Quilting bees and blues

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

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

Folly & truths

WN/WN/MT Aug 2020

Folly & Truths

2472 words

One.

The Cure of Folly. Overwhelmed by insanity, the world might be a better place if we had a surgical cure for madness, but alas, surgeons can’t fix everything or everyone. Hieronymus Bosch (c. 1450 – 1516) imagined this scene around the time Christopher Columbus made his second voyage to Caribbean Islands and just before John Cabot was the first known European on the North American mainland – journeys that to “Flat Earther believers” seemed examples of pure folly. [Above: detail from The Cure of Folly, Museo del Prado, Madrid.]

Belief that removal of a “stone” in the head could cure “madness” was one of many unscientific ideas of humanity that spawned strong believers and industries. Such “stones” might have been actual subcutaneous nodules or more deeply-situated objects imagined in the brain. Factoids lurked behind fantasy, as so happens with many other follies. Bladder stones, for example, surely were real and caused grief. These unmitigated miseries could be relieved only by lithotomy, for patients lucky enough to survive the horrible experience of surgery without anesthesia, extensive blood loss, and likelihood of postoperative sepsis. No such evidence of relief exists for relief of mental illness by removal of scalp nodules or drilling into the skull by trepanation, beyond a placebo effect. Surgical cure for insanity, was an insanity itself, as Bosch’s painting attests, where he not only visually spoofed the bizarre idea of surgical cure of madness, but also implied a cure to the folly, in the operating theater of public opinion by means of the satirical title.

How does an individual gain confidence or belief in an idea, a skill, or a technology? The discernment of the utility of some thing or the truth of an idea is a critical function learned in childhood and honed throughout life. An open mind that is willing to learn and unconstrained by ideology helps this arbitration. A mind further trained by education and critical analysis improves the odds of giving fair measure to an idea, skill, or device. Humans have had countless ideas and inventions, but for any of these to persist in society they must be tested in commercial and intellectual marketplaces and reconciled to public belief and utility. An idea or technology sticks around when enough of the public – a quorum – becomes confident of its value and truth.

During a recent virtual pediatric urology meeting, in discussions over ideas of validity and truth, Julian Wan reminded us: “there are three types of arguments – the nature of relevant knowledge at hand; pragmatism; and sectarian belief.” As the tagline for The X-Files once promised: “The truth is out there,” although it’s not the same for everyone.

The large contest in play for H. sapiens today, is the ability of people to coalesce around some shared sense of basic truths that enable them to discern and choose between authoritarian societies versus representative democracies. This matter is especially intense now in this interconnected and fragile world where our technologies can distort truth and physically destroy the planet.

 

Two. 

Truth. Isabella Baumfree is a timely person to consider. Born into slavery in a small Dutch-speaking community in the Catskills around 1787, she grew up known as “Belle.” Although New York state began to abolish slavery in 1799, emancipation was not complete until July 4, 1827.  Belle “escaped” just before this, in 1826 with her infant daughter, but she preferred to say that she “walked off,” anticipating the emancipation. She had to leave three other children behind and two years later she went to court to recover her son, then five years-old and enslaved in Alabama. Remarkably, she won. In 1843 she renamed herself Sojourner Truth and became an abolitionist and women’s right’s activist. Her speech in 1851 at the Ohio Women’s Rights Convention in Akron “Ain’t I a woman?” established her celebrity and was reiterated widely throughout the years of the Civil War. Sojourner Truth moved to Battle Creek, Michigan, in 1857 and died at home in 1883.  [Picture above, National Portrait Gallery, c. 1870.]

Sojourn, of course, describes a temporary stay or condition and the extraordinary name Sojourner Truth, writ large, implies a traveler who experiences various postulations of truth in pursuit an ultimate best version of it, through their days and times. The conditionality of facts and truths is not just a matter for philosophers – it is the daily work of historians and scientists who seek to disprove established beliefs (and follies) with better facts and reasoning. Sojourner Truth’s name is a fitting metaphor for the conditionality of truth, whether ascertained by ideology and sectarian fiat or by observation and reasoning, and even once ascertained it is always amenable to further examination.

 

Three.

History and science are good antidotes to folly, provided that their logic trumps the  ideologies and beliefs that so often constrain people. Folly is the antithesis of good history and science. It is, by definition, foolish – lacking defining characteristics of our species: good sense, reason, prudence, and foresight. The rigor of history and science brings verifiable data and rational argument to old beliefs, in pursuit of the idea of truth. This pursuit depends upon free inquiry, free speech, peer review, criticism, and public education – all characteristics of open societies and the institutions sustain those societies. Ultimately, however, the cure of folly requires that people change their minds, based on data, analysis, and argument.

Governments, universities, industries, and all businesses, as they serve themselves, also serve the public interest and their integrity is tied to the public trust. Naturally, our expectation is that self-interest for industry and business is usually greater than their public service, but for governments and universities the public interest should dominate. Good science and good history (in the sense that “good” captures the idea of truth and reflects fundamental values of humanity) do not necessarily find nourishing soil in authoritarian societies, universities, corporations, or “top-down” organizations. In fact, authoritarian government has never worked well for people, history, or science. [Above: The Alchemist, Mattheus van Helmont.]

Society’s instruments, namely its governments, universities, and businesses, too often maintain stubborn illiteracy of history and science. These organizations ignore some truths that are becoming very clear with massively-accruing evidence of basic facts: infectious diseases recur in catastrophic waves, people need basic securities, and human environmental impact is deleterious to a human future. One wonders, then, what are the actual purposes, the main value, of those institutions (governments, universities, businesses, the press, etc.) to “we, the people?” Limiting the question just to government (recognizing that a huge body of scholarly work, beyond capacity of this writer and essay, continues to study this question). The Declaration of Independence, states it simply:

“… in order to form a more perfect union” so as to protect the basic human aspirations for “life, liberty, and the pursuit of happiness.”

Government facilitates these aspirations most fundamentally through basic securities of public safety, public education, assurance of jobs and justice, as well as public and personal health. Security of food and shelter are no less important, as this Covid epidemic is showing. These are the needs of “We, the people.”

 

Four.

New medical students just joined us in Ann Arbor, although the absence of our usual White Coat Ceremony at Hill Auditorium deprived us of the chance to see them on stage, hear their introductions, and give them short white coats, stethoscopes, and MCAS pins. Cliff Craig recently sent Matula Thoughts a note recalling his precise moment of entry in 1969, before the White Coat Ceremony was introduced to our medical school. Cliff and his fellow students assembled to hear the dean, without any family members, children, or friends on hand to offer support and cheers, as would come with the White Coat event years later. [Below: Cliff c. 2019.]

“It was 1965, the first day for the University of Michigan Medical School class of 1969. We saw no white coats, nor short ones either. Dean Hubbard said (paraphrased): ‘You are all worried about failing out, I am not worried about that. I am worried that some of you will be bad doctors, and I wish I knew who you were, I’d kick you out right now.’ That was immediately followed by our first class; – so much for class ‘bonding.’

One year later, in 1966, on the first day of our second year, we were all advised to show up with a short white coat which could be purchased at Ulrich’s (along with the books we needed for the second year). It was a year punctuated by many demonstrations and sit-ins on campus against the Viet Nam war (Tom Hayden etc.). Dean Hubbard then addressed us again (paraphrased): ‘I want you to remember when you wear your white coat, you represent not only yourself but this medical school, the medical profession, but most importantly you represent me! If you want to participate in any of the activities on central campus, take off the white coat.’

I met Dean Hubbard at commencement in the early 2000s, and reiterated what he told us on those occasions. His response: ‘Did I really say that?'”

Time passed and now Cliff is professor at UMMS, specializing in the pediatric orthopedics. He keeps in touch regularly with several classmates including otolaryngologist Mike Johns, who served UM brilliantly as interim EVPMA after being Dean of the Medical School at Johns Hopkins and then Chancellor of Emory University. Rick Rapport, another classmate, is a retired neurosurgeon in Seattle.

 

Five.

William Hubbard was the first “full time” dean at UMMS, in the sense of having no conflicting duties such as departmental chair (like Cabot) or clinical practice (like Furstenberg). Hubbard served from 1959 through 1970, resigning to become a senior vice president at the Upjohn Pharmaceutical Company in Kalamazoo. Just the year before, the regents had given him responsibility as dean to also manage the hospitals of the growing medical center.

One evening in March, 2006, after usual work hours, voices were heard in the otherwise quiet hall outside the office of the Associate Dean for Faculty Affairs, who was curious to see who was wandering about in the administrative area of Dean Allen Lichter. This led to the good fortune of meeting former Dean William Hubbard who had come by to view his portrait. Fortunately, a camera was nearby to capture Dr. Hubbard and his painting from more than 30 years earlier. Fashions change and our deans’ portraits are now in storage. It was fortunate to have been hanging when history was still on display when Dr. Hubbard strolled by and he seemed pleased to reflect back on his time at Michigan. It is too late to ask Hubbard to recall his memories of Nesbit and Lapides, or to get his recollections on the issues of his years as dean, but we can hear Dr. Hubbard through his former students, Drs. Craig, Johns, Rapport, and other classmates who have turned out pretty well. Their origin stories certainly place strong emphasis on the roles of the University of Michigan Medical School, deans like Hubbard, and many of the Medical School teachers who helped form generations of leaders and best.

 

Postscript.

Clair Cox was one of the leaders and best to have come from the University of Michigan Medical School. As a resident in the 1970s at UCLA, reading the urology literature, I became familiar with the name Clair Edward Cox, II, who published interesting and good papers from Bowman Gray School of Medicine (now Wake Forest Medical School) and later the University of Tennessee in Memphis. Little did I know we would become friends during my time in Ann Arbor, where the University of Michigan connected us. I’m sad to report that Clair passed away a few weeks ago.

Clair was born on September 3, 1933 in St. Francisville, IL, and grew up in Mt. Pleasant, MI, excelling in studies and sports. With a Regents Alumni Scholarship, he completed three years of undergraduate studies at the University of Michigan and then entered the Medical School. In his sophomore year, he met junior nursing student Clarice Adele Wicks and they married in 1958 when Clair graduated with an M.D. His Medical School Class of 1958 was a remarkable group in a remarkable time, entering postgraduate medical education in the new era of specialty practice, massive research funding, and a high point of academic medicine. At Michigan, this was at the end of Furstenberg’s long tenure as dean, from 1935 to 1959, when the dean practiced medicine at nearly a fulltime clip whilst tending to the medical school administration. Frederick Coller retired as chief of surgery in Clair’s graduating year and Reed Nesbit, head of urology, was nearing the peak of his career having brought Transurethral Resection of the Prostate (TURP) to the mainstream of international urologic practice. Both men inspired Clair as a medical student and Nesbit, particularly, became a resource as Clair ascended the hierarchy of academic urology.

Clair and Clarice moved to Denver for surgical training at the University of Colorado, anticipating a path to thoracic surgery, but urology gained the upper hand in his interest and the couple continued west to San Francisco for urology training that he completed in 1963 at the University of California. The couple returned east across the country to Winston-Salem, NC for an academic urology position at Bowman Gray where Clair advanced through the ranks to professor. In 1972 Clair was recruited to lead urology in Memphis at the University of Tennessee and held the chair position for 27 years until he stepped down, having trained 90 residents. He continued to work for another 10 years until retiring in 2009.

Dr. and Mrs. Cox raised four boys who would give them 12 grandchildren. In retirement Clair enjoyed his family, their home, and the family ranch in Hernando, Mississippi. His last academic paper, a historical investigation, entwined the stories of a fellow Memphis urologist (Thomas Moore), Graceland, Elvis Presley, and the American Urological Association. Michigan Football frequently brought Clair, Clarice, and occasionally a son and grandson back to Ann Arbor. Of Clair’s multiple university affiliations, the Michigan connection was the strongest, as evident to visitors to the lovely Cox home on Sweetbriar Cove in Memphis where maize and blue colors and UM symbols flourished. The Nesbit Alumni Society includes UM Medical School graduates along with the UM trainees who became urologists and Clair was pleased to be a member, after all Nesbit was his first teacher of urology. Clair once said that while he enjoyed working in five excellent medical centers, it was the University of Michigan that was always closest to his heart and running through his veins. Just as he felt the University of Michigan distinguished him as a citizen and a urologist, he distinguished the University of Michigan as an exceptional alumnus, educator, clinician, and scholar.

Clair Edward Cox, II, died peacefully at home on July 9, 2020. [Above, Dr. Cox on his ranch in Hernando, 2017.]

 

Thanks for reading Matula Thoughts, this first Friday of August 2020.

David A. Bloom

University of Michigan Department of Urology

 

Origin stories

WN/MT July 3, 2020
Origin stories
2518 words



One.

Hunkering down this spring, we explored Ann Arbor’s Water Hill neighborhood during social-distanced walks and saw flags that anticipated the Fourth of July. Tomorrow’s holiday brings to mind Danielle Allen’s book, Our Declaration. The American national origin story centers around a representative democracy formed disruptively when 13 colony-states spun off from a parliamentary monarchy. Even at the start, the story was complicated by the colonial expropriation of lands from their indigenous inhabitants and enslavement of abducted Africans to build the economy. These matters remain unreconciled, and so some Americans today will display the flag upside down, take a knee, or illuminate irreconciliation in other ways.

As the number of states increased in America, state sovereignty contested federal authority over a variety of issues amidst economic crises, wars, environmental catastrophes, epidemics, and paradigm shifts in technology. Life got more complex with technology, subspecialization, regional interdependency, and the sheer scale of rising population. Many matters transcended state boundaries and demanded federal solutions. Consider, for example, a public debate in 1820 on the role of federal government in matters of personal health, public health, medical licensure, specialty certification, and health care economics versus a similar debate today. The debaters in 1820 would have scratched their heads wondering what possible business the government could claim in such issues, except possibly a limited responsibility for public health.

The basic Jeffersonian aspirations within the Declaration, however, seem to hold true and anchor most of the attempted solutions to the nation’s big and little problems. Those personal aspirations – life, liberty, and the pursuit of happiness – bear repetition, especially now in July, 2020. It now takes great rhetorical acrobatics to discount the role of equitable public and personal health care in life, liberty, and the pursuit of happiness in today’s complex world. A debate in 2020 over the roles of federal government in matters of personal health, public health, medical licensure, specialty certification, and health care economics would be quite different than that imagined debate of 1820.

One big effect of this pandemic may be that the public may find a way to build a new vision of government “by the people and for the people” that will fine-tune the aspiration of “life, liberty, and the pursuit of happiness” to the complexities of 21st century civilization. Governmental responsibility for “life, liberty, and the pursuit of happiness” entails securities of personal freedoms, food, and employment, as well as public safety and public health. Any line placed between public health and personal health, or between public safety and personal safety is an arbitrary choice. These basic securities should be expected of any state or society, worthy of the term civilization.


Two.

Baseball comes to mind now, but this season is off to a slow start, if it happens at all. So meanwhile, a bit of time travel to the past is in order: a little more than ninety years ago (May, 1930) Ty Cobb threw out the first pitch at a new baseball park in Hamtramck, Michigan. [Picture below: 1928 International Newsreel photograph of Lou Gehrig on left, Tris Speaker, Ty Cobb, & Babe Ruth taken in April 1928.]

Cobb was a national celebrity who had retired from the Detroit Tigers in 1928 after 22 seasons and came back for opening day at Hamtramck, although he never actually played a game there. The new stadium, replacing Mack Park, would serve as one of the historic Negro League venues through 1951.

Mack Park had been home to the Detroit Stars, but after the grandstand burned down in 1929 the venue was relocated to the Hamtramck site, opening in May 1930. The Detroit Wolves took over for the Stars, in a new East-West league in 1932, but folded in the unfavorable economic times. The Detroit Stars was resurrected in 1933, but lasted only one more season at Hamtramck, that then lay empty. The Stars had a third life in 1937, but that too lasted only one more season. Detroit city acquired Hamtramck Stadium in 1940 and renovated it through Roosevelt’s Works Progress Administration as part of a larger Veterans Park project. Hamtramck Stadium has since hosted high school and Little League games, but after 2012 it fell into disrepair and neglect. Of the 12 remaining Negro League stadiums only Hinchliffe Stadium in Paterson, New Jersey and Rickwood Field in Birmingham, Alabama were in use longer than Hamtramck.

Michigan has some puzzling names, in that the historic contexts of their origins have been lost to most people today. Hamtramck, more than most American communities, reflects dominating effects of immigration and displacement of native people. [Below: Site marker installed August 2014.]



Three.

Hamtramck, a tiny city surrounded by Detroit, had little commonality with Ann Arbor, only 44 miles away, in that spring of 1930 when the University of Michigan Medical School was reeling from the firing of Hugh Cabot in February as dean and chief of surgery. No dean would replace him for three years and the school’s executive committee assumed the role of dean. Frederick Coller was named chair of surgery and appointed Reed Nesbit as the head of urology, but he was a “head” with a single deputy. It’s unlikely that Nesbit and the University of Michigan community knew much about Hamtramck Stadium when it opened that May 1930, although Nesbit became a devoted fan of the Detroit Tigers and certainly knew the name, Ty Cobb. Hamtramck Stadium would become one of the important Negro League venues and is listed on the National Register of Historic Places. [Below: Col. John Francis Hamtramck takes possession of Fort Lernout, part of mural at Detroit Water Building. Wikipedia.]

Jean-Francois Hamtramck (1756-1803), a French-Canadian soldier born in Montreal, came south to join the Continental Army and became a decorated officer in the Revolutionary War. He then served in the Northwest Indian War, displacing native American communities, and was the first commandant of Fort Wayne (Indiana). In 1796 he transferred to Fort Lernoult and the settlement of Detroit, where he died seven years later.

The Jay Treaty, designed by Alexander Hamilton and negotiated by John Jay in 1794, had ceded the fort from Britain to the United States effective 1796, when Col. Hamtramck moved there with 300 troops. Britain reclaimed the fort, by then named Fort Detroit, in the War of 1812. After the Battle of Lake Erie, the fort was returned to the U.S. and renamed Fort Shelby. In the aftermath of this and the Northwest Ordinance Act, territorial judge Augustus Woodward came to Detroit from Virginia with radical ideas on education that he deployed in the University of Michigania in 1817.

The town within Detroit that took Hamtramck’s name began as a farming community of German immigrants and incorporated as a village in 1901. There, the burgeoning Detroit Stove Works attracted industrial workers and shifted the demography from rural farmers to immigrant urban factory workers. By 1910 the Dodge Main Assembly Plant dominated the town, attracting new immigrants and within 20 years the town became heavily Polish and middle class. Of the thousands of factory workers in the 1920s, nearly 80% owned or were buying their own homes. Attracting a new generation of different immigrants, the town (2 square miles and 23,000 people) is now the most densely-populated and most ethnically diverse in the state and in 2015 became the first in the United States to elect a Muslim-majority city council.


Four.

Lessons of history. Each season brings particular infectious risks and in those days when Ty Cobb threw out that opening pitch at Hamtramck 90 years ago, parents were anxious about the summertime threat of polio to their children. Much less commonly, “infantile paralysis” also affected adults and such a victim, it was widely believed, was Mr. Franklin D. Roosevelt, a successful politician when it struck him in 1921 at age 39. He spent years in recuperation, and even afterward continued to struggle with the sequelae of severe lower extremity weakness, that he masked from the public when re-entering the political world as Governor of New York in 1928 and ascending to presidency in 1933. In retrospect, it is more likely that Guillain-Barre was the cause of his neuropathy. The polio story would intersect with the University of Michigan story two decades later. [Below: Photo: Two early-1950s March of Dimes “Fight Infantile Paralysis” posters designed by artist John Falter (of Falls City, Nebraska). (History Nebraska 10645-1197, 10645-4333)]

In the summer of 1953, many children throughout the northern hemisphere contracted polio, a seasonal fear of parents. Two children of a UM faculty member in the Surgery Department and practitioner at St. Joe’s were among those diagnosed. They were hospitalized for three weeks in the old “Contagious Hospital” during the presumed infectious period and then transferred, when afebrile, to a large ward of 32 beds in University Hospital (Old Main) on 10 West for the next five months of complete bed rest wearing knee-high boots, to prevent contractions, 24 hours a day.

One of the children, our colleague Skip Campbell, recalls watching Medical Sciences I Building being built from the ground up as he lay in bed. The “Sister Kenney Treatment” involved hot steaming under wool blankets twice daily. Both Campbell children recovered, although Skip’s sister had a life-long limp due to unilateral muscle atrophy. Skip recalled: “Quite a few kids in that place died, including a little girl in our room. Remarkably, I don’t remember a single nurse, doctor or my parents wearing mask!” [Personal recollection, Darrell Campbell, Jr., May 1, 2020.]

Sister Elizabeth Kenney (1880-1952) was a self-trained Australian nurse. After experience in WWI and with the 1918 influenza epidemic who in 1942 opened a clinic in Brisbane where she utilized heat packs and exercise among other regimens for polio. She brought her ideas to the US and settled in Minneapolis where the city gave her a house and she taught and practiced for 11 years. That work would lead into a new field variously called Rehabilitation Medicine, Physical Therapy, and Physiotherapy. [Below, Nurse Kenney, August 4, 1915 enroute to service in the Great War. Wikipedia, John Oxley Library, State Library of Queensland.] 



The Salk vaccine and enormous clinical trial (largely funded by FDR’s March of Dimes) coordinated by his professor Thomas Francis at the University of Michigan in 1954 largely eliminated the risk and fear of polio in North America. Salk used “killed virus” in his vaccine and despite safety testing, some batches from Cuter Laboratories contained live virus later linked to over 250 cases of iatrogenic polio. Greater government oversight of vaccine production was called for, but ultimately an oral vaccine from Albert Sabin’s team proved safer and gave more lasting immunity, although U.S. authorities were not initially interested in anything but the Salk series of injections and Sabin had to conduct his first large scale trial in the Soviet Union in 1959. [Below: Photo: Nebraska clinical trial of the Salk polio vaccine, May 1954. From KOLN/KGIN-TV, Lincoln and Grand Island. (History Nebraska RG809-51)]

Polio testing children, May, 1954.


Five.

Shimomura Crossing the Delaware, a provocative self-portrait of the artist Roger Shimomura, is prominently displayed at the National Portrait Gallery in Washington DC, – a wonderful place to visit when museums open to the public again.

At first glance Shimomura seems to turn history upside down, but with a little contemplation his work amplifies the idea of the American Dream. The artist fairly claims that America is his country too in 2010 as much as it was that of George Washington, who is more traditionally envisioned crossing the Delaware River on December 25, 1776. Shimomura’s large and striking painting, created nearly 70 years after Executive Order 9066, recapitulates the 1851 work of Emanuel Leutze at the Metropolitan Museum of Art (Washington Crossing the Delaware), but replaces Washington with Shimomura, the colonial troops with samurai warriors, and the geographical location with San Francisco Harbor and Angel Island, once a processing point for Asian immigrants.

In 1942, Shimomura, was not quite three years old when he and his family were forcibly relocated from their home in Seattle to an internment camp in Idaho. Franklin Roosevelt’s Executive Order 9066, signed two months after Pearl Harbor, caused this horrible trauma. That single presidential action designated military commanders to designate exclusion zones from which any American citizens or non-citizens could be excluded and relocated. Census data helped compile lists of such persons. Ultimately, 120,000 people, around two-thirds being U.S. citizens, were relocated to around 50 internment camps.

Ultimately, it is clear that the executive order and resulting program were based on “willful historical inaccuracies and intentional falsehoods,” according to a 1942 Naval Intelligence report that was suppressed by Roosevelt’s solicitor general Charles Fahey. The relocated people had posed no security threat, it was evident even at the time. Fear and ethnic bias left this terrible blemish on Roosevelt’s administration and the American narrative. 

The point here is that each of us creates their own origin story from their history as they know it – built on individual identities, beliefs, and aspirations. George Washington and Roger Shimomura had theirs, you and I have ours, and George Floyd had his. Each is as remarkably different as they are similar, sharing remarkable fundamentalities. John F. Kennedy may have said it best in his speech at The American University, Washington, D.C., June 10, 1963: “For in the final analysis, our most basic common link is that we all inhabit this small planet, we all breathe the same air, we all cherish our children’s future, and we are all mortal.”


Postscripts.

Another Shimomura. 

Osamu Shimomura (1928-2018) is a name that rings a bell for biological scientists. Not directly related to the American painter, Osamu was born near Kyoto he was a 17-year-old living in the Nagasaki area when the atomic bomb exploded 25 km away, blinding him for about 30 seconds and then drenching him with the black rain of the fallout. Against the odds he survived, was educated, and achieved great academic success, culminating in a Nobel Prize in chemistry in 2008 for his discovery of aequorin and green fluorescent protein. 

 

Ed Tank reminiscences.

Sherman Silber: “I am very sorry to hear of Ed Tank’s passing.  He taught me a lot from gender assignment in intersex cases to high diversion with pediatric hydronephrosis, which got me in deep trouble with some very opinionated and obstinate people.  He taught me a lot about adrenogenital and testicular feminization, and the bigger issue of the origin of gender identity and SEX preference.”  

Paul DeRidder: “I just read your latest “Matula Thoughts” and saw the article on Ed Tank.  In my senior year of medical school, 1971, I took a rotation in Urology.  Ed Tank was more or less my mentor.  I remember him well.  He was a determined surgeon, strong personality and great mentor.  I remember his suggestion that I review a text in pediatric urology, which I diligently went to the library to review many times.  He saw me in the library and was surprised that I was diligent enough to spent time reading the suggested text in my free time at the library. It was because of Ed, my feeling, that I was accepted to the Urology program as an intern, 1972.  When I completed my training, Ed had moved to Portland and as I was looking West to set up practice, I contacted Ed and asked if there were any openings in the Portland region.  HIs comment was “oh, no it is paradise here and we are saturated with Urologists.” He suggested I look elsewhere. Great guy!”


Thanks for reading Matula Thoughts, this July, 2020.
David A. Bloom

Flat vs. round

WN/MT June 2020

Flat vs. round.

2949 words

[Blue Marble from NASA Terra at 438 miles.]

Last month, world attention was dominated by a disruptive virus, angered by ugly politics, briefly turned to a space station special delivery, and horrified by the retrograde murder of George Floyd. Michigan Urology also lost one of its foundational alumni, Ed Tank.

 

One.

A flat Earth was a reasonable belief for Homo erectus and their other hominin cousins, including Australopithecus sediba shown below in reconstruction at the University of Michigan Natural History Museum (visited just prior to the closure for coronavirus). The campfires, hunting grounds, and cave dwellings of early humans reinforced a sense that their environments were mainly two-dimensional landscapes of hills, valleys, and forests.

That mind-set changed when clever Homo sapiens, sailing the seas and studying the skies, figured out the true fact of the round Earth: sailors noticed mountain peaks well before they saw the shorelines as they approached land and astronomers, lucky enough to see eclipses, deduced that circular shadows on the moon could come from spherical bodies. Aristotle captured some of these ideas in writing and a few intrepid navigators had enough faith in a round Earth hypothesis to venture west across the Atlantic, millennia later. [Below: lunar eclipse, Wikimedia, with permission, Tom Ruen 14 October, 2014.]

John Cabot in 1497 was one of the first identified Europeans to navigate to the North American Continent. Unnamed Norse explorers and fishermen as far away as the Basque region fished the Grand Banks seas and set foot in present-day Newfoundland and Labrador centuries earlier, but it was John Cabot from Bristol, England, to whom the first name can be attached. Originally named Giovanni Caboto from Genoa, he worked his way to Venice, then Spain, and finally England seeking funding for an expedition. Bristol, the second largest city in England and a major port, was where he raised enough capital to build a three-mast ship of 60-feet and 50 tons and find a crew to follow his belief in a round Earth. King Henry VII gave Cabot a Royal Warrant (a “visa” of the time) to explore what was presumed to be Asia. Cabot’s single ship crossed the rough North Atlantic with a crew of 18-19 in 34 days, explored Newfoundland or Labrador, and accurately returned to Bristol in 15 days.  The journey was repeated successfully once, but the ship was lost in 1498 on a third try. [Below: traditional globe.]

Five years before Cabot’s journey, another immigrant from Genoa, then living in Spain, crossed the gentler southern Atlantic Ocean to Caribbean Islands with three ships. Christopher Columbus had obtained financing from King Ferdinand and Queen Isabella, making two other return trips, but never reached the mainland. In fact, no one from the Spanish contingent reached the actual North American continent until 1513. It is possible that Columbus and Cabot met in Spain between 1490 and 1494, but Cabot certainly knew about the travels of his fellow countryman. Columbus and his sons branded their enduring legacy effectively. Cabot, lost at sea on his third voyage, wasn’t so well represented by his son Sebastian who was more interested in his own opportunities than advertising his father’s accomplishments. The Cabot story was eclipsed until now. Was Giovanni Caboto an ancestor of Hugh Cabot? It’s quite possible.

 

Two.

Retrograde visions. Orlando Ferguson (1846-1911), a self-styled professor from Hot Springs, South Dakota, copyrighted his Map of the Square and Stationary Earth in 1893, subtitled “Four Hundred Passages in the Bible that Condemns the Globe Theory, or the Flying Earth, and None Sustains It.” He completely discounted two and a half millennia of recorded human history and verifiable knowledge in favor of his literal translation of the Bible and belief in a “square and stationary Earth.”

Born near Du Quoin, Illinois, Ferguson moved to Dakota Territory in the 1880s, opening a grocery store and hotel. After a fire destroyed the hotel, he built a bath house near Siloam Springs and became known as “doctor” to some patrons. Fergusson’s map never gained traction and fell out of sight until discovery more than a century later. The map was donated in 2011 to the Library of Congress by State Senator Don Homuth. [N. Jackson. Library of Congress Receives Rare Map depicting Earth as Flat. The Atlantic, June 22, 2011.]

Edwin Abbott Abbott (1838-1926; shown above, Wikipedia), English schoolmaster and clever satirist, poked fun at his stultifying Victorian culture with a book in 1884 called Flatland: A Romance of Many Dimensions. Perhaps not wanting to be identified too closely to the ancient idea, Abbot used the pseudonym “A Square.” One of its illustrations (below) may have served as a model for the gendered entrances to the original Michigan Union, when it was built in 1917.

One of Abbott’s students at the City of London School, Herbert Henry Asquith, became Prime Minister of the United Kingdom from 1908 to 1916. Later the Earl of Oxford, Asquith, didn’t take Abbott’s Flatland literally when he oversaw the dispatch of the British Expeditionary Force (BEF) to the Western Front in The Great War in 1914. (Hugh Cabot would join the BEF in 1916.) The Flatland story was picked up in a 2007 film and two shorter films, Flatland: The Movie (2007) and Flatland 2: Sphereland (2012). Abbott’s “romance” was a clever fantasy and is still an entertaining read (below), but The Flat Earth Society is a meme for people unfortunately stuck in obsolete versions of reality or obstinately clinging to it for self-serving reasons.

 

Three.

Hardy Hendren, an iconic presence in my clinical education and even more so for that of John Park, introduced me to the Flat Earth meme, once commenting: “If you stick around long enough, you’ll meet someone who believes the world is flat.” It was a good lesson and I didn’t have to wait long to find members of the Flat Earth Society. Hendren was one of the best early explorers of the round earth of pediatric urology, but warned his students that Flat Earther’s always try to block progress. [Above: Hendren as visiting professor at University of Michigan 2012.]  Luddite is closely synonymous for the frame of mind in which persuasive argument, careful observation and reasoning, or scientific evidence fail to release a person from primitive beliefs.

Hardy educated his trainees in many ways even outside the operating room, where his rigor of thought, innovation, and tenacity were unmatched and those disciples carried his ideas and philosophy around the world.

Hendren’s clinics, relationships to referring physicians, and care for his supporting team set powerful examples for generations of students, residents, and fellows. After his own diagnosis of colon cancer, publicly discussed for all to learn from, Hardy quit smoking and became evangelical in urging those he encountered to quit. Trainees, colleagues, and people on the street were lectured vigorously. So too were parents of the children he treated – I marveled at his bravery, holding out a trash can to astonished parents in clinic to dispose of their cigarettes and lighters. Some may have seen this as an affront to personal choices, but Hardy was on a mission to minimize comorbidities of his patients, dispelling Flat Earth views of the world, including that of the healthy cigarette. Alberto Pena, Mike Mitchell, Rick Rink, John Park, Joe Borer, David Joseph, and Craig Peters with so many others took notice and found their own ways to perpetuate Hardy’s work in their practices and carry his ideas around the world. (Below: modern version of Cabot’s journey.)

 

Four.

Debts of gratitude. Almost everyone I know in health care proudly carries debts to influential teachers and role models. While the term, debt of gratitude, raises eyebrows of grammatical purists it does seem to work for most of the rest of us, especially in terms of our mentors and role models. Hardy Hendren stands tall in my list. Although I didn’t train with Jack Lapides, only knowing him in his retirement years, Jack, too, is high on the list for the contributions he made to our field and his style of intellectual rigor was impressed on his trainees and disseminated throughout their careers to their own students and colleagues such as myself. I have heard Jack mentioned with reverence over the years by so many of those who came within his orbit including Bill Baum, Marc Taub, John Hall, Barry Kogan, Steve Koff, Evan Kass, Bart Grossman, Gary Wedemeyer, Jay Hollander, and Ed Tank to name just a few. Our role models, and so much more of what is good in humanity, get drowned out by the daily tragedies and evils that compel our attention to news cycles.

Last week’s UMMG Town Hall responded mainly to the covid disruption of our work and lives and something David Spahlinger said caught my attention. He offered the metaphor that in the present phase of our national and personal traumas many people are in the “valley of disillusionment.” In our UM health system David is in the tough position of being the daily lightning rod for complaints, anger, disillusionments, and expectations for solutions to extremely difficult problems. Yet as an internist and intensivist, working in the thick of things and as president of the health system making rounds throughout all corners of the medical center, he is eminently credible. His talk noted that some of our colleagues “bristle” when they are told that “we are all in this together,” because the reality is that the suffering is inequitable. People suffer in very different ways – from the front line maintenance worker to the ICU nurse to the junior emergency department resident to the exhausted hospitalist to the beleaguered phone line staffer to the senior administrator trying to do their jobs. Each person’s home and family situation is unique and it is perhaps presumptive when leaders presume cohesion of a group. Spahlinger wisely said:

“The financial impacts of no merit increase and suspension of retirement contribution are not felt equally by everyone. Likewise, not everyone is working on the front line risking their own health. Those at home are under stress as they wonder if they have a job to come back to. My point is that everyone is suffering in different ways. The reason I say we are all in this together is that I don’t think we can prevail as an organization and carry out our mission unless we face the challenges ahead together.”

From my point of view as a colleague of David Spahlinger over the past 30 years, we all owe a great debt of gratitude for his excellence as a clinician and credible leader in our health system.

 

Five. 

Ed Tank. Michigan Urology lost one of its most extraordinary alumni when Ed died in Portland, Oregon on May 13 at age 88, leaving his wife Rosalie, four children, seven grandchildren, and a three-year old great-grandson. Born on March 23, 1932 in New Rochelle, NY as the first of two children, Ed grew up in the midst of the depression admixed with the urban excitement of his region. As a young boy he recalled meeting the legendary Yankee baseball player, Lou Gehrig (1903-1941) in an elevator. The Tanks moved to Western Springs, Illinois, in the Chicago area sometime around 1938 and Ed attended public schools in the La Grange district. The east drew him back for college at Amherst where he dove deeply and enthusiastically into liberal arts, in addition to having an outstanding collegiate wrestling career. In college he fell in love with Dixieland Jazz and loved to travel to Jimmy Ryan’s Jazz Club on Manhattan’s West Side to hear Wilbur de Paris and his band.

Medicine attracted Ed late in his college years and after graduating in 1954, he returned to Chicago for a postbaccalaureate year at Loyola to fulfill medical school requirements. This got him into St. Louis University Medical School, graduating in 1959. Along the way on a road trip back to Amherst for his third year college reunion Ed reacquainted with a childhood friend, Rosalie Butterfield, in Philadelphia and the couple married six months later. In St. Louis the couple had their first child while Ed was coincidentally rotating on the obstetrics service where Rosalie gave birth to Ellyn Marie.

In July 1959 Ed began surgical internship and residency at the University of Michigan under Gardner Child, III. The couple remained in Ann Arbor for two additional years, living quite happily as Rosalie recalls living in converted wartime housing then still present in Pittsfield Village and growing their family, with Julie who was born at St. Joe’s.

A research year was necessary in the surgery program, unless a resident had served in the military – and if so they were forgiven the year. Ed chose to do his research in Boston 1962-1963, working closely with Bill Bernard on hyperbaric medicine and was inspired to pursue pediatric surgery. A third daughter, Katie, was born at Boston Lying-In Hospital.

The Tanks returned to Ann Arbor in the summer of 1963 through summer of 1965, as Ed completed his surgery training under Gardener Child and during Reed Nesbit’s last years of leadership in urology. In July 1964 their son Ted was born at University Hospital.

Ed took the family back to Boston at Children’s Hospital for two years of training under Robert Gross, whom Rosalie recalls more of “a name” rather than a strong influence in Ed’s training at that time. She recalls Arnold Colodny’s strong influence then and Ed’s “double dose” of pediatric urology rotations under Alan Perlmutter.

In the summer of 1968 Ed returned to the University of Michigan as its first pediatric surgeon, but encountered turf issues with other surgical disciplines, distrustful of the emergence of pediatric surgery as a discipline. Thoracic surgeons were unwilling to “relinquish” the chest to Ed. Jack Lapides, Michigan’s new chief of urology, offered additional training in the urology domain and Ed, therefore, spent two years as a urology “resident” under Lapides while still holding responsibilities as a faculty member. Ed Tank then became the first trained pediatric urologist at the University of Michigan and remained on the faculty until May 1973 when he took a job in Portland at Oregon Health and Science University. The University of Michigan then had no pediatric surgeon until Arnie Coran came in July 1974.

Portland had been selected after a “big family discussion,” according to Rosalie. Ed enjoyed his work there with Jack Campbell, but found he had to focus on pediatric urology exclusively, even though he had hoped to practice general pediatric surgery as well. Ed was a superb clinician, surgeon, and teacher and inspired a generation of students and residents, one of the earliest being Rob Kay who came from UCLA medical school to Portland for residency 1974-1979, before going to the Cleveland Clinic. Ed’s first associate in pediatric urology was Steve Skoog who came in 1992, having trained at Walter Reed Army Medical Center and the Washington National Children’s Hospital under Barry Belman in 1985-1986. Steve recalls his first case with Ed was a 7-year old with Mayer-Rokitansky syndrome who had a Young-Dees urethroplasty and bilateral reimplantation.

Ed, wanting to cut back somewhat clinically, left the university in the mid-1990s and joined the Northwest Urologic Practice with Tom Pitre, operating at Emanuel Hospital.

Ed was leader in pediatric urology nationally, serving as Chair of the Section on Urology of the American Academy of Pediatrics 1990-1991. Some of his papers stand as “classic” in pediatric urology literature. Ed loved the Northwest and continued his boyhood love of fishing. He and Rosalie explored the round earth from Alaska to Antarctica. Ed was a big reader – always carrying a serious (nonfiction!) book with him. Rosalie recalls that she couldn’t talk him out of lugging a large hardcover biography of Truman or Eisenhower with them as they trekked the Himalayas.

Ed and Rosalie then focused most of their time in Sunriver Oregon and on their grandchildren, but continued some work for a time at Madigan Army Hospital and Native Health in Alaska before it had regular coverage. His collegiate passion for Dixieland Jazz persisted throughout his life and he made Rosalie a convert to it, with “umpteen jazz trips” across the country and around the world.

Ed and Rosalie loved and supported local classical music and repertory theater. Ed was a cheerful and generous maverick and always a passionate teacher, whether the subject was pediatric surgery, fish anatomy, crabbing, or subjects of his wide-ranging reading. Ed Tank was the first bona fide pediatric surgeon and pediatric urologist at the University of Michigan – a wonderful physician, teacher, role model, and friend to those lucky to have known him.

[Below: the subtle arc of the horizon from Portland to Detroit on a Delta Airlines Boeing 737 five miles high.]

 

Postscript.

On this round and small Earth, everything and everyone is connected. Events and ideas that originate at one spot may reverberate widely and persistently around the sphere. Navigation of the round Earth was not universally beneficial, certainly not for indigenous peoples of the Americas, Australians, or enslaved Africans.

David Spahlinger’s point, quoted above, links a number of issues at this distressing moment in time, including our rattled workplaces at the University of Michigan and the death of George Floyd on a Minneapolis street. I took from David’s statement at the Town Hall, that a legitimate understanding of the diversity of suffering predicates any solution to any particular challenges of the moment (and any claim to unity, i.e. “we are all in this together”). This applies beyond UM to regional, national, and global predicaments of poverty, war, and human justice. If individuals of diverse perspectives and circumstances are to find solutions to existential problems, any effective leadership for them must be credible –  credibility built not only on respect for diversity but also commitment to fair amelioration of inequities as we rebuild from months of the covid economic crisis and centuries of retrograde human inhumanity.

 

Thanks for reading Matula Thoughts, this June, 2020.

David A. Bloom

University of Michigan

Back on the road to contagious hospitals

Matula Thoughts 1 May 2020
2430 words


Back on the road to contagious hospitals

“Reading gives us someplace to go when we have to stay where we are.”
Mason Cooley, American aphorist, 1927-2002.


[UH & UMMS Early spring 2020 on the road from old AA train station to main campus of Michigan Medicine.]

One.

Back on the road. May is usually a sweet spot in the calendar, but not so sweet around the world this year. Some random mistakes in the RNA sequences of a single common virus created a new version that has wrecked worldwide havoc on health, hospitals, and economies. Normally in May, memories and anticipations run strong, for it is a particularly sensual time of the year when colors, smells, tastes, sounds, seem to have especially bright notes after winter dormancy has lifted in the northern hemisphere. That sense of memory and anticipation is reflected in William Carlos Williams’s curious piece, Spring and All [By the road to the contagious hospital], written by the New Jersey physician and published in 1923. The title has long intrigued me and the content continues to puzzle me. Williams was a doctor in New Jersey, who wrote in his spare time. He was an excellent physician, my friend Joan Chiaviello Flanigan recalls from his care for her family when she was a child.

The odd free verse poem of Williams is deliberately mal-organized into 27 sections (identified by Roman enumeration I through XXVII, minus the missing number VII), with random prose interludes of commentary, “chapters,” and unidentified “footnotes” interspersed throughout it. An upside-down Chapter XIII follows a normally-oriented Chapter 19 in the unspecified introduction to the poem. Most verbal images precede spring and are neither attractive or cheering. Spring and All, both poem and its world, is very much upside down and disordered, until XXII and the Red Wheel Barrow that helps set things right. [Below: the confusing “Chapter XIII.”]

 

Little did we expect, just a year ago writing here about Williams, that we would actually be back on the road to contagious hospitals this May in 2020. Luckily, the Michigan Medicine field hospital at the athletic complex did not require deployment several weeks ago because social distancing and personal hygiene flattened our covid19 curve enough to preclude the new contagious hospital in Ann Arbor – at least for now. Given the widely disseminated knowledge of historians and scientists, it is incredible that we were surprised (again) by a terrible infectious pandemic.

Two.

Contagious diseases worried the University of Michigan Medical School in 1897 when it converted a small laundry shack behind the Homeopathic Hospital into a Contagious Ward for diphtheria, smallpox, and scarlet fever, diseases barely mentioned in medical schools today. In 1914 the city of Ann Arbor, still recalling a 1908 smallpox epidemic, gave the university $25,000 for a new Contagious Disease Hospital with 24-beds in an isolated area, well to the east of the larger hospital grouping. The civic contribution was as much a matter of self-protection than generous philanthropy, although the two attitudes are not unrelated, for philanthropy after all is a self-protective attribute of humanity at the species level. [Below: Michigan’s Contagious Hospital 100 years ago. Bentley Library.]

Williams wrote Spring and All [By the road to the contagious hospital] at an exuberant time for the University of Michigan and its Medical School. Urologist Hugh Cabot, recently appointed dean (in 1921), was building a great medical faculty and new hospital. Michigan’s  contagious hospital of that time is now long gone and the idea of contagious hospitals had all but disappeared in Ann Arbor and around the world, until this past winter. Some modern hospitals, such as our new Mott Children’s Hospital have been built for contingencies of terrible new epidemic possibilities such as SARS and Ebola, as well as resurgences of ancient ones like measles – perplexing and only understandable because of persistent human folly. Contagious hospitals revived in Wuhan and Manhattan this winter, although they seem to be more contagious dormitories rather than hospitals as we now think of them.

Three.

A May birthday. One birthday to recall this month is that of Dorothy Mary Crowfoot Hodgkin, born on 12 May 1910 in Cairo, Egypt. I first became interested in Hodgkin when I saw a painting of her at the National Portrait Museum in London, last winter during a visit for the wedding of the daughter of my good friends from our training years in London, Robert and Anita Morgan. The painting was prominently displayed and instantly attractive, but a mistake in the label next to it caught my attention.

Dorothy was the oldest of three daughters of John Winter Crowfoot, a civil servant in the Ministry of Education, and his wife Grace Mary Hood. Living and working in Egypt for many years, the family returned to their native England each summer in the hot months and during one of those summers WWI began. In that August of 1914 the parents left their girls with paternal grandparents near Worthing to return to Egypt, where father could continue work.

After the war, the reunited Crowfoots relocated to Sudan where Mr. Crowfoot was put in charge of national education and archeology, until 1926. The girls attended local schools in Sudan and Dorothy became fascinated by archeology and the mosaic tiles in Byzantine-era churches. She also developed an interest in chemistry and her mother, a botanist, gave her a book on x-ray crystallography for her 16th birthday. Dorothy combined her interests by drawing pictures of mosaic patterns and doing chemical analyses of the tile cubes, called tessera. At age 18 she returned to England to study chemistry at Somerville College, Oxford, and received first-class honors in 1932, proceeding then to Newnham College, Cambridge for Ph.D. studies.

Dorothy worked with John Desmond Bernal on applications of x-ray crystallography to protein analytics and their work on the structure of pepsin turned out to be the first biological crystallographic analysis. Dorothy obtained her Ph.D. in 1937 for work on sterol structure and she held a post as Oxford’s first fellow and tutor in chemistry until 1977. In 1964 Hodgkin won the Nobel Prize in Chemistry. [Below: Hodgkin’s model of penicillin. Science Museum London, Science and Society Picture Library.]

Molecular model of Penicillin by Dorothy Hodgkin, c.1945.

One of her students, a young woman named Margaret Roberts at Oxford from 1943 through 1947, wrote a dissertation on the x-ray diffraction of the antibiotic gramicidin that led to a good job in industrial chemistry but Roberts turned to politics around 1950, married Dennis Thatcher in 1951, and qualified as a barrister in 1953. In 1959, then Margaret Thatcher, she was elected member of Parliament, rising to Prime Minister in 1979. In her office at 10 Downing Street Thatcher displayed a portrait of her former teacher. Hodgkin, however, was a life-long supporter of the Labour Party. [Below: Hodgkin legend with corrected name of artist. National Portrait Gallery London, December, 2019.]


The mistake that caught my eye at the National Portrait Gallery was in the adjacent description of painting and artist, Maggi Hambling, where her first name was written “Maggie,” but someone (I’d imagined it might have been the offended artist herself) crossed out the final “e” with what seemed to be a pencil. No matter, the museum is now closed down for a lengthy renovation and time will likely heal this minor error.

Four.

Among the many innovative changes Ganesh Palapattu has brought to the Department of Urology is the broadening of the weekly grand rounds conferences to periodic wider learning experiences that extend beyond world of urology, that he calls “Teach us something.” A session of this nature in late February featured Professor James Kibbie, Chair of the University of Michigan Organ Department who taught us something in the School of Public Health (SPH) where one of the 16 pipe organs of the University of Michigan temporarily resides. In late February Professor Kibbie spoke on “Bach and the Organ,” and treated our faculty and residents to three beautiful pieces (played on the James Walgreen Létourneau Organ on loan to the SPH) from the 270 surviving organ compositions of Bach. [Above: Professor Kibbie at urology grand rounds.]

Kibbie has been collaborating with computational faculty to understand the science behind Bach’s music and a recent grant from Barbara Sloat allowed him to record all of the Bach organ works, all 270 pieces, performing them on instruments of Bach’s era located mainly in Germany. These works are available to the public through the University of Michigan. [From Prof. Kibbie: “If you want to add the URL for the university’s website with the free downloads of my Bach recordings, it’s http://www.blockmrecords.org/bach.”%5D


[Above: Kibbie, Vesna Ivanĉić, Sam Kaffenberger.]
The pipe organ, complex and large, manipulates forced air through many ingenious pipes. Mistakes are inevitable in all spontaneous performances and Professor Kibbie explained how organ recitals are particularly susceptible, having three keyboards, multiple stops, layers of foot pedals, hundreds or more pipes, and up to 100,000 parts. Paired with the human factor, pipe organs offer countless opportunities for performance variations and transcription errors. Of course, Professor Kibbie’s ear can register musical mistakes that fly by most of us with untrained attention.

Everyone makes mistakes from the moment they arise in the morning, whether squeezing out too much or too little toothpaste, rolling through a stop sign on the way to work, or parking too close to an adjacent car – the possibilities are myriad although most are inconsequential. Error is something we understand in clinical work. Medical mistakes may be transcribing errors when writing (now, typing) patient stories, missing veins on blood draws, or making erroneous clinical decisions. To err is human, to err consequentially is unfortunate.

Algorithms promise perfection, if we are naïve enough to forget that they are written by humans. Whereas a piano played spontaneously offers novel idiosyncratic momentary interpretations, innovations, or mistakes that combine to make each performance unique – and mistakes are nearly inevitable –  a programmed piano (player piano) is free of performance interpretation and variation. The standardization (assumed to be error-free, but any algorithm is only as good as its author) brings freedom from the anxiety and art of human performance.



Five.

A scarlet tanager showed up in our old neighborhood last May around this time. My neighbor, Mike Hommel, called to alert me one Friday afternoon when I was indoors on the computer working on the Urology Department history. Mike is a great naturalist who can spot morels on the ground and birds in the trees better than anyone I know and that day, specifically 10 May 2019, he spotted this little fellow, tired and resting after a long flight from somewhere in the south. The splash of color is amazing and has served its evolutionary purposes well. This little guy was not too concerned by our attention as it shifted trees periodically and hopped to the ground to feed from time-to-time.

Had William Carlos Williams spotted a scarlet tanager on his road to the contagious hospital, the poem would probably have been much different. (Such are the contingencies of life.) Piranga olivacea used to be categorized in the bird family Thraupidae within the Passeriformes family (the perching birds with one backward and three forward toes) but DNA studies have reclassified them to the cardinal family (Cardinalidae). When I was younger the Linnaean binomial classification held little interest for me, but my perspective has changed. I looked for the tanager the next day, but he had moved on. A number of deer, however inspected me carefully. They used to drive us crazy, eating everything we planted, and either we would shoo them away or our dog, Molly, would give chase. By May, 2019, Molly’s arthritis had erased her interest defending the property and at that point the property seemed to belong more to the deer than to Molly or us, which was just as well for we had sold the house to downsize in downtown Ann Arbor.

Other hopeful signs of spring popped up last month, oblivious of the prevailing RNA threat to humans. [Above and below: early April 2020, Ann Arbor Water Hill area.]

[Above: pond in West Park. Below: new normal – outdoor picnic tables at Zingerman’s replaced by spaced waiting areas for take-out orders.]

 


Postscript.

Disruption. Is clinical medicine a performance art, as aspired to by professionals since Hippocratic times, or is it becoming an algorithmic practice? Professor Kibbie provoked this question. The doctor-patient relationship has been disrupted by the “encounter” framed by the electronic health record (EHR) format, that is the ubiquitous EHR-directed patient “encounters” have replaced the narratives my generation was taught to elicit. We used to initiate evaluation of patients using the so-called SOAP notes (subjective, objective, assessment, and plan) that align with the medical gaze – Sherlockian/Oslerian scrutiny by a trained observer. 

A “chief complaint” was a story that could be boiled down to a phrase, but narrative demanded more and gave the chief complaint context. Shoulder pain could be a malignant metastasis or a rotator cuff injury and it was important to know if the injury was life-style related, due to occupation, or traumatic; the story behind the pain, its comorbidities and social determinants, are no less relevant than the pain itself. Abstraction of a patient’s story to a drop-down phrase or an ICD-10 numeric diagnostic code is a poor substitute for conversation, medical gaze, and narrative. We should resist this terrible trend as best we can and create EHRs that support narrative inquiry and medical gaze rather than commoditize encounters.

One hundred years ago, Hugh Cabot got off the train from Boston at the old Ann Arbor station (shown at the top) and initiated the first century of Michigan Urology, not knowing that he would have little more than a decade to do it. Medical care had its disrupters back then, new technology, burgeoning subspecialties, and novel models of practice. Some tension existed between the old and the new approach to disease. Classical Oslerian ideas are routed in the bedside medical gaze and dialogue with the patient to understand and explain the problem. The new scientific approach sought to understand disease based on facts derived in research laboratories, other sources of verifiable data, or from the patient as a virtual laboratory. Clever clinicians recognize it is not a matter of one or the other, patients deserve both approaches. Brutal realities of a post-covid19 world will favor the curt, transactional, commodity aspects of health care. Role models in fiction and fact such as Sherlock Holmes and William Osler, and new analyses such as The Good Doctor – Why Medical Uncertainty Matters, a book out soon by Kenneth Brigham and Michael Johns, help navigate this new era of disruption.

[Below: sign of spring, late April, near Barton Pond.]



Thanks for reading Matula Thoughts of May, 2020.
David A. Bloom, University of Michigan Department of Urology

April, perhaps the cruelest month

WN/MT 3 April 2020
2356 words

This April, perhaps the cruelest month



One.

April, was the original title of this painting by American impressionist Frederick Childe Hassam, a century ago, in 1920. It was an optimistic time when the world was rebounding from years when the thin veneer of civilization seemed to be wearing away with war and influenza. The pendulum of events changed for the better and, in Ann Arbor, Hugh Cabot started up a century of modern urology at the University of Michigan.

It is a mystery what drove Hassam, just then, to go back to his very beginnings with this work. Maybe the emergence of the world from the edge of catastrophe just then was a factor. He renamed his painting, Green Gown, the woman in green being Rosa Delia Hawthorne, Hassam’s mother, depicted in an April a half century earlier when three months pregnant with Frederick (born October 17, 1859 in the family home in Dorchester, Massachusetts). [Above: April, Courtesy, Gibbes Art Museum.] The gorgeous composition shows Hassam’s imagination of his mother at 27 years of age, reclining pensively on a settee, as if considering her next 6 months of confinement or the joys and trials of parenthood. A daffodil arrangement in the right foreground reinforces the time of year in the original title. Yet it was an odd concept for a painting, with the artist picturing his mother in the first trimester of pregnancy with him, at his actual beginning. This was a curious contrast to Whistler’s famous consideration of his own much older mother a half century earlier.

Hassam’s painting is a suitable introduction to April, the beginning of spring in the northern hemisphere, when showers anticipate May flowers, as the saying goes. Another painting by Hassam, The Avenue in the Rain (in the White House Collection) depicts Fifth Avenue in NY around the time of WWI and perhaps during some April showers. This was one of 30 paintings in Hassam’s Flag Series.



Hassam purchased a home in 1919 in East Hampton where he most likely painted April the following year and would live another 15 years, dying in East Hampton at a respectable 75. The country was in a patriotic mood in April, 1920, with the Great War and recent influenza epidemic no longer existential threats, but the national optimism eclipsed any prudent attention and resources to prepare for the next iterations of existential threats. This April, normally a time for beginnings, existential threats are back at civilization’s door. [Above: The Avenue in the Rain. Hassam, 1917. White House Collection, since the Kennedy Administration. Below: Oval Office 2009, photo by Pete Souza with the president and the picture on the wall.]





Two.

A century is a convenient milestone, although most humans fall short of this in their life spans. The modern average of “three score and ten” or so, however, is ample time to leave something behind, if one is fortunate, in good works, successors, and kindness. Octogenarians, septuagenarians, and centenarians are rarities, the products of good genes and lucky circumstances. The U.S has 80,000 centenarians, the U.N. estimates 343,000 worldwide in 2012 and projects 3.2 million by 2050.

A century is an extreme stretch for a single human, few make it that long, but human collectives – nations, organizations, corporations, and other teams – are not limited biologically and for them a century is a useful ruler to measure accomplishments and create historical narratives. So, consider medical practice and urology in April 1920, in particular, when the grim experiences of war and influenza were fading from memory, although some lessons learned were working their way into civilian health care. The growing scientific knowledge base of medicine and its burgeoning subspecialties by 1920 had rendered medical school alone insufficient training for the new generation of medical practitioners; internships and residency programs were producing a new world of graduate medical education that became the career-defining element of medical training.

This centennial year of urology at the University of Michigan is an opportunity to understand our organizational corporate past and some of the many stories relevant to Michigan Urology. Additionally, the centennial is a chance to personally reconcile with our roots in healthcare and at the University.

With the present world turned upside down by Covid19, the AUA in Washington, DC and Sunday Nesbit reception are cancelled, but we look forward to the autumn and September 24-26 with the Nesbit alumni reunion here in Ann Arbor, featuring guest speaker alumni Carol Bennett, Barry Kogan, Ananias Diokno, Carl Smith, Curtis Nickel, Mitch Albom, and Sherman Silber, among others. The first of our two books on Michigan Urology will soon be available (and also online via Michigan Publishing), this being Urology at Michigan – The Origin Story, tracing the development of genitourinary surgery, the University of Michigan, its Medical School, and the introduction of modern urology to Ann Arbor by Hugh Cabot. Book two will cover the first hundred years of urology at Michigan, year by year, expanding on the Konnak and Pardanani text that Jim Montie commissioned 20 years ago. We hope to finish this in the next year.

This April 2020 it’s natural to pause for a moment and consider what urology practice and education were like 100 years ago. Cystoscopy, a new skill of the late 19th century, required special instruments and novel expertise that defined urology and fueled its early creative burst. A new breed of surgeons picked up cystoscopy, improved the technology, gained insight into genitourinary dysfunction, and created miracles of minimally-invasive therapy. Nonoperative and open solutions to urinary problems expanded urology, after it was so-named in 1902. Urology came together as an open organization in 1910, created rational training programs for young physicians, and formed its own journal in 1917. Little of this progress translated to the battlefields of WWI, but the civilian progress accelerated after its conclusion, although barely in time to be applied in the next war.


Three. 

 

In April, 1920, the Cabots were adjusting to their new lives in Ann Arbor. Hugh was busy as chair of the Surgery Department and the sole urologist at the University of Michigan. Cabot’s two competitors in Ann Arbor, still calling themselves genitourinary surgeons, had left the university to practice a few blocks away at St. Joseph’s Mercy Hospital and neither they nor Cabot had any interest in collegial relationship. The University Hospital complex was physically constrained and outdated, pale in comparison to the facilities Cabot left behind in Boston, but a quantum leap from the 2,500-bed hospital he had commanded in France on the Western Front of the Great War.

The Cabot family was living temporarily in the President’s House, having cajoled the Regents into its use pending the anticipated summer arrival of incoming President Burton. Anxiety was growing within the university administration as it tried to coordinate renovations demanded by the Burtons and uncertainty over the Cabot’s plans. At work, Cabot had to manage the teaching and clinical responsibilities of his small Surgery Department, deploying the full-time compensation model. To grow his small and inbred Surgery Department Cabot leveraged his military connections to bring two essential additions to Michigan that year, Frederick Coller and John Alexander.


Four.

Just about halfway between the start of the Michigan Urology centenary and now, I began my era of training. It was 1971 and urology was at a watershed. It sat between an era of board-certified urologists with life-long certification working in individual or small practices and the present era of urologists with contingent re-certification working in large practices or multispecialty health systems. In 1971 fiberoptic cystoscopy had only recently replaced first generation cystoscopes, illuminated by distal mignon lamps of Edisonian technology; transurethral surgery was one of surgery’s rare minimally-invasive operative procedures; major open reconstructive urologic procedures were available at only a few centers; the intravenous pyelogram and retrograde injection studies were the main imaging modalities (ultrasonography was in its primitive stages); and training programs were mostly small and weakly standardized. That year, Jack Lapides Section Head of Michigan Urology from 1968 through 1983, introduced his strongly disparaged idea of clean intermittent catheterization.

Meaningful visual cystoscopic acuity for old-time urologists required much skill, art, and experience. For learners, peeping over the shoulder of  cystoscopists (whenever they decided to let learners have a look), the opportunity was fleeting. This scenario earned Jack Lapides his covert nickname, Black Jack: for he was known to temporarily disconnect the light cord (by stealth of hand) before letting the learner look through the scope and asking what they saw. [Below, Jack Lapides photo by DAB.]



Lapides had been a loyal and productive lieutenant to Reed Nesbit for some 20 years. When Reed was aiming toward retirement in 1967, Jack no doubt felt inclined to take over the leadership of the small section. The two urologists seemed to have gotten along well professionally, although there was no doubt as to who was in charge and it didn’t seem that a strong friendship existed outside the workplace. Lapides had been running his own separate and independent residency program at Wayne County Hospital, graduating a single chief each year whereas at this point the UM program was finishing 2-3 per year.

Karl Montague (UMMS 1968), visited by us last autumn at the Cleveland Clinic, recalled his experience as a junior medical student rotating on urology. Karl had been focused on a career in cardiology, primed in that direction by an NIH fellowship in Basel, Switzerland. Urology at the University of Michigan was then a mandatory clinical rotation and Montague recalls some of Lapides’ pedagogical antics (at the VA):

“Dr. Lapides was demonstrating cystoscopy to a group of us medical students in our third year. Of course, this was before the time of video teaching and the learner had to peer over the shoulder of the teacher who had positioned the scope over a landmark view of anatomy or pathology, while the patient was under anesthesia as happened to be the case that day. So Dr. Lapides had the first student in turn to look in the scope and asked: ‘Do you see the verumontanum?’ The student, after a few awkward moments said ‘Yes’ and Lapides checked the position and asked the next student, who again agreed. When it was my turn, I looked and looked and finally said ‘No.’ It turned out that the Professor was holding the scope in the middle of the full bladder, nowhere near the veru. He seemed to like me after that day and later in the rotation asked my career plans. I told him it was cardiology. He said: ‘Think about urology, and if it interests you, come back and talk to me.'”

Montague did give some thought to urology and that changed his career arc and life. It was a clever and kind approach on the part of Lapides, kinder than the anecdotal “Black Jack” stories. [Below, Montague in his office at Cleveland Clinic, autumn 2019.]




Five.

Kindness & Kurt Vonnegut Jr. (November 22, 1922 – April 11, 2007). The Vonnegut books I read in college, medical school, and during residency offered great escape from study with humor, satire, and surreptitious insight into the thing we call, the human condition. More than appreciated at the time, Vonnegut expanded my sensitivities to the comorbidities of life, environmental deterioration, and the quality of kindness. Cat’s Cradle (1963), iconic book, offered very short chapters that fit my short extracurricular attention span. [Above: “Two Young Women Seated playing cat’s cradle.” Suzuki Harunobu, ca. 1765. Wikipedia.] Slaughterhouse-Five (1969, film 1972) didn’t mean so much to me then, but years later hearing a beautifully performed audiobook, I felt its powerful impact, reflecting Vonnegut’s lived experiences as a prisoner of war in the Allied firebombing of Dresden. Even though I served in a peacetime Army for four years after my residency training, I had gained enough maturity, experience, and knowledge to appreciate that mind-bending book. 

Vonnegut told stories of contrived odd characters and places. While exaggerated and even preposterous, he resonated with the best and worst of human attributes. God Bless You Mr. Rosewater (1965) only came recently to me, as I was tracking a quote that reflects Vonnegut’s dark humor and the hope that underlies his satire. The quote came from an anticipated baptismal greeting:

“Hello babies.

Welcome to Earth.

It’s hot in the summer & cold in the winter.

It’s round & wet & crowded.

On the outside, babies, you’ve got 100 years here.

There’s only one rule that I know of, babies –

God damn it, you’ve got to be kind.”

T.S. Eliot once called April “the cruelest month” so it seems fitting to conclude now with thoughts of kindness, a trait that seems to come naturally to some people, but most of us have to work at it, balancing it against our selfish particularities. Kindness is a very human trait, the very basis of civilization, although many other creatures evidence kindness in numerous ways. Kindness is, no doubt, tied into mirror neurons, oxytocin, and other incredible biologic inventions that we are dimly aware of at best. Motherhood is the ultimate expression of kindness, perhaps that was on Hassam’s mind to some extent in April, 1920.

 

Postscript.

With few centurions living today, only historians can tell us much about what daily life was like during the big influenza epidemic of 1918-1920 that ended around the time Michigan Urology’s first century began. And, of course, one hundred years from today, will many people fully understand the anxieties, terrors, and tragedies of the present moment in time.

Kindness is always at risk in the busy workplaces of healthcare, and this will be especially tested in this current pandemic threat (Coronavirus 19), that has taken civilization by surprise. We are too often surprised by infectious diseases, whether cyclic or novel and while our immune systems may be surprised, our brains have no excuse. Here is an amateur historian’s list of the last big pandemics:

HIV/AIDS rising from 1976 to 1981 and peaking 2005-2012, killing 36 million

Influenza H3N2 1968 killing 1 million

Influenza H2N2 1956-58 killing 2 million

Influenza H1N1 1918-1920 killing 20-50 million

Sixth cholera pandemic 1910-1911, killing somewhat under 1 million, estimated.

Influenza H3N8 1889 – 1890 killing 1 million

Third cholera pandemic 1852-1860 killing 1 million

Black Death (bubonic) 1346-1353 killing upwards of 200 million

The Plague of Justinian (bubonic) 541-543 killing up to 25 million

[Above: Red Cross volunteers assembling gauze face masks at Camp Devens, MA, 1918.] 

Thanks for reading Matula Thoughts this April, 2020. It will be a rough month.

David A. Bloom
Department of Urology
University of Michigan

March thoughts, idle and otherwise

WN/MT 6 March 2020

March thoughts, idle & otherwise
2102 words

 

One.

Be cautious in mid-March, the spirit of Julius Caesar warns. It’s not idle advice, for Caesar must have had a tin ear to the political dissent building up around him, or else the mantle of authority made him feel unassailable until he was terminally disabused of that conceit on the Ides of March 15 in 44 BCE. A coin issued by Brutus two years after Caesar’s assassination (shown above) celebrated the would-be king’s downfall. Before the Ides of March became notorious, that day in the Roman calendar was reserved for religious observances and settling of debts. It so happens that the big settling of debts in American society two millennia later has been displaced a full month in the calendar to April 15 for taxpayers like me and businesses not clever enough to find the loopholes. [Above: Eid Mar coin reverse, the tail side. Below: Wikipedia, The Tusculum likeness of Julius Caesar, photographer Gautier Poupeau.]

No one wants to be overly superstitious, but it is wise to venture forth with a measure of caution not only on the Ides of March but every day, monitoring your physical and political environments, on the lookout for “hungry looking” Brutuses and watching for reckless scooters, distracted walkers or drivers, rising seas, hurricanes, fires, blizzards, tornados, or merely uncovered sneezes and coughs. (By the way, why is it socially accepted that we expect ourselves or others to cover coughs or sneezes only when “feeling sick” with a fever? Why doesn’t every adult carry a handkerchief or tissue to cover every cough or sneeze – especially in these coronavirus times ?!)

Ancient Roman days were counted differently than they are now, with three named points each month: the Nones in the early month, the Ides in mid-month, and the Kalends on the first of the next month. Assassination perp Brutus issued the coin in the fall of 42 BC, and that Eid Mar denarius shows a “freedom cap” positioned between two daggers.

The denarius was the standard coin in the Roman Empire from 267 BC until replaced by the antoninianus in the mid-3rd century AD, the coin of Galen’s day. The silver in the coin was initially worth about a day’s wages for skilled laborers at that time in Rome, today that equivalent amount of silver is less than $4. Emperor Nero, about 100 years after Caesar’s assassination, began to debase the coin, substituting cheap metal for the silver, until hardly any silver was left by the end of its use. The Eid Mar value, however, has greatly appreciated – a single coin recently fetching 325,000 Swiss francs ($332,583) at auction on Oct. 6, 2016.

[Above: Eid Mar coin obverse – the head side with Brutus. Below: Silver content debasement by year of Roman Empire denarius and its successors, 11 BC to 250 AD. Wikipedia: Data from Walker, D.R. (1976-78), The Metrology of the Roman Silver Coinage. Parts I to III. Nicolas Perrault III.]

 

Two.

Coffee Houses. My youngest daughter and her husband, both academics, do much of their work in coffee houses, as do many of their generation. Before computers and the internet, coffee houses were places to meet and converse. Now, it’s more common to see people with ear buds in place and eyes focused on their work on laptops and (annoyingly) on phones.

The coffee house of Edward Lloyd on Tower Street in London around 1686 was the room where it happened that marine insurance blossomed and grew into an essential component of modern business and life. Insurance was a necessary ingredient in the emergence of the limited liability company, that is, the modern corporation underpinning modern capitalism. Coffee houses have been important social hubs for over 300 years in Western Society and the tea customs in Asia have been around much longer. The Cosy Corner Tea Shop of Mrs. Hugh Cabot opened in Ann Arbor 1923 and became a small part of the Michigan Urology story, with its own backstory of how social changes and the Great War changed expectations for one faculty wife. Coffee and tea houses today serve as primary places to plug into earpieces and computers so as to disconnect from people and immediate scenes around you and leap into distant people, scenes, and your own imagination. Oddly, socialization and social media are not very compatible.

The Coffee House, in the winter of 1905/1906, a painting by Alson Skinner Clark (1876-1949), shows the State Street Bridge amidst smoke, fog, and early “skyscrapers” over an icy river. You can barely identify the actual coffee house. [Above: Institute of Art, Chicago.] The title suggests Clark either painted the scene in real time (en plein air) or recalled it from his time in the neighborhood, although he was also an accomplished photographer and may have used that medium to help fashion the painting. The view is not vastly different a century later, the high rises are higher and more numerous, the horsepower of street transportation has increased (without much increase in the transit time per mile), and the price of a cup of coffee has gone up. That same neighborhood these days contains at least several Starbucks and other coffee houses. [Below: State Street Bridge in early spring 2019 during AUA national meeting.]

 

Three.

Coffee beans. I can’t spend too long in coffee houses without recalling the great Danish story teller Karen Blixen, known more widely by her pen name, Isak Dinesen. Out of Africa in 1937, described her years in British East Africa (modern-day Kenya) between December 1913 and August 1931. She initially tried to raise cattle, but switched to growing coffee beans although that, too, proved difficult. The soil and high elevation were not perfectly conductive, East African conflicts in First World War interfered with supplies and equipment, and ultimately the Great Depression made the business untenable. Having run through her family’s money, Blixen returned to her family home in Denmark to write. Her work there proved far more successful and enduring than the Karen Coffee Company and she became a world celebrity, dying in 1962 at age 77. Orson Wells planned a film anthology of her work, but never completed it, producing only The Immortal Story (1968). Babette’s Feast (1987) became an extraordinary black and white film of a somber isolated Scandinavian village and Out of Africa (1985) was gorgeously filmed in color featuring Meryl Streep and Robert Redford. Last autumn, while at the terrific CopMich meeting organized by Dana Ohl and Jens Sønksen, I spent an afternoon at the Blixen family home in Rungstedlund. [Above: Photo by Sophus Juncker-Jensen (1859-1940) taken in 1913 shortly before Blixen’s departure for Africa. Below: Karen Blixen’s home, Rungstedlund, 2019.]

The Isak Dinesen quote that comes to mind after an hour or so in a coffee house is from Seven Gothic Tales:

“What is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.”

Unpleasantly, the name Karen, like many other terms on social media, has become a derogatory meme. [Below: Wikipedia: Baroness Karen von Blixen-Finecke at Kastrup Airport CPH, Copenhagen 1957-11-02.]

 

Four.

A book on urine. In 1917, when Karen Blixen was cultivating coffee by day and telling stories to her friends at night and Michigan Urology founder Hugh Cabot was serving on the Western Front for the British Expeditionary Forces during WWI, Arthur Robertson Cushny, former University of Michigan professor from 1893 to 1905, was working at University College London when he published Secretion of the Urine, a book explaining the machinery and infinite artfulness of urine production. [Above: Cushny, Wellcome Museum. Below: title page.]

Cushny took uroscopy to a new level of detail. Uroscopy began in ancient times with basic sensory evaluation of urine (color, odor, taste, etc.). Medieval uromancy offered speculative linkage of urine findings to diagnosis, and microscopic evaluation later opened new levels of visual detail. Chemical and microbial analysis, using 19th century tools and technology, provided meaningful therapeutic opportunities, but Cushny’s book of 1917, Secretion of the Urine, explained how urine was formed in health and disease, by filtration at the glomerulus and reabsorption/secretion along the renal tubules.

Arthur Cushny (1866-1926) had come to the Medical School in Ann Arbor to replace John Jacob Abel, a UM graduate from 1883 who had returned to Ann Arbor in 1891 to teach, pursue research, and create the world’s first department of pharmacology. Abel transformed the formal and ancient lectures on materia medica and toxicology into pharmacology instruction with demonstrations applicable to clinical practice of his time. Johns Hopkins lured him away in 1893, but that opened the door for Cushny to replace him as chair. Dean Victor Vaughan found Cushny in Berne, investigating the problem of death from chloroform anesthesia and developing methods of titrating the delivery. Cushny was an effective teacher and a productive researcher in Ann Arbor, but returned to Europe for an attractive job as chair of pharmacology at University College London in 1905 and in 1918 returned to his native Scotland as chair in Edinburgh, where he died in 1926. Secretion of Urine was a major contribution to physiology and urology. [Cushny AR. The Secretion of the Urine. London, Longmans, Green, 1917.]

 

Five.

You are what you eat, like most aphorisms, contains truth and hyperbole. It extends easily to other bodily inputs such as you are what you drink. [Above: The Cook, Guiseppe Arcimboldo 1570. National Museum, Sweden.] Last month’s suggestion, that you are what you read, regarding on The Crisis periodical, fortifies a parallel claim for mental nutrition, which came to mind again in another magazine that compels interest, The Economist. A recent piece in the recurring essay entitled “Johnson” (after Samuel Johnson, of dictionary fame), combined the recent custom of selecting “words of the year” and the phenomenon of adverse climate change. “Johnson” offered a number of candidates for word of the year, noting that according to the Dutch dictionary Van Dale, Dutch-speaking Belgiums voted for winkelhieren, a term for “buying locally,” as the 2019 word of the year. [Economist Jan 4, 2020, p. 62.]

Ann Arbor offers excellent examples for buying locally including Zingerman’s and Kerrytown markets for food and stuff, Literati for books, or Camera Mall for photographic things. Amazon is convenient, luring, and addictive but it robs from local communities (livelihoods and taxes). Plus, given the packaging and reported 30% return rate, that particular limited liability corporation accelerates planetary degradation. Perhaps a community becomes what it buys. If people buy mainly from Amazon, they will be an Amazon community as local businesses recede like the glaciers – not such an attractive possibility.

 

Postscript x 2: peas and war.

Gastronomic identity. In 1826 Anthelme Brillat-Savarin wrote, in Physiologie du Gout, ou Méditations de Gastronomie Transcendante: “Dis-moi ce que tu manges, je te dirai que tu es.” [Tell me what you eat and I will tell you what you are]. In 1940, Victor Lindlahr, nutritionist and enthusiast of the so-called catabolic diet, wrote a book You are what you eat: how to win and keep health with diet. In strict chemical and physiologic terms, it’s hard to deny that fact, although it’s nice to believe the human sum is actually greater than the sum of its nutritional parts, as the Italian painter Guiseppe Arcimboldo (1527-1593) hinted in his arresting works, such as Vertumnus. [Above: Emperor Rudolph II as Vertumnus, Roman god of seasons. c. 1590, Guiseppe Arcimboldo. Skokloster Castle, Sweden.]

The Battle of Columbus. Just around this time of year, in 1916 (March 9), Francisco “Pancho” Villa’s División del Norte raided the small border town of Columbus, NM and retreated back to Mexico. United States President Woodrow Wilson, while holding the U.S. back from the Great War in Europe (that Hugh Cabot entered as a volunteer with the British Expeditionary Forces) eagerly sent 4,800 U.S. troops led by General John Pershing over the U.S./Mexican border to capture Villa. [Above: Unmindful of the Ides, U.S. troops crossed into Mexico in March 1916 in pursuit of Pancho Villa. Photo courtesy U.S. Army Military History Institute.] The 9-month punitive incursion south of the border failed to capture Villa, but it did recruit University of Michigan Ph.D. Paul de Kruif, who joined as a private. The campaign ended in January 1917, without achieving its objective. Pershing claimed the effort a success, even though it seemed that the U.S. soldiers were the main parties punished. de Kruif went on to join the WWI effort after the U.S. officially entered the conflict, serving in the Sanitary Corps as a lieutenant and then captain before returning to Michigan for a short time. His next job was at the Rockefeller Institute until he was fired, rendering him the freedom to become a medical journalist and collaborator in 1926 with Sinclair Lewis in Arrowsmith.

 

Thanks for looking at this month’s communication from the University of Michigan Department of Urology. What’s New is the email version and matulathoughts.org is the web-based version.

David A. Bloom

Matula Thoughts February 7, 2020

Matula Thoughts 7 February 2020 Leaps, literacy, & opinions 2142 words One. Leap Year. A celestial accounting anomaly this month on Saturday February 29 will have only minor impact on people’s lives and world economies. The extra business day, when … Continue reading

2020 – a new blank slate

Matula Thoughts 3 January 2020

A new blank slate

2376 words

One.

 

Tabula Rasa 2020.

Optimists begin New Years with clean slates. Most people negotiate internal tension between optimism and pessimism, but the sense of opportunity that comes with a new year generally tilts the balance toward optimism and the chance to start anew with mistakes and sins of the past perhaps forgotten, if not forgiven. The blank slate, though, is only a metaphor; each year ahead will build on stories of the past – history – and the contingencies of immediate moments. [Above: Blank wax tablet.Wikipedia.]

The new year, next decade, and century ahead for Michigan Urology, may be shaped by the century that unfurled after Hugh Cabot came to Ann Arbor late in 1919, but the critical determinants of the future will be the ingenuity, industry, and success of our educational programs, research, and clinical delivery. The idea that the essential deliverable of academic medicine is patient care, while not historically prominent, is absolutely clear today. That essential deliverable, as we have said in our department of urology for some years, is kind and excellent clinical care, thoroughly integrated with education and innovation. With that, as the “North Star,” navigation becomes simple.

The Latin phrase tabula rasa originates from blank slates or waxed tablets that, after erasure of chalk or melting the wax, are available for fresh notation. Aristotle was one of the early thinkers who likened the mind to a clean writing slate and Avicenna, Thomas Aquinas, and John Locke, among many others, expanded the idea until modern neurobiology brought science to the matter. Metaphors are merely tools for thinking and communication, not absolute “true facts” that Don Coffey sought to recognize amidst the litter of contemporary information. Steven Pinker’s book of 2002,Blank Slate: The Modern Denial of Human Nature, calls out the metaphor and explains that human behavior is not constructed on a blank slate, or tabula rasa, but is heavily programed. [See Pinker’s TED Talks 2008 and 2019.]

Blank Slate is also the clever name for an Ann Arbor Ice cream shop, the actual ice cream serving as a medium for an ingenious palate of flavors. Ice cream, one of the great inventions of humankind, is a delight in any season, although winter demand slackens enough for the Creamery to close up for the coldest months (above at Liberty and S. First Streets). Having borrowed the metaphor for this monthly message, I was duty bound to ask (and receive) permission from Michigan grad Janice Sigler who opened Blank Slate in July, 2014, with her husband.

 

Two.

January 1920 was an optimistic time for Hugh Cabot in Ann Arbor at a high point of his career. Modern Urology, his noteworthy 1918 textbook, capped his 15 year rise to central authority in the field. An early volunteer for the European conflict, well before American entry made it a world war, Cabot commanded a 2,500-bed general hospital on the Western Front by war’s end. His return to Boston at the end of January 1919 was front-page news in the Boston Herald, although not without glitches. Cabot’s team of doctors and nurses was blocked from leaving the train at the Boston station where a reception was waiting for them. A military authority ordered the ensemble to remain on the train and continue on the train to Camp Devon, Massachusetts and then New York City for official discharge of duties. After discussion Cabot declined the order and the entire medical team disembarked from the train to join the waiting reception and then dispersed into the crowd to resume civilian life. [Below: Boston Herald. Front page. “Harvard Surgical Unit held prisoners by error on arrival in Boston.” January 31, 1919.]

As Cabot resumed civilian life the world seemed enroute to a better future in terms of public health, geopolitics, economics, technology, and art. The devastating Great Influenza Epidemic was over, but other pandemics followed. Geopolitical solutions to WWI would pave the way to WWII and later conflicts. The economic world collapsed in less than a decade. Rapid advances of technology that seemed so wonderful in the early 20thcentury proved two-sided by century-end with antibiotic resistant bacteria threatening food safety, robots displacing jobs, computer malware holding businesses and cities hostage, identity theft via internet, and social media manipulation of public elections. The public eagerly embraces Orwellian Big Brother – reassuringly renamed Alexa, Hey Google, and Siri – with ubiquitous cameras on streets and in homes paving the way to authoritarian control of society through artificial intelligence.

 

Three.

The “blank slate” of the new year, brings to mind resolutions and the human itch for personal mastery of something – work, play, family, or hobby. Just as they were once inspired, Bach and Casals are posthumously inspiring future composers and musicians today. The cello suites have had a remarkable 300-year journey since Bach started writing them as exercises for his young wife in 1717. Casals discovered the largely-forgotten music in a shop in 1890 and mastered its performance by 1896 when he became principal cellist in Barcelona at the Gran Teatre del Liceu. [Below: Title page of Anna Magdalena Bach‘s manuscript: Suites á Violoncello Solo Senza Basso. Wikipedia.]

Casals had ups and downs, like everyone, but the worst immobilized him for two weeks in 1939 when he didn’t leave his room in Paris, exhausted from recording the six Bach suites (Casals hated the recording process) and despairing over Franco’s take-over of Spain. Casals was thoroughly burned out, although the favored terminology of the time described him as emotionally exhausted and depressed. Thankfully, he rebounded and his career reached new heights. Nearly 20 years later, at age 80, he married 20-year-old Marta Montañez y Martinez, dismissing concerns over their age discrepancy: “I look at it this way: if she dies, she dies!” [Cesare Civetta. Mar 14, 2018. “Pablo Casals sacrificed his career to protest Franco.” https://CesareCivetta.com/blog] [Below: From Encyclopaedia Britannica, Pablo Casals, 1965. Erich Auerbach, photograph, Hulton Archive/Getty Images.]

The inspiration of the suites lives on: Yo-Yo Ma was inspired by Bach’s cello suites at age 4 and today, at 64, travels six continents to perform all six suites in single sittings at 36 locations.

Combustion control has been a defining feature of our species beginning around campfires for comfort, cooking, and conversation. Heat may erase tabula rasas, but metaphoric self-combustion in modern society seems a new thing. It is not clear when burnout is a “legitimate” dysfunction or an extension of quotidian fatigue? That state of reduced personal efficacy, emotional exhaustion, and depersonalization describes the condition today called burnout, that suddenly, it seems, has become epidemic in many professions, including health care. Conferences, surveys, and editorials proliferate and  medicalize the matter. The Lancet offered a useful perspective in an editorial, Physician burnout: the need to rehumanise health systems. The wording is counterintuitive – the “rehumanization” of human health care. [The Lancet. 394: 1591, 2019.]

 

Four.

So how is it that health care became “dehumanized”– that very suggestion seems to be an oxymoron, a contradiction in terms, as René Magritte cleverly depicted in his surreal paintings such as the 1953 Wonders of Nature (©René Magritte). The dehumanization phenomenon in medicine seems linked to the systematization, corporatization, and commoditization of healthcare. Systems are necessary in modern healthcare, of course, but the displacement of what historically was called the doctor-patient relationship with checklists, guidelines, and clinical pathways distracts from the human element. The EHR-directed patient “encounters” have largely replaced the narratives of the human conditions wrapped-up in taking “the history.”. Corporate medicine is quickly replacing small practices and bringing with it tainted ideas of business management, specifically the failed ideas of Taylorism, managerial accounting, and the North Star of shareholder value.

The idea of the limited liability corporation has largely built the modern world, as human society has given corporations many special rights such as limited liability, free speech, and some special benefits that ordinary people cannot have. (Back around 2003 Julian Wan gave me a book that explains this – The Company – A Short History of a Revolutionary Idea, by John Micklethwait and Adrian Wooldridge.) Undeclared but implicit in that Victorian innovation is a social contract that businesses exist not merely for shareholder value, but more broadly for stakeholder value – jobs, employees, benefits, suppliers, community – and for value to society-at-large, the most important stakeholder of all.

It is natural that some parts of health care are legitimate commodities, functioning optimally in a market-based economy without the necessity of an intermediary professional agent. Examples are many – flu shots, over-the counter medications, food supplements, and countless others. Other healthcare functions are complex, multilayered, and highly professional, such as renal transplantation, mental health treatment, and management of malignancy. In between these extremes are the essential transactions of visits to physicians, dental care, emergency department visits, orthopaedic care, periodic eye care, and treatment of urologic conditions – these are a mix of commodity and profession. The arbitrage of those two elements of society is an endless conversation.

The extension of personal mastery in one’s subject of choice, whether by New Year Resolution or not, is self-vaccination against burnout. The enhanced personal well-being can re-humanize your medical workplace in more ways than this essay can explain. Recently, up in Flint at the Hamilton Community Health Center, Mike Giacalone, Jr., the Chief Medical Officer, was explaining Hamilton to interviewing journalists and said that for the Flint patients, “every visit is not just a medical visit, but equally so a social, economic, and behavioral visit as well.” While particularly relevant in Flint, this should be a universal aspiration in health care. The medical gaze should try to “take it all in” and triage the needs of a patient and family as best possible, in spite of the rigidity of the EHR- constrained medical encounter programmed around a chief complaint.

 

Five.

Media and messages. Whether the medium is ice cream, canvas, blank paper, musical instrument, computer screen, stage, construction site, clinic room, operating room, or learner – artistry can be performed.

Everyone is a lifelong learner, but the health care field demands special attention. Undergraduates and beginning medical students are the most impressionable blank slates and for that reason the responsibility of role models, teachers, and mentors is perhaps the greatest for them among the learners we teach. For many of the younger set their first experiences seeing a physician, nurse, or physician’s assistant at work (sometimes in instances of personal care of a UTI, stone, or surgical correction) imprints and fosters a lifelong pursuit. Whenever possible, these opportunities for shadowing or introductory teaching should be embraced. Residency training, however, is the most critical blank slate of all in medicine, fashioning the knowledge, skills, artistry, and professionalism for a career. [Images above & below from “the internet.”]

Blank slates are opportunities, but risk erasure of the past although that is necessary with wax tablets and chalkboards. Parchment and paper were a big improvement allowing durable manuscripts and books, still at risk from fire (accidental or intentional) or other forms of destruction or deterioration. The new world of digital information carried the conceit that humans could become “paperless”, but that is ultimately not only impractical but also a genuinely bad idea for free societies.

When governments, sectarian authorities, or corporatocracies control printing presses, airwaves, or other social media – society is captive to a few reigning opinions because inconvenient stories, opinions, ideas, or truths are conveniently avoided or erased. Clever memes and tweets easily subvert social groups and human ideals. One great feature of the human condition is the testing and synergism of opinions, ideas, and technologies that can build civilization for the greater good of mankind and sustainability of the planet. The central idea of free speech at the heart of civilization, is being sorely tested by the unexpected opportunities of modern technological social media.

From our parochial perspective in the art and business of health care, erasure of history is an especially unfortunate reality, but we see it with each change of technology in health records. The operative procedure notes and pathology reports from the earlier part of my career seem to have vanished with the paper records we utilized when I started here in Ann Arbor, as I have learned when trying to answer requests from people regarding, say, an exstrophy closure operative report in the 1940’s, a hospital course in the 1960’s, or thyroidectomy pathology findings from the 1970s. Those floppy discs we had in the 1980s and zip-drives of the 1990s are increasingly difficult to access as obsolete technologies disappear. No one today can ensure that the massive data in electronic records will be converted to the media of the future – it seems unlikely that the “data cloud” of 2020 will be maintained in a future data cloud or its equivalent of 2050.

When Ed McGuire brought me to Ann Arbor in 1984 my blank slates were 3×5 index cards and the newly launched Macintosh Computer. Our hospital then had separate inpatient and outpatient paper charts. The Surgery Department administrators cautioned me to not get used to my Apple Computer as UM was preparing to launch the Wang Computer System. I didn’t listen – but still have the cards (one for with every patient I saw at Michigan) and that original Macintosh (now a book end).

 

Postscript

Matula Thoughts analytics, 2019. We have no sense of the total readership of the monthly What’s New delivered by email, but the web version matulathoughts.org has levelled off at 3357 views and 2199 visitors from 78 countries as of 31 December 2019, down from 3458 views, 2226 visitors from 89 countries in 2018, probably due to personal retreat from the chair position of the Urology Department at the University of Michigan. This past year we shortened the essay from 10 to 5 numbered items and dropped the word count to 2000 or so, although still far less convenient than a 140-character microblog tweet.

This leveling-off of Matula Thoughts recalls the Hippocratic Aphorism: Art is long, life is short, opportunity fleeting, experience hazardous, and judgment difficult. Other interpretations of the Ancient Greek vary the nuance and words, but clearly this personal essay, the first Friday of each month, is anachronistic and risky in offering personal judgments and observations. Those facts are more than balanced by the personal delight in hearing back from a handful of readers each month, thus extending these essays to dialogue and conversation, challenging facts, pointing out errors, and teaching me. Comments last month were especially appreciated. For all these, thank you.

 

David A. Bloom

Department of Urology

University of Michigan, Ann Arbor