Expectations and epistolaries

Posted by dabloom

Matula Thoughts
January 1, 2021
Expectations and Epistolaries

2941 words

One.

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

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

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

Two.

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

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

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

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

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

Three.

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

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

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

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

Four.

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

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

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

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

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

Five.

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

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

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

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

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

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

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

Postscripts.

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

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

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

Trees fall in forests.

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

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

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

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

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

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

Autumn leaves and certitude

Posted by dabloom

Matula Thoughts 6 November 2020
4129 words

One.

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

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

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

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

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

Two.

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

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

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

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

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

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

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

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

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

Three.

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

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

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

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

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

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

Four.

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

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

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

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

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

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

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

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

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

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

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

Five.

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

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

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

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

Postscript.

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

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

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

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

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

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

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

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

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

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

Additional Postscripts.

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

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

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

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

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

Quilting bees and blues

Posted by dabloom

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

Flat vs. round

Posted by dabloom

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

2020 – a new blank slate

Posted by dabloom

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 20^thcentury 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

A century and a millennium

Posted by dabloom

DAB Matula Thoughts October 4, 2019

A century and a millennium

Michigan urology begins its centennial celebration
2087 words

One.

But first, consider what happened in 1623. Horace Davenport, the great American physiologist, University of Michigan educator, and de facto historian of the Medical School asked that question when he introduced physiology to a class of medical students. This story has been told here before, but it deserves repetition for each new generation of trainees as well as for the rest of us, who tend to forget Davenport’s lesson. The prize for the correct answer, Davenport said, would be an “A” for the class with no further expectations – no attendance, no labs, no homework, or exams.

The medical students scrambled with answers, all erroneous and some ridiculous, but no one came close to the correct one – the publication of Shakespeare’s First Folio in 1623. After the playwright died in 1616, friends collected his works, many printed in smaller books called quartos, and they published the First Folio, actually titled Mr. William Shakespeare’s Comedies, Histories, & Tragedies. This consisted of 38 plays and over 150 poems, in addition to Shakespeare’s portrait by Martin Droeshout, one of two authentic images of the author. Of the 750 copies printed, 223 survive and 82 are in the Folger Collection in Washington, DC.
Davenport’s point was that the practice of medicine doesn’t play out in isolation, it is part of the context of life, the unique circumstances of humanity with its individual stories, dramas, aspirations, co-morbidities, and accomplishments. William Shakespeare’s work encompassed the range and depth of the human condition more completely than any artist before or since.

Before learning physiology, much less practicing medicine, Davenport claimed, the human condition must be studied to the extent best possible by each of us although the “self-awareness” of humanity as a species can never be complete. Self-awareness requires some sense of time and place, and these senses are enhanced by knowledge of history. The history we each know may be reality or mythical, a distinction that good historians just as good scientists work to discern. The arts help navigate the ambiguities of that distinction.

Two.

And what happened in 1919? One hundred years ago, Hugh Cabot, Michigan’s first urologist and new chair of the surgery department arrived in Ann Arbor and performed his first operative procedures at the University of Michigan. Cabot’s first specific urologic cases in Ann Arbor have not yet been identified, but a letter in the papers of UM President HB Hutchins of 1919 explains the successful appendectomy on a patient known to and likely referred by Hutchins “in the Surgical Clinic October 13.” This was Cabot’s second day at work and he helpfully told Hutchins:

“Since the operation patient has progressed very satisfactorily and we see no reason why he should not make an uneventful recovery. Twenty-four hours later this case would have been a complicated one, and the prognosis would not have been as hopeful.”

The letter was typed on stationary that read: University of Michigan, Department of Surgery, University Hospital (nearly identical to what this senior author found on arrival to the Medical School and Hospital 65 years later, although the names were different). The faculty listed in 1919 were C.G. DARLING. M.D. GENERAL SURGERY; I.D. LOREE. M.D. GENITO-URINARY SURGERY, C.L. WASHBURN. M.D. ORTHOPEDIC SURGERY; AND C.J. LYONS. D.D.Sc. CONSULTING DENTIST.

Ira Dean Loree was Michigan’s principal genitourinary surgeon up until that time in the small Surgical Department, although his senior, CG Darling, also did work in that emerging subspecialty as well. If stationary is to reflect mindset, neither Darling nor Loree embraced the new terminology of urology, the neologism of Ramon Guiteras in play since the formation of the American Urological Association in 1902 (of which Cabot had been president in 1911) and embraced by Cabot in his influential textbook Modern Urology in 1918.

Three.

A thought experiment. Given that Hugh Cabot came to Ann Arbor and introduced modern urologic practice to the University of Michigan a century ago, we might reflect upon what happened a century before then, in 1819, when the fledgling University of Michigan was only two years old. Not much was actually going on educationally in its initial Detroit site then and no medical school existed in the territory of Michigan, which was not yet a state.

The year 1819 brought the first major peacetime financial crisis in the United States and the Tallmadge Amendment that was passed in the House of Representatives, but got lost the next year in the Missouri Compromise. The amendment would have prohibited slavery in the impending statehood of Missouri, but got traded away for the admission of Maine as a free state.
What about 1719, 300 years ago? The world was being mapped with increasing realism and imagination. Herman Moll’s “codfish map,” A New and Correct Map of the Whole World in London was a step along the way to visualization of the political and geographical reality of the planet. Also that year Robinson Crusoe, was published, arguably the first English novel, a fictional account of an actual event.

Slavery began in the American colonies a century earlier, it was in August 1619 according to the illuminating 1619 Project, a partnership of the Pulitzer Center and the New York Times. The Idea of America, an essay by Nikole Hannah-Jones, is informed and provocative. [NYT Magazine. August 18, 2019. The 1619 Project.]

Five hundred years back in time, on 20 September 1519, Portuguese explorer Ferdinand Magellan began his trip that would circumnavigate the planet, thereby quieting down the Flat Earth enthusiasts of the time, although that stubborn phenotype reappears in alternative forms, notably, the climate change deniers of today. Magellan had five ships, two more than Columbus, and carried supplies for 270 men and two years. In spite of mutiny, desertion, catastrophic storms, starvation, and raids from local natives, Magellan made it to the Philippines by March, 1521, where he was killed in battle by natives who resisted his offer of religious conversion. Other officers took charge and a single ship made it back to Spain on 6 September 1522. Leadership lessons still abound.

In 1419, during the Hundred Years War, France surrendered to Henry V and Normandy was re-annexed to England providing the nidus for Shakespeare’s great imaginative play 180 years later. Joan of Arc would have a fiery end in this town in 1431 and Charles VII, King of France, recaptured the city in 1449. A strong earthquake devastated the city of Ani in Armenia in 1319. A century earlier, in 1219, Genghis Khan sought advice on the Philosopher’s Stone from Qui Chuji (Taoist Master Changchun) and St. Francis of Assisi introduced Catholicism to Egypt during the Fifth Crusade. Navigation was improved in 1119 by Chinese author Zhu Yu who described the innovative use of magnetic compass and separate hull compartments in ships. Japanese statesman Fujiwara no Michinaga (966-1028) retired from public life in 1019 after installing his son as regent, but remained behind the scenes as Japan’s de facto ruler until his death nine years later. In spite of the coincidence of pronunciation, however, there is no way to connect Michinaga to our State of Michigan today in October, 2019, more specifically than as bookends to a millennium of human stories and progress.

The point to this thought experiment is that matters of immediate moments pale in the grand scheme of human centuries and glacial millennia. Nevertheless, those momentary and seasonal concerns constrain most human attention. Our lives are framed by the past and moments of grand inspiration transcend the mundane times. King Henry V’s exhortation to his troops at Agincourt, as imagined by the Bard of Stratford, is as inspiring as George Gipp’s softer “Win one for the Gipper” speech before Army played Notre Dame in 1928, and portrayed by Ronald Reagan in the classic film Knute Rockne, All American, in 1940.

Four.

Autumn in Ann Arbor brings the excitement of new students, football, and the academic season of meetings and visiting professors. Marty Koyle came from Toronto (with provenance from the Brigham, Dallas, UCLA, Denver, and Seattle) last month as our visiting professor in pediatric urology. Marty is a great clinician, surgeon, and educator, and he is one of the few urologists today with an active practice in pediatric renal transplantation (in addition to the astonishing John Barry). Over three days Marty interacted with faculty and residents, leaving an indelible imprint. Courtesy of Julian Wan, we repaid Marty and his wife Ellen in part with the Michigan Football experience, witnessing a close struggle to defeat Army. [Above: Army on the defensive; Below: Marty at the Pediatric Urology Conference.]

The tradition of visiting professors was indoctrinated at Michigan in the time of Cabot, who himself shuttled among peer institutions and brought the best experts to Ann Arbor faculty and students, notably with strong relationships between the Mayo Clinic and St. Bartholomew’s in London. Cabot’s successors, Frederick Coller, Reed Nesbit, Jack Lapides, Ed McGuire, and those who followed, maintained the important tradition to expose our learners to the best surgical educators and ideas. [Below: Puneet Sindhwani, Department of Urology and Transplantation Chair, University of Toledo with Marty Koyle after Grand Rounds.]

[Above: Tailgate at Zingermans.]
Athletic traditions have been closely entwined in the academic mission, offering counterbalance from book-learning and clinical medicine. Performances, great or aspiring to greatness, entertain and serve as rallying points for institutional spirit. Even back in Cabot’s time, important conversations and political alignments took place on the sidelines as the following letter shows – when Cabot followed up to Governor Green (1927-1930, Republican):

“You may remember at the time of the Wisconsin Football Game you were kind enough to suggest that I write you after election concerning certain matters of medical interest which we discussed that day. Now that this turmoil of election is over I am taking the liberty of complying with your suggestion. …”

This was hardly a rare follow-up to social encounters at Michigan games.

Five.

A century of urology followed at the University of Michigan after Cabot’s arrival, directly impacting hundreds of thousands of patients, more than ten thousand medical students, and hundreds of residents – who in turn impacted their share of patients and learners. In that century, two world wars and other conflicts were fought, two major economic collapses occurred, and climatic and geologic catastrophes pummeled the planet. In the grand scheme of things, the particular story of urology at Michigan may be small, but it is our history to know and tell. Furthermore, some of the myriad stories within the larger story are instructive, many are inspiring, others are sobering, and all should be examined in context.

Today, October 4, 2019, our current departmental faculty, residents, nurses, clinical teams, research teams, staff, and alumni are gathered for the Nesbit Society events, culminating with the Michigan-Iowa gridiron contest, where, no matter the outcome, important conversations and good fun will be had at the tailgates and on the sidelines.

Postscript.

October factoids. On 16 October 1901, shortly after moving into the White House, President Theodore Roosevelt invited his adviser and friend Booker T. Washington (below), to dine with him and his family, provoking an outpouring of condemnation from southern politicians and press. No other African American was invited to dinner at the White House for almost thirty years.

Sinclair Lewis, author of Arrowsmith, a book modeled on the University of Michigan Medical School in the early 1900s, suffered a terrible personal loss this month in 1944, when his first son was killed during efforts to rescue the Lost Battalion.

The 1st Battalion, 141st Infantry (36th Infantry Division, originally Texas National Guard) had been surrounded by German forces in the French Vosges Mountains on October 24, 1944, and attempts by other troops failed to extricate the men. The 442nd Regimental Combat Team, a segregated unit of Nisei (second-generation Japanese Americans), ultimately was successful after 5 days of battle and rescued 211 men by October 30, but suffered more than 800 casualties. For size and length of service the 442nd is the most decorated unit in U.S. military history. Above is Wells Lewis with father and stepmother Dorothy Parker in 1935 on way to accept Nobel Prize. The death of Wells in France took place only nine years later.

131st Field Artillery, 36th Infantry Division (Texas National Guard of the U.S. Army) who were survivors of the sunken USS Houston. They were captured by Japanese forces and taken to Java in March 1942 and then sent to Singapore and Burma where they worked on railway construction crews, as later depicted in the 1957 film The Bridge on the River Kwai. It was not until September of 1944 that it became known they were prisoners of war.

Thus went some highlights from the last century and the last millennium.

Thanks for reading Matula Thoughts.

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

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