactitude for all people, so why is 98.6 degrees Fahrenheit held to such precision, even though we know it’s variability in health is narrower than other physiologic parameters? Epigenetic response to modern life (industrialization, central heating, air conditioning, air pollution, global warming, etc.) surely influences the “normal” core human temperatures. Time of day, season, and age must matter as well. The site, method, and precision of measurement also effect any number obtained.

    The “normal” of 98.6 degrees Fahrenheit traces back to Carl Wunderlich (1815-1877), a German physician who questioned things (above, per Wikipedia). In 1868 he proposed 37 degrees Celsius as normal after studies using a foot-long thermometer, requiring upwards of 20 minutes to register the temperature. Surgeons may recall the term Wunderlich Syndrome, a nontraumatic surgical emergency of spontaneous retroperitoneal hemorrhage that may be caused by renal neoplasms. Mackowiak, Wasserman, and Levine in 1992, updated Wunderlich’s number. [JAMA 268:1578-80, 1992]. Newer studies suggest that “normal” human temperature has dropped by 0.59 degrees centigrade for men and 0.32 degrees centigrade for women. Urologists and zoologists know that core body temperature is a few degrees too warm for optimal testicular function in man, along with many other species, hence the “social distancing” of their placement. Evolutionary biologists may want to take note that as core body temperatures decrease, there may be no thermal reason for human testes to descend, which may severely limit the market for pediatric urologists. Kangaroos, and other creatures too, may have to adjust their testicular placement to accommodate themselves to a warmer planet (their bifid penile anatomy, caudal to the gonads, is stranger still.) [Below, Wikimedia, photographer and kangaroo unknown.]

    Crises test all creatures, from viruses to humankind, forcing epigenetic changes that allow adaptation and evolution not only of individuals, but also their societies. Homo sapiens has taken this force of nature to unprecedented levels, but just as every new era brings out innovation, each challenge uncovers new generations of Flat Earthers who retreat to comforting beliefs, dogmas, and ideologies. In the arc of human progress, truth usually wins out and each crisis finds its own necessary technologies, although the arc of progress is not smooth, but often wobbly and intermittently retrograde.


    Postscripts.

    Summer reading. Caste, The Origins of Our Discontents by Isabel Wilkerson is a timely book. The title riffs on the first two lines and pun of Shakespeare’s 1593 play, Richard III: “Now is the winter of our discontent/Made glorious summer by this sun of York.” John Steinbeck echoed this in 1961 in the title of his final novel. Coincidentally, my summer reading also included the historical novel, Hamnet by Maggie O’Farrell, that imagined the lost life of Shakespeare’s only son (1585-1596). [Below: Title page First Quatro, Richard III.]



    Caste (above) considers social and political power, but Wilkerson begins the book with “The afterlife of pathogens,” an astonishing coincidence with today’s pandemic news and world-wide political discontents. This first chapter describes a heat wave in the summer of 2016 that thawed Siberian permafrost and liberated anthrax spores from long-dead reindeer, thus causing a new epidemic in living reindeer and their indigenous herders, the Nedet people. Wilkerson then links that pathogen awakening to current political awakenings around the world.

    “The anthrax, like the reactivation of the human pathogens of hatred and tribalism in this evolving century, had never died. It lay in wait, sleeping, until extreme circumstances brought it to the surface and back to life.”


    Coincidences. G.K. Chesterton (1874-1936), English writer and author of the Father Brown priest-detective books, called coincidences spiritual puns. A less spiritual person than Chesterton might call coincidences cosmic puns or stochastic puns, but the idea is the same: unrelated but concurrent events or facts may seem to have been “divinely ordered” or happen “by the luck of the draw.” Chesterton’s actual quote comes from his book, Irish Impressions, in 1919, a year that coincides with the start of the first century of urology at the University of Michigan:

     “All literary style, especially national style, is made up of such coincidences; which are a spiritual sort of puns. That is why style is untranslatable; because it is possible to render the meaning, but not the double meaning.”

    Considering this first half of 2020, random chance is due to favor better luck in pathogens.

    Thanks for reading Matula Thoughts this Labor Day, 2020.
    Best wishes,
    David A. Bloom