Matula Thoughts May 7, 2021
People are out and about this spring in sharp contrast to last year when Ann Arbor’s sidewalks, streets, and parking lots were virtually empty. If you happen to walk on State Street near the UM Art Museum you may see a large-scale sculpture by Jaume Plensa called Behind the Walls. This made its debut at Rockefeller Center in 2018 and then had a stay in Mexico City, before settling here at UM. [Above: Plensa’s Behind the Walls.]
I first noticed the monumental face during a “covid walk” last spring – actually, a friend pointed it out to me. The sculptor’s intent of updating the “see no evil” meme of the three wise monkeys seemed clear but, as I returned to Behind the Walls on other walks, deeper nuances of the self-blinded face expanded. After a year of sightings and casual thoughts regarding Behind the Walls, I was prepared for the documentary about Jaume Plensa shown by the UM Penny Stamps School of Art Series in collaboration with the UM Art Museum and its director Tina Olsen. Plensa had this to say, using the metaphor of “a message in a bottle”:
“In a world full of injustice, disasters and suffering, it seems banal to speak of beauty, frivolous even. I am convinced that beauty has an extraordinary force, an extraordinary capacity for regeneration. It has an obligation to illuminate us.” [Approximately 56 minutes into the film.]
“I’ve spent my whole life trying to construct a language, an alphabet, an ideology, a … thought that would help me understand others better. I suppose there is also a search that is related to the message and the bottle, my message. I try to write it with more precision but especially I also try to make even stronger bottles, more stable so they can get as far as possible.”
“The things around us, the people, the objects, are sleeping like children who suddenly fall asleep in a car. Sculpture, creation, has this enormous capacity for waking us up again.”
“I believe that in my case there has been a thorough search for something I haven’t found yet, which is to understand how I relate to the outside, my relationship with the world, the community, others, especially my relationship with myself. Me myself, towards myself, because I know if I reach that distant point in myself, I will understand it in others.” [1:16]
Behind the Walls goes beyond the cynical monkeys who chose not to observe anything that they expected to be unpleasant or “evil.” Plensa says something more. The hands over the face – disconnected from the arms, shoulders, and torso – are naturally assumed to be self-directed to cover the eyes, although it is just as easily imagined that external forces – culture, society, peer pressures, politics, or sectarianism – as likely to be the levers positioning the hands.
Ty Seidule’s book, Robert E. Lee and Me (mentioned on these pages in March), is a case in point of how personal world views are built by the cultures that raise, educate, and sustain us. Col. Seidule, whose childhood and education were framed by the monumental legacy of Lee, became a career officer in the U.S. Army and completed his service with a Ph.D. in history from Ohio State University and position as chair of the history department at West Point. At the Military Academy he noticed a striking absence of confederate memorials on the campus (in stark contrast to the rest of the country) and his life-long adulation of Lee vaporized as he came to understand the myth of the “lost cause of the south” and the sad painful fact that Lee betrayed his country. (Thanks to Professor Victor Garcia, University of Cincinnati College of Medicine, who sent me the book.)
Empty places. Just as Ann Arbor streets were empty last May, so too were its classrooms from pre-school through graduate school. A second school year has now begun under the Covid cloud and the fighting over “open vs. virtual” schooling continues. [Below: Ann Arbor parking lot at West Huron and North Ashley on Saturday May 2, 2020 at mid-day, normally full at this time of year, but startlingly empty in the second month of the pandemic.]
School closures for infectious diseases are nothing new, we recently uncovered a similar situation more that 100 years earlier – even before the previous great pandemic. Reed Youmans, grandson of Reed Nesbit, recently sent us a box of clippings, photos, and notes retained by the family, and one newspaper clipping referred to Reed Nesbit’s uncle, Dr. Otis Nesbit of Valparaiso, Indiana. One October night in 1913 the Superintendent of Gary Indiana Schools visited the general practitioner at home and asked him to “come over to Gary and help me keep my schools open” because of “a regrettable situation common to most school communities of the day.”
“People then had the fanciful idea that if they locked up their schools, they’d have no infantile paralysis, no diphtheria, no scarlet fever, or smallpox or whatever, Dr. Nesbit said on occasion of his retirement last week, following nearly 28 years as head of the Gary Schools Medical Department.” [“School chief voices praise of Nesbit,” The Gary Post – Tribune. Tuesday, August 5, 1941.]
Even then the idea of closures to mitigate communicable diseases was contested. Nesbit’s uncle turns up in the UM Urology story and will be explored in our second book, A Century of Urology at the University of Michigan. The first book, The Origin Story of Urology at UM, is available electronically and we expect hard copies soon. The open access link:
Recurrent infectious diseases plagued schools and communities a century ago, even though the principles of vaccination had been well-established for more than a century. Furthermore, the germ theory, recognized then for five decades, wasn’t understood well enough to apply to the finer details of respiratory droplet contamination, although many sensible people understood the value of wearing masks in surgical situations and epidemics. The big Influenza Pandemic would begin only four years after Otis Nesbit was recruited to the Gary schools and the story continues to repeat – as the past year has shown.
1932. The microcosm of UM urology can be claimed to have begun in 1919 when Hugh Cabot arrived in Ann Arbor. Urology residency training began in Ann Arbor in 1924 when Charles Huggins followed Cabot from Boston and Reed Nesbit came from California the next year as Cabot’s second trainee to become a urologist. Cabot was fired by the regents in 1930 and his virtually unknown protege Reed Nesbit became the head of the tiny urology section.
Nesbit quickly began making a name for himself and for Michigan Urology. By 1932, he had published papers (Annals of Surgery, Archives of Surgery, JAMA, J. Mich. Med Soc.) and that year joined the American College of Surgeons (ACS), a younger organization than the AUA, and one that would bring him to a high point of his career three and a half decades later.
Yet in 1932, two years after Cabot’s dismissal, the Medical School was still adrift without a dean. The nation too was adrift – the Depression and Dust Bowl were torturing millions of Americans. Millions more worldwide were suffering from worsening geopolitical and economic conditions. The Dow Jones Industrial average reached its post-Depression nadir of 41.22 in 1932. Brave New World by George Orwell was published. Motion pictures were a pleasant distraction from the dreary times; the film Arrowsmith, based on the Sinclair Lewis Novel (centered around a fictional version of UM Medical School) tied with The Champ for most nominations at the fifth Academy Awards but lost out to Grand Hotel for best picture.
Jack Lapides, a studious young man from Rochester, NY, came to the Ann Arbor campus in 1932 as an undergraduate. So too did Arthur Miller, an aspiring writer from New York City. Each travelled different paths to success with their UM educations, although they must have passed each other on campus, we found no evidence that they interacted.
In 1932 the federal role in health care was directed to public health, rather than individual health care. The U.S. Public Health Service Syphilis Study of Untreated Syphilis in the African American Male at Tuskegee was initiated this year in Alabama to study the natural history of untreated syphilis and the study continued until 1972, attracting little national attention, particularly in its early years. A decade later effective antimicrobial therapy became available (penicillin) in the U.S. however the study failed to offer that possibility to its subjects – a terrible mistake. [Below; Doctor injects subject with placebo. Tuskegee Syphilis Study, administrative records (1929-1972), National Archive. Wikipedia.]
The gratuitous Nazi human experimentations around that time were becoming public and would show the darkest side of humanity. Few people then recognized the parallels of the two programs; even though the motivations were different, it is a slippery slope from one to the other. Ethical concerns over Tuskegee were raised within the Public Health Service (PHS) in 1955 and over the next decade, but it took a whistleblower within the PHS, Peter Buxtun, to bring the national attention that ended the experiment in 1972.
Prescientific vs. scientific medicine. Clinical experimentation has been part of medical practice for much of human history; trial and error is at the root of the observation and learning that underlies the scientific process – trying to find out what’s true. Just as our clinical analytical sense has sharpened over time, so has our ethical analytical sense – trying to do what’s fair.
Systematic and statistical analysis of clinical trials with groups of people entered the mainstream of medical education and practice in Paris with the clinimetric approach of professor Pierre Charles Alexander Louis (1787-1872) (see Origins p. 30, 30n) who debunked the use of bloodletting in pulmonary tuberculosis, culminating in his 1836 book and the Society for Clinical Observation of his students, including Bostonians Samuel Cabot III and Oliver Wendell Homes. [P.C.A. Louis, Researches on the Effects of Bloodletting in Some Inflammatory Diseases, Boston Hilliard, Gray, 1836.] [D. McCullough, The Greater Journey, Simon and Schuster, NY, 2011.]
Holmes, back in Boston in 1843, proposed the idea that another infectious disease, childbed fever, was transmissible from patient to patient.
In 1847 Ignaz Semmelweis (1818-1865) utilized a clinical trial in a Vienna Hospital – “randomized” by assignment (according to hospital admission on an odd or even numbered day) to one of two public maternity clinics – to study childbirth fever. The two clinics historically had marked disparities in death rates, that was widely attributed to the fact that the First Clinic was the teaching service for medical students whereas the Second Clinic was the teaching service for midwives. [Below: Puerperal fever death rate by years, Vienna General Hospital 1841-1846, Wikipedia, Ignaz Semmelweis.].
The medical students divided their days between the autopsy room and the First Service, while the midwives mainly spent their time on the Second Service. Semmelweis postulated that the medical students were transferring some sort of “cadaverous material” to their patients and he instituted a policy of hand rinsing in calcium hypochlorite solution between the autopsy room and examination of patients.
The experimental work of Semmelweis showed that “cadaverous poisoning” via uncleansed hands not only caused the higher mortality in the First Clinic but could be downgraded significantly by hand-cleansing between patients. His work was mocked, his ideas were unpublished at the time, and he was dismissed from his job. His career and life went downhill and he died of unclear reasons after forced hospitalization and mistreatment in a mental hospital at age 47 in 1865.
In contrast, Lister’s clinical experiments, just around the time of Semmelweis’s death were widely published, showing that sepsis (of another origin) could be prevented using carbolic acid to prevent limb gangrene and generalized sepsis after open fractures, applied on a patient-by-patient basis.
Disabilities constitute a disparity in health care just as in most other public goods of society. The documentary Crip Camp mentioned last month on these pages centers around a camper who became a writer, producer, and director of the film. James LeBrecht was born with spina bifida. His disability prevented ambulation and his parents told him he would need to be very outgoing to be accepted in life by “normal” people, explaining that he had to approach other people because “they are not going to come up to you.” He become an extrovert in his neighborhood, but attendance at Camp Jened in the Catskill region of New York in 1971 offered LeBrecht his first chance to live and play without embarrassment among other (also disabled) kids. A nucleus of those campers later became major participants in the Disability Revolution that led to the American Disability Act (ADA) of 1990. [Above: George H.W. Bush signs ADA June 26, 1990 on White House South Lawn. Pictured (left to right): Evan Kemp, Rev. Harold Wilke, Pres. Bush, Sandra Parrino, Justin Dart.]
LeBrecht unabashedly recalled how urinary incontinence forced him to contend with diapers until a urinary diversion freed him from them, although still left him dependent on stomal supplies and vulnerability to leakage mishaps. Four medical advances were changing the lives of spina bifida children around that time LeBrecht went to camp:
a.) Safe and effective post-natal repair of open spinal cord and cutaneous defect by pediatric neurosurgeons became routine after the midpoint of the 20th century;
b.) The Holter Shunt for hydrocephalus;
c.) Urinary diversion, most specifically the Bricker ileal conduit diversion that came into major use in the 1950’s in conjuncture with extirpative cancer surgery but within a decade found routine application to spina bifida children to prevent urinary incontinence, infections with sepsis, and upper tract damage;
d.) The work of Jack Lapides in Ann Arbor.
In 1971 the American Academy of Pediatrics recommendations for infants and children with spina bifida recommend “after urinary diversion” followed by intravenous pyelograms to keep track of the upper urinary tracks. Routine urinary diversion, the standard of care, was life-changing for LeBrecht and thousands of other spina bifida children.
A major change coming into play in 1971 changed life even more greatly for spina bifida folks and many other people. The Jack Lapides methodology of clean intermittent catheterization was first publicized then, initially for adults with lower urinary tract dysfunction but within a few years extended into the spina bifida cohort. Papers with Diokno and Kass, eliminated the need for surgical urinary diversion and gave spina bifida children a better and safer way to manage their urinary tracts. [A.C. Diokno, J. Lapides et al, “New approach to myelodysplasia,” J Urol 116.6 (1976): 771-772.] [E. Kass, J. Lapides, “The significance of bacilluria in children on long-term intermittent catheterization,” J Urol 126.2 (1981): 223-225.]
Crip Camp was one of the five nominees for best documentary film last month, but My Octopus Teacher won the Oscar.
I know this much is true is the name of a book (Wally Lamb, 1998) and an extraordinary motion picture miniseries (HBO, 2020) depicting two brothers, one with terribly disabling mental illness although both boys were tortured by their perceptions and misperceptions of reality.
What we each know to be true is limited by what we are taught, what we chose to see, and what we chose to evaluate. Just as science and medicine depend on truth, the imaginative worlds of art, literature, and motion pictures at their best and most enduring seek to portray the veracities of life and society. A recent PBS documentary on the writer Flannery O’Connor quoted her as refuting the idea that fiction was an escape from reality, saying that good fiction was “a plunge into reality.”
It should be no surprise that households of scientists and healthcare workers may yield artists of one sort or another – or vice versa. These pages last month noted that the TV series House (2004-2012) portrayed a brilliant Sherlockian diagnostician, counter-intuitively misanthropic and dependent on pain medication. Dr. House was played by actor Hugh Laurie, son of a well-known English physician, Ran Lurie. The actor later said he felt guilty for being paid more money to present a fake version of a physician than his father ever earned as a doctor.
The classic urologic example of this is Katharine Hepburn (1907-2003), daughter of a Connecticut urologist, Thomas Norval Hepburn (1879-1962) for whom an endowed lectureship exists in Hartford. Her career spanned 60 years on stage and screen, achieving 12 Best Actress Nominations and four Oscars. [S. Berg, Kate Remembers, 2003.] The next Hepburn lecturer is set to be our Nesbit alumna Ann Gormley (1993 fellowship with Ed. McGuire).
Hugh Bonneville, son of legendary British urologist J. P. Williams (1926-2020), allegedly took the surname of a favored automobile model to spare his well-known father any notoriety. Bonneville’s Earl of Grantham in Downton Abbey certainly reached many more people than the skilled hands of Mr. Williams, even if less viscerally. J.P. Williams was a respected consultant at the Institute of Urology in London, an acclaimed Harley Street practitioner, and author with John Blandy (an important teacher in Ed McGuire’s training) of the History of the British Association of Urological Surgeons. J.P., as he was known, founded the Chrysalis Club, an informal monthly forum for trainees in urology.
Vanessa Kirby was brilliant in the recent film, Pieces of a Woman. She is the daughter of prominent London urologist Roger Kirby (b. 1950), an early pioneer of robotic prostatectomy, founding editor of several journals, and director of the Prostate Center on London’s Wimpole Street. Vanessa just missed out on a best actress Oscar award last week to Frances McDormand of Nomadland – both works being keen observations on human pain and suffering.
These coincidences remind me of my friend and colleague, Ian Thompson, Jr., who once hoped write a book called, How Urology Changed the World. Thomas Hepburn, J.P. Williams, and Roger Kirby (and surely others) would figure strongly in it, as their children in entertaining us through theater help us understand it.
Behind the Wall, tucked away between the old and new portions of the UM Museum of Art, is ironically obscured by a large red figure as well as the busy pedestrian and vehicle activity of State Street. But you will see it if you look.
Thanks for reading Matula Thoughts this May 7, 2021.
David A. Bloom