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Expectations and epistolaries

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Matula Thoughts
January 1, 2021
Expectations and Epistolaries

2941 words

One.

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

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

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

 

Two.

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

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

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

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

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

 

Three.

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

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

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

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

 

Four.

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

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

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

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

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

 

Five.

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

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

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

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

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


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

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

 

Postscripts.

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

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

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

Trees fall in forests. 

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

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

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

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

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

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

 

Mastery

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Matula Thoughts December 6, 2019

Mastery

2473 words

 

One.

Master cellist Pablo Casals received the Presidential Medal of Freedom, on this December day in 1963, among the first cohort of recipients, in a bittersweet ceremony two weeks after President Kennedy’s assassination. Kennedy had come up with the idea for the award, but Lyndon Johnson presided at the event by default.

The Presidential Medal of Freedom was a successor to the Medal of Freedom that derived from Harry Truman’s Executive Order 9586 (signed July 6, 1945), establishing an award for notable civilian service during WWII. Over 20,000 such medals were given out, mainly by the secretaries of state, war, and navy up through 1961. Kennedy re-oriented the award with his Executive Order 11085 (signed February 22, 1963), broadening the name to Presidential Medal of Freedom and shifting its scope to include cultural achievements. Other awardees with Casals that evening December 6, 1963, were architect Ludwig Mies van der Rohe; painter Andrew Wyeth; singer Marian Anderson; writers E.B. White, Thornton Wilder, and Edmund Wilson; Rudolf Serkin pianist; Edwin Land inventor; Edward Steichen photographer; Clarence Randall businessman; educators Genevieve Caulfield, James Bryant Conant, Alexander Meiklejohn, and George Taylor, and others including John Enders for his vaccine work. It was quite a gathering. [Above: Casals at Carnegie Hall, 1917. Bain Collection, Library of Congress.]

Casals, one of the great cellists of all time, at age thirteen had found a tattered copy of obscure Bach unaccompanied cello suites in a Barcelona shop, mastered the six pieces, and took them to international attention that would inspire generations of cellists such as Yo-Yo Ma. On Wikipedia you can find audio clips of Casals playing parts of the First Cello Suite. The Casals entry from the same source offers a quote from George Carlin attributed to Casals, who when asked at age 93 why he continued to practice three hours a day replied, “I’m beginning to notice some improvement.” Fact or true fact, it’s a beautiful thought and one certainly in keeping with the artist’s persona.

 

Two.

Born in Catalonia Spain in 1876, Casals died in Puerto Rico in 1973. His life was one of mastery and professionalism, interrupted by a terribly low point around the time of the Spanish Civil War, when he was a refugee in France. Fleeing Franco’s efforts to liquidate political foes, Casals learned that he would have his arms cut off if he returned. Anguished over the fall of the Spanish Republic, distressed by it abandonment by democratic nations, fearful of his own safety in France as the Nazi’s rolled across Europe, and exhausted by demands of recording the Bach cello suites (the first recording made of them), Casals fell into a deep depression and didn’t leave his room in Paris for two weeks. Burned-out, as some people now would say, he eventually rallied and got back to his work. Much later Casals gave his memoirs to a writer, Albert E. Kahn, who published Joys and Sorrows: Pablo Casals, His Own Story in 1970.

Kahn, it should be noted, was nephew of the master industrial architect Alfred Kahn who worked with Hugh Cabot in Ann Arbor to plan and build Michigan’s acclaimed University Hospital in 1925. Kahn also designed Hill Auditorium, Clements Library, Angell Hall, Betsy Barbour Residence Hall, Burton Memorial Tower, Harlan Hatcher Library, Ruthven Museum, among other buildings on campus. Kahn’s son, Eddie, a contemporary surgical trainee with Nesbit under Cabot, became Michigan’s second neurosurgeon (after Max Peet). Sixty Kahn buildings are on the National Historic Register list, but it was the Clements Library in Ann Arbor for which Kahn wanted to be most remembered.

Stories of the Bach suites and Casals are interwoven by Eric Siblin in The Cello Suites (Grove Press, New York, 2009). Mastery is an aspirational trait that most people seek in one way or another, whether it be mastery of a skill or hobby, mastery of a job, or mastery of parenting. Kennedy’s idea for the Presidential Medal expanded a national honor related to war to the mastery of the constructive skills of civilization – the humanities. Kennedy’s empathy and respect for those arts reverberates today and marks him as a master statesman, no doubt imperfect as is anyone, but a master of the presidency. [Picture: Casals performing for the Kennedys at the White House, November, 1961.]

 

Three.

Kennedy had a special linkto the University of Michigan dating from his campaign speech on the steps of the Michigan Union at 2:00 AM on October 23, in 1960 when he proposed the idea of the Peace Corps. The national shock at his assassination only three years later was profound for most people, no matter how they had voted. [Above: Time cover from John F. Kennedy Library, Boston.]

At this time in 1963 the Section of Urology of the Department of Surgery at the University of Michigan was in the final stage of Reed Nesbit’s leadership. Nesbit’s mentor, Hugh Cabot, had been an undisputed master of the subject of modern urology in the early 20th century, while Nesbit subsequently became the undisputed master of many of its skills, most notably transurethral resection of the prostate. Nesbit was also a master educator, training at least 83 residents and additional fellows, although we are still trying to get a precise count (demonstrating once again how elusive true facts and actual history can be).

In December 1963, as Nesbit was winding up another good year as chief of urology at Michigan, he undoubtedly read of Casals and the other Presidential Medalists the following day in the Ann Arbor and national newspapers. The only other senior faculty member in the Section of Urology faculty with Nesbit in the Section of Urology in 1963 was Jack Lapides who was Chief of Urology at the VA and at Wayne County General Hospital (since 1950). Joe Cerny (N ’62) was a junior faculty member. Harry Lichtwardt had been Vice Chair of Urology at Wayne County General Hospital, since 1951. The three new residents in 1963, halfway through their year at this time of the season were Dale Alkema, Larry McDonald, and Bernie Sloan, while the chief residents were Robert Bishop, Dewey Heetderks, and Harold McDonald. Nesbit was likely starting to think about his annual Christmas letter around this time. Meanwhile I was in my first year of college, oblivious to the field of urology and wondering if I would master anything at all.

The news cycle, one hundred years ago, centered around the daily papers with a 24-hour rhythmicity. The national news for December 6 contained little information that today’s newshounds would recognize, except perhaps for mention of the Warren Commission in the New York Times, an Oswald reference in the Ann Arbor News, and a Big 10 athletic scholarship limit reported in the Michigan Daily. [Thanks to Katie Baxter for finding these.]

The inaugural Presidential Medals of Freedom winners were not revealed to the public until the next day, December 7, in addition to other newsworthy items, including the 22nd anniversary of Pearl Harbor.

 

Four.

Senait Fisseha. Not every week does The Lancet feature an article on a Michigan faculty member, but that happened recently with a profile on Senait Fisseha, Clinical Professor of Obstetrics and Gynecology. [Lane R. Profile. Senait Fisseha: empowering women through reproductive health.The Lancet. 394:1405, 2019.]  Medical Director of the University Center for Reproductive Medicine in 2008, Director of the Division of Reproductive Endocrinology and Infertility in 2011, and creator of the University of Michigan Center for International Reproductive Health Training, Senait  has developed a partnership between Michigan and St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia.

Another shout-out for The Lancet relates to Ella Doerge, who graduated from our program last year and is currently pursuing further training in a London fellowship with Tim O’Brien. She recently sent me the following comments and picture she took at The Lancet Library.

Hi Dr. Bloom,

Just dropping you a line to see how things are going back on the homefront in Michigan. I’m a month or so into working at my fellowship at Guy’s and am getting more and more familiarized with life in the UK, both in the health care system and in the city at large. While we share the English language with the English, there have been more differences in culture and conversational conventions than meet the eye that I’ve been uncovering. While it’s been good here, I think I’m irrevocably American, in mentality, how I prefer to practice medicine, and how I interact with my environment.

Anyway, I thought of you in particular a few weeks ago because I had the opportunity to spend a day with one of the lead editors of The Lancet. I got to peruse the library with volumes dating back to their first publications which I’m sure you would have found particularly interesting (photo attached). I also sat in on their weekly editorial board meeting with their editor-in-chief in which they made all the decisions for papers to include in the coming week’s issue.

 

[Above: Lancet Library; Below: Ella with Duncan Morhardt during their days at Michigan.]

 

Five.

Burnout is a hot topic. It rightly focuses attention on our students, residents, and colleagues who are struggling more than usual. It offers many opportunities for blame, administrative burden, the electronic record, mandatories, administrators in general, third party payers, regulations, fee-for-service systems, RVUs, corporate medicine, throughput demands, constrained schedule grids, and the gray days of winter. It provides new opportunities for talks, papers, and even jobs. But let’s not blame burnout, per se; many physicians lose a sense of the magic in their profession and others are truly overwhelmed by “TMI” and conflicting responsibilities. And, of course, some organizations provide poor workplaces.

Burnout cannot be detected by biomarkers and as of yet has no ICD 10 diagnostic code. Once it was considered a binary phenomenon – you either have it or don’t, just as Casals in his darkest days couldn’t leave his room to re-engage with the world. Individuals, at some point, may be overwhelmed by work and can’t continue it. Surveys and questionnaires (“instruments”) allegedly diagnose “degrees of burnout” which seems to have been externalized, from an internal or personal condition, to a workplace fault. No responsible leader can avoid discussing the topic and “measuring” their teams for it with further surveys, thereby adding counterproductively to the enlarging ambient administrative burden. By medicalizing burnout and viewing it as a “disease,” like a generalized form of carpal tunnel syndrome, we gas-light the matter, conveniently obscuring leadership a causal factor, but no matter how we frame it we, as leaders, are responsible for workplace conditions that heavily contribute to the condition.

It is unreasonable to expect successful people, even the masters of their arts to be “on fire” every day. Pablo Casals had days of tedium, frustration, annoyance, and – as is well documented – anger and embitterment over the political realities of his nation. His dysfunctional interlude in Paris was multifactorial in origin – the recording process was particularly alien and painful for him – but he rebounded. Could intrinsic motivationbe the converse of “burnout” or provide a “vaccination” against it? Daniel Pink’s book, Drive, caught my attention in my early days as chair and affected my world-view. I gave out numerous copies of it and had many productive discussions on it with executive coach David Bachrach and faculty colleagues. The ideas integrated beautifully with concepts of lean processes that Toyota, John Shook, and locally Jack Billi, Jeanne Kin, and Malissa Eversole have shown me. The key features of intrinsic drive,or self-motivation, that Pink teaches are purpose, mastery, and autonomy.

Purpose envelops healthcare professions, you shouldn’t have to look far to find it, although it can become obscured in crowded and tense modern workplaces. Mastery is a matter of training, life-long learning, and deepening maturation of perspective. Our residencies and fellowships get us started, our practice and continuing education hone our skills, and hard-won wisdom opens the door to mastery, which is never complete, as Pablo Casals lightly noted in 1964 when he said: “I’m beginning to notice some improvement.”

Autonomy is the challenge, in these times of complex health care teams. Of course, no person is an island – we are members of a deeply interwoven eusocial species and rely on others to bake our bread, brew our beer, and prepare our meats and tofu. Autonomy is relatively conditional. In rare instances, some people can effectively bully their way into great degrees of autonomy and achieve wonderful things, although usually with a personal toll – e.g. Steve Jobs. The challenge for leaders, whether at single unit levels or presiding at large systemic levels, is to understand and protect the autonomy needs of workers under their authority. The complex teams of modern medical practice preclude absolute autonomy of any one person. Everyone reports to someone from custodian to CEO, yet members of most teams function best when driven by their own intrinsic motivation rather than external carrots or sticks, targets or incentives; the challenge is unleashing that intrinsic motivation. When employees understand their contribution is valued, when they have freedom to improve that work, and when they feel fairly compensated, then intrinsic motivation can thrive – and that is the best inoculation against burnout.

 

Postscript.

Dick Dorr passed away last month. He was an iconic figure in Michigan Urology and a pillar of the community, leader of St. Joseph’s Mercy, and faculty member in the University of Michigan Department of Urology in his later career. Richard Paul Dorr was born 8/17/1936 in Saginaw and became a loyal Spartan at Michigan State prior to coming to the University of Michigan Medical School to obtain an MD in 1961. After surgical internship at Wayne County General Hospital he served as Captain in the U.S. Army Medical Corps and Commander of an Airborne Division Medical Company at Fort Benning, Georgia. Dick returned to Ann Arbor in 1964 for urology residency at the University of Michigan that began under Reed Nesbit and concluded under Jack Lapides in 1968, when he went across the street to St. Joe’s to begin urology practice and develop a superb team with Tim McHugh and Hugh Solomon. Dick served as chief of the medical staff from 1980-82. He became a member of the American College of Surgeons, in the tradition of Dr. Nesbit. A master of urology, and ever the student, Dick completed a fellowship in pediatric and reconstructive urology with the cutting-edge team at East Virginia Medical College in 1984. Following that he had important corporate roles in the St. Joe’s system before returning to fulltime practice in 1990 with Tim and Hugh. In the last six years of his career he worked at the University of Michigan Medical Center during the leadership period of Jim Montie. Dick died on 11/6/2019 and these pages cannot do justice to that master of urology. He is survived by two siblings, his wife Jane, and children Richard, Susan Dorr Goold (colleague in Internal Medicine here at UM), and Mark. Dick and Jane have five grandchildren, two step-grandchildren, and three great-grandchildren.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

November one

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DAB Matula Thoughts November 1, 2019

One hundred years of urology
2615 words

One.

The origin of urology at the University of Michigan centers around its first three urologists Hugh Cabot, Charles Huggins, and Reed Nesbit, each having enormous impact in their individual ways. Cabot’s impact was academic, clinical, and organizational. Huggins came to Michigan for what was then called “postgraduate training” under Cabot and was inspired to a career in urology that took him to the University of Chicago as chief of urology and eventually to a Nobel Prize. Nesbit, roommate of Huggins as trainees, became Cabot’s successor and a noteworthy urologist, whose clinical innovation, organization leadership, and education of future leaders of his century, had few equals.

The story of genitourinary surgery, of course, actually began much earlier, with pre-Hippocratic roots and slow evolution until the second half of the 19th century when health sciences, modern technology, and medical subspecialties emerged and revolutionized medical care. The University of Michigan story is entwined with those changes, as one of the earliest public universities and in 1869 it was the first university to own and operate a teaching hospital. By the early 20th century the University of Michigan Medical School was noteworthy among its peers in teaching and research, but lagged behind in the clinical arena, a fact that some viewed as due to its small-town location. After the 1902 neologism by Ramon Guiteras the term ii replaced that of genitourinary surgery, although not until many years later in Ann Arbor.

Exactly one hundred years ago, on November 1, 1919, the University of Michigan Medical School, although still stuck in educational and clinical paradigms of the previous century, was on the precipice of major change that would launch it into the major leagues of 20th century academic medicine. Dean Victor Vaughan, an immeasurable influence since his arrival in 1874 as one of Michigan’s first two Ph.D. candidates, had been distracted by duties in Washington during WWI and was reeling from the death of one of his sons who had been about to return home from his service in Europe on the Western Front. Vaughan had other national leadership responsibilities on his plate in addition to the war effort and his inattention to Michigan had left the Medical School without chairs for its two main departments – internal medicine and surgery. In Boston Hugh Cabot had recently returned home from 2.5 years of service overseas to find his private surgical and urologic practice “evaporated.” He discovered the Ann Arbor opportunity for a fulltime salaried job as chair of surgery and jumped at it. Beginning work on October 12, 1919, he initially stayed at the Michigan Union, but soon convinced the regents to allow him with his wife and four children to live in the unoccupied University’s President House until a new president was in place.

Cabot was a necessary change agent for the Medical School. He was a top-of-the-line international urologic celebrity even before his 1918 textbook Modern Urology. It is telling that his predecessors in genitourinary teaching and practice at Michigan, interim surgery chair Cyrenus Darling and clinical professor Ira Dean Loree, had been holding on to the older name for the field. Cabot was a self-declared urologist. A prolific speaker and writer, he was assiduous in connecting with new ideas, other specialties, and novel technologies. During the war he became a skillful administrator, ultimately rising to Commanding Officer (CO) of a British Expeditionary Force (BEF) hospital with over 2,000 beds near the front. While he would bring leadership and modernity to Ann Arbor, his brusque style had already created detractors on the national scene, as evident in files at the Bentley Library where a letter to Victor Vaughan from Bostonian Dr. Frederick Shattuck on September 30, 1919 commented:

“Dear Vaughan:
I am greatly interested in your capture of Hugh Cabot for whom I have high regard and much affection, not so much because he is a first cousin of my wife, though very much younger, as for himself and what he is. His departure will be a loss to me, personally, and I think a loss to this community; but the more I reflect on the matter the more I feel that he can render greater service, and thus derive greater satisfaction from life by accepting your offer. Like other strong, positive men, he has made enemies, but I think his capacity to deal with men developed markedly during his service as C.O. of Base Hospital No. 22, B.E.F. There were difficulties connected with that practice which do not appear upon the surface, and it is my belief that, taking all things into consideration, he handled the job extremely well…”

Shattuck concluded the note offering condolence to Vaughan on the recent loss of a son in Europe, referring to the actual moment Vaughan got the terrible news just about as he was to preside over a session of the AMA at its Atlantic City meeting that summer. Cabot also must have been at that meeting, according to the correspondence, and it is likely that it was when and where he first learned of the Ann Arbor job, perhaps directly from Vaughan (letter below).

 

Two.

The first century of urology in Ann Arbor: October 1919 to October 2020. Michigan Urology now entertains a year-long celebration of its centennial. Cabot introduced modern urology to the University of Michigan when he arrived on October 12, 1919, and began to build a formidable clinical engine. He recognized that clinical practice is the essential piece of the tripartite mission of academic medicine, providing the milieu for medical education, factory for new knowledge, and regional reference point for clinical expertise. The clinical milieu generates inquiry and provides a testing ground for the ideas and technology to improve healthcare, and it is the spiritual center of the organization. Clinical programs provide the essential deliverable of academic medical centers. The clinical enterprise is also the financial engine.

Since 1972, Michigan Urology has called its alumni group the Nesbit Society, not from ingratitude to Cabot, but out of respect to his trainee Reed M. Nesbit who became the first Section Head of Urology, after Cabot’s abrupt departure in February, 1930. Over the next 37 years Nesbit made Ann Arbor an epicenter for medical education and clinical innovation. Nesbit trained nearly 80 residents and fellows (we are still trying to determine the exact number), and an extraordinary number of them became leaders in academia and their communities. As a principal innovator and master of transurethral prostatectomy, Nesbit made Ann Arbor a destination for doctors wanting to learn the operation as well as for “patients in-the-know” to get treatment. A number of Cabot’s other clinical faculty also became internationally dominant figures in their newly evolving clinical arenas, of thoracic surgery, neurosurgery, and orthopaedics as well as general surgery, thus bringing the University of Michigan to the center stage of clinical medicine for the first time in its evolution. Nevertheless, Cabot’s vision of a synchronous multispecialty academic health system eluded the University because the hospital functions and professional units (the clinical faculty) were competitive rather than synchronized.

 

Three.

The Nesbit 2019 Scientific Day last month was packed: Peggy Pearle from UT Southwestern in Dallas (above, with Stu Wolf from Dell Medical School in Austin, and Rod Dunn from our Dow Health Services Division) was featured as our Nesbit Visiting Professor with one talk on controversies in medical management of stones as well as another on ureteroscopy; UM President Emeritus Jim Duderstadt discussed the unique impact of the University looking back and looking forward; Jim Cogswell of the School of Art and Design gave a multimedia presentation on the mysteries of dark matter; Dan Dierdorf UM offensive lineman from the famed 1969 team and famed sportscaster presented his Michigan Memories; Stuart Wolf our own star faculty alumnus described the Michigan lessons he is deploying at the new Dell Medical School in Austin, and our departmental leaders gave updates on their divisions including Program Director Kate Kraft and CopMich Co-chair Jens Sønksen. This writer presented Centennial Thoughts and Ganesh Palapattu gave the State of the Department address. We had many wonderful returning alumni and I wish I could have shown them all on these pages, but more pictures can be found on the Nesbit100.com website. I also wish we could have had our traditional alumni talks, but we deferred those for this special Centennial Program, save for Peter Fisher’s unique talk of his personal experience that was both terrifying and uplifting: Everyone should experience sudden cardiac death —- and live. [Below from the top: Dan Dierdorf, Pete Fisher between Will Roberts and Phil Sweetser, Ganesh & Manfred Stöhrer.]

Manfred Stöhrer from Germany, Jens Sønsken from Denmark, and Kash Siddiqi from the UAE travelled far for this meeting. Some of us had been with Jens just a few weeks earlier in Copenhagen, and our ties to him and his team in Copenhagen go back nearly 30 years. The association with Manfred is just as long, with strong ties through Ed McGuire (below) and myself. Our actual but geographically distant faculty included Sherman Silber, now adjunct professor from St. Louis (below with postdoc Yuting Fan – Fanny), and Brian Stork and Jessica Phelps of our Muskegon West Shore Urology practice.

We consider UMMS graduates, residency trainees and alumni, faculty, regional colleagues, and other friends of the Department of Urology as Nesbit Society members, and many joined us to enrich the meeting. Bruce Bracken, John Hall, Phil Sweetser, Betty Newsom, the Chang duo of Cheng-Yang and Ted, Mike Rashid, Dave Morris, the Taub duo of Marc and David, the Kozminski duo of Mike and Michael, C. Peter Fischer, Howard Usitalo, Stan Swierzewski, Charles Gershon, Charles Reynolds, Jay Hollander, Amy Li, Parth Shah, Hugh Solomon, Joanne Dale, George Schade, Noah Canvasser, Katy Konkle, Bert Chen, Tim Schuster, Craig Kozler with son Oliver, Pete Fisher with son Jake who was interviewing for medical school, Brian Lane, Herk Khaira, Atreya Dash, Ray Tan, Ron Suh, and Scott Gilbert. Rebekah Beach, Frank Begun, Tim Bradford, David Burks, Ward Gillett, David Harold, Will Johnston, Earl Koenig, Surendra Kumar, Amy Luckenbaugh, David Perlow, Paul Sonda, and Nick Styn. Ed Kleer and Elena Gimenez from St. Joseph’s Hospital. Samir Basata, Bob Isacksen, Andre King, David Lutchka, Konda Mouli, Eric Stockall, and David Wenzler. UMMS alumnus Richard Tsou came from Hawaii Pacific Health. Jim Peabody and Nesbit alum Hans Stricker from Henry Ford Health System. From East Lansing we were honored to have Shirley Harding from Michigan State and Nesbit alum Len Zuckerman and Sparrow Residents Margeaux Dennis, Eric McKeever, Andrew Schwinn, Alex Shannon, and Ross Voelker. David Miller won the Konnak Faculty Service Award.

The evening reception at Zingerman’s Greyline event space at the Marriott was terrific with Thad Polk and Red Berenson who offered stories of hockey and Putin. Next year’s meeting will conclude this year-long Centennial Celebration of Michigan Urology and will center around the Wisconsin football contest. The dates will be September 24-26, 2020.

 

Four.

The game. The tailgate at Nub Turner’s GTH Investments provided a more relaxed social gathering point than the scientific program of the previous day. With the concurrent Homecoming Weekend and Parent’s Weekend, Ann Arbor was hopping. The victory over Iowa was a modest win, and it was largely won by our defense. The B-52 flyover was a crowd-pleaser, and the Veteran of the Game was a UM graduate named Thomas Houdek (below).

Michigan Urology has many notable veterans, although none more distinguished than Edward J. McGuire, the man who succeeded Jack Lapides in 1983 and hired me in 1984. Courtesy of Julian Wan we sat in the Club seats with Khaled and Mary Ellen Hafez (below).

 

Five.

Seasonal note. Autumn is fishing season in academic medicine when senior medical students prowl the nation’s training programs for residency education to select where they hope to learn their lives’ work. This process of residency training, postgraduate medical education, was quite informal in Cabot’s time, a century ago – a sort of “arrange-it-yourself” process for periods of time from weeks to years in length. Now the process has been standardized and is regulated by professional organizations including the AUA, ABU, ABMS, and ACGME.

Training programs simultaneously audition medical students in clinical clerkships in summer and fall of the senior years and interview them formally in fall and winter. Each party then submits their “rank lists” to a national site and matches are made for urology residency training positions. The process of interviews, selection, and then the actual residency training of 5-8 years is delegated to the Program Director, a position that has grown increasingly complex over the years since the terms of Gary Faerber, Khaled Hafez, and now Kate Kraft. Selection, education, and supervision of residents requires a small village of helpers and Kate is assisted by Sapan Ambani and a team of committees. This year Michigan Urology had over 375 applicants, offered around 66 interviews, and will end up matching with four trainees who will begin their residency training next July 1. Michigan Urology matched five last year, one of whom will have an 8-year period that will include a substantial research component, and this is Joel Berends. Ganesh, Khaled, Kate, and Sapan plan to alternate 4 and 5 year classes.

 

Postscript.

Vaughan’s reply to Shattuck. Only two days after Shattuck’s revealing response to the dean’s reference inquiry, Vaughan replied:

“My dear Friend:-
I am fully aware of the fact that Dr. Hugh Cabot being as strong a man as he is has made enemies and their criticisms have not failed to reach my ear, at least some of them. However I believe in Dr. Hugh Cabot and am greatly pleased that the prospect lies before me of having him as my colleague in work which I believe to be of the greatest importance to the future of American medicine. I congratulate myself and my school upon being able to obtain his services.

I wish to thank you for your words of sympathy. I had five sons in the Army and it seemed that the good fortune of having all of them returned to us was about to be accomplished. My eldest son was Chief of the Medical Service in the Roosevelt Hospital at Chaumont during the entire period of the war. After the armistice he was detailed to work up typhoid fever in the American Expeditionary Force. He had collected all of his data and was on his way home when he was accidentally drowned in a small river in France. It is the first time that death has visited our family. Time alone will assuage the sorrow but words of sympathy from such a dear friend as you will do much to mitigate our sorrow. Yours sincerely, V.C. Vaughan” [letter below]

 

PPS

In little over a decade Cabot brought the University of Michigan Medical School into the top tier of academic health centers. He recognized that a superb, attractive, and financially robust clinical engine was at the center of medical academia and he delivered on that necessity. Yet he spent down political capital rather than building it and he had a tin ear for the faculty and staff he led; it was not quite like his successful, albeit shorter-lived, experience as commanding officer at the Western Front of WWI. His successors in urology at Michigan continued to build one of the finest urology programs in the world, and Cabot surely would have been astonished to see what it looked like 100 years after he first set foot in Ann Arbor as its one and only urologist. [Below: Faculty, residents, alumni, guests at Nesbit Society meeting 2019.]

We thank those who joined us for this kick off for our Urology Centennial Celebration and invite you and those who couldn’t make it this year to the conclusion in 2020, September 24-26.

Best wishes as we begin November, 2019.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

A century and a millennium

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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

Matula Thoughts September 6, 2019

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Matula Thoughts September 6, 2019

Urology at Michigan is a century old
2411 words

 

One.

The origin of Michigan Urology. The state of Michigan and its sole university had no medical school when Moses Gunn (above) came to Ann Arbor in 1845. Gunn had heard rumors that a medical school might be formed in this small town and moved here after graduating from Geneva Medical College in New York. He came by train in mid-winter with a cadaver in a trunk and began practicing medicine, accruing surgical expertise, and teaching anatomy to aspiring students in the back room of his office.

Gregarious, talented, and confident, Gunn networked with Zina Pitcher and others interested in creating a medical school for the University of Michigan and within three years the school became a reality. Dr. Pitcher, leading the university board of regents, included Gunn among the five founding faculty of the medical school in 1848 and classes began in the fall term of 1850, after a building was constructed. Gunn taught anatomy and practiced a wide range of general surgery, perhaps best reflected in the textbook of his contemporary, Samuel David Gross, A System of Surgery, although that didn’t appear until 1859. Genitourinary surgery was then an important facet of general surgical practice and the first textbook Gross wrote earlier in 1851 was specifically on the topic of genitourinary surgery – A Practical Treatise on the Diseases and Injuries of the Urinary Bladder, the Prostate Gland, and the Urethra. Gunn undoubtedly was familiar with these books of his fellow academic surgeon, at some point in his career.

Genitourinary surgical disorders were necessarily taught and practiced at the University of Michigan since those early days of the medical school in Ann Arbor and Moses Gunn was the starting point, although the actual first moment is unknown. His operation on a man with “phymosis” in a surgical demonstration for medical students is the earliest example we have found of Gunn performing an ancient procedure necessary for men with symptomatic restriction of the preputial aperture. Nothing innovative was offered at that occasion, but it must have been a useful lesson for the medical students in 1866. Gunn by then had moved to Detroit to live and practice, believing Ann Arbor’s medical school should have been relocated there because of its hospitals and larger population. He returned to Ann Arbor, twice weekly by train, to teach by lecture and surgical demonstration, until gong to Chicago in 1867 as professor of surgery at Rush Medical School.

Procedures such as Gunn’s dorsal preputial slit or circumcision for phimosis, paraphimosis, or recurrent balanoposthitis, have been necessary since the earliest days of mankind. More complex interventions, such as lithotomy for bladder stones, had also been performed since well before the days of Hippocrates, who cautioned healers to leave “cutting for stone” to specialists of the time – namely itinerant lithotomists. They were itinerant for good reasons, they didn’t readily want to share their single skill and their clinical outcomes probably mandated short stays in any location. Little information about them exists, aside from Frere Jacques and the nursery rhyme that commemorates him two millennia after Hippocrates.

Genitourinary surgical practices muddled along with little change over the millennia until science and technology permitted innovations, safety, and better outcomes in the later 19th century. Moses Gunn, by then in Chicago, witnessed these changes amidst the emergence of a group of surgeons who incorporated new skills, instruments, and the novel tool of cystoscopy into their larger practices. Cyrenus Darling as Lecturer on Genito-urinary and Minor Surgery in 1902, and Ira Dean Loree as Lecturer in Genito-urinary Surgery in 1905 and Clinical Professor of Genitourinary Surgery in 1907 (both pictured below) were the first specifically-designated genitourinary practitioners and teachers at the University of Michigan.

[Above: Darling; below: Loree. Bentley Library]

 

Two.

Urology and the 20th century. Small clusters of genitourinary specialists accumulated in several locations in North America, notably Boston and New York. Ramon Guiteras in New York was one of these young men and in 1902 he came up with a new word to define the newly re-tooled specialty, partly to differentiate it from the empiric practice of venereology that had been part of the genitourinary domain. Urology, the new word, was not quite perfect semantically, but worked well enough and replaced the older terminology, more quickly in some places than here in Ann Arbor, where the Medical School and University Hospital job titles held on to genitourinary surgery. Both the school and the hospital needed to enter modernity and the new century, which had moved on since the fin de siècle of the 19th century.

Hugh Cabot, a young surgeon in Boston, was among the first to embrace the Guiteras neologism of urology, and his textbook in 1918, Modern Urology, was among the earliest to use the name in a title after the Guiteras text of 1908. A progressive in many ways, although startlingly biased in other dimensions. After more than two years on the Western Front during WWI, Cabot found private practice in Boston unfulfilling and was eager for a career change when he arrived in Ann Arbor around this time of year in 1919.

Cabot hit the University of Michigan like a hurricane and within a decade brought the modernity of urology to the medical school and the hospital. The amateur historian in each of us sometimes defaults to a “before and after” construct, and urology at the University of Michigan truly began when Cabot first arrived in Ann Arbor, in September, 1919. Michigan’s genitourinary surgeons, Darling and Loree, quickly recognized their incompatibility with the new boss and resigned from the medical school leaving Cabot, the urologist, their practices and teaching responsibilities.

 

Three.

Imagine that world of 1919: World War I was winding down and the Spanish flu was still ravaging North America and Europe. The Great War killed 17 million people, while the influenza epidemic killed 20 million, proving once again that humans don’t really need to kill each other off as other species can do so far more effectively. Prohibition and women’s suffrage were occupying much of the national political conversation. At the University of Michigan President Hutchins was ready to step down but the regents hadn’t found a replacement and the Medical School was at loose ends.

Victor Vaughan had been a transformational figure at Michigan since his starting days in 1874 and assumption of the medical school deanship in 1891. He became a national figure academically though his initial investigations and teaching in biochemistry, physiology, and bacteriology, followed by his medical service during the Spanish American War. The medical school, that Vaughan had effectively stewarded, shined in the 1910 Flexner Report but began to run down, especially during World War I as he spent time in Washington helping manage military medical affairs and was increasingly distracted from duties as dean. By 1919 the chairs of internal medicine and surgery remained vacant, in spite of modest efforts to fill them, and plans for a much-needed replacement university hospital were dormant. [Below: Vaughan portrait by Gari Melchers, also shown here last month.]

The year 1919 was one of deep loss for the Vaughan family, when one of their five sons perished by drowning just before returning from duty in France. Dean Vaughan was notified while in Atlantic City at a meeting of the American Medical Association in June and, after what must have been a horrible pause, collected himself enough to deliver concluding remarks for the session he was chairing at the moment.

[Class picture 1919]

In Ann Arbor, prior to Cabot, the teaching and practice of genitourinary surgery had been mostly in the hands of Ira Dean Loree, a respected member of the community and one of the 20 local citizens behind the creation of Barton Hills Country Club, that opened in 1919 with its Donald Ross golf course. Loree, Vaughan, and Darling are seen in the UMMS class picture (above) at the end of the 1919 spring term, unaware that Hugh Cabot was about to disrupt their lives. As summer came to an end, Vaughan was resuming life back in Ann Arbor still faced with the two open chairmanships and the deteriorating clinical and educational physical infrastructure of the Medical School. Meanwhile, in Boston, Cabot had returned from duty in France but was frustrated on resumption of his clinical practice. At some time around then, Cabot learned of a unique opportunity in Ann Arbor, and he jumped at it. He had not been on anybody’s radar screen of candidates at that time. Vaughan, in fact, quietly favored his internal faculty candidates Carl Huber and Frederick Novy, according to a personal letter to one of the Vaughan sons in the autumn of 1918.

 

 

Four.

Cabot’s decade in Ann Arbor began with a first visit in September, 1919. He came by train and stayed at the new Michigan Union, where Vaughan and President Hutchins housed their major recruits. The first visit impressed the Michigan leadership and impressed Cabot as well, who saw the Medical School as a perfect canvas for his bold ideas that fused the provision of just and medical care to a democratic society, emerging subspecialties, brisk incorporation of new technologies, multi-specialty group practice, and clinical education from full-time salaried academic clinicians. Cabot was an excellent educator, a powerful administrator, a world-renown urologist, and an effective politician who usually got his way. He came to Michigan as professor and chair of surgery, following Gunn and de Nancrede, but unlike them built a powerful surgical faculty known not only for teaching, but also for academic productivity and clinical excellence. He was also predominantly a urologist. Cabot recruited and developed a robust cadre of young faculty, especially distinguished in the surgical fields with Max Peet, John Alexander, Frederick Coller, Charles Huggins, Reed Nesbit, and others who enriched and dominated their emerging subspecialties, winning accolades up to and including the Nobel Prize.

Within a year and a half from his start, Cabot became dean of the Medical School where his accomplishments were extraordinary. While managing day-to-day functions of the medical school and continuing to grow his voice in urology, he presided over the dissolution of the Homeopathic College, the construction of a new University Hospital (the fourth iteration of our hospital since 1869), and the deployment of the first world class cadre of clinical faculty at the University of Michigan.

We intend to elaborate on this story in two parts to mark our centennial. The first part, The Origin of Michigan Urology, will be in print later this autumn and will tell the story of our field and our university up to (and through) the Cabot era. The next part, The First Century of Michigan Urology, will cover the ensuing 100 years up through 2020 and we project its completion in two years as the story evolves. It was a remarkable century.

 

Five.

Fast forward over an astonishing 100 years from Cabot’s arrival in 1919 to last month in Copenhagen and the CopMich Urologic Symposium. Dana Ohl and Jens Sønksen began a collaboration two decades ago that culminated in this biennial event alternating between Ann Arbor and Copenhagen, where Jens is chair of the surgery department. This Third CopMich Urology Symposium was held west of Copenhagen at the lovely Hotel Hesselet in Nyborg on the seaside of the “Great Belt” a wide strait between Copenhagen and Jutland, connected by the magnificent Øresund Bridge. The three-day symposium (above) covered reproductive urology, urologic oncology, pediatric urology, stone disease, pelvic floor and pain, patient information, psychosexual health, telemedicine, and an amazing new generation of research projects mentored by Dana Ohl and Jens Sønksen. From this collaboration, nearly 100 peer-reviewed publications have resulted. [Below: a.) Jens, Diana Christensen, Christian Jensen; b.) Anne Cameron, John Wei, Mikkel Fode; c.) Helle Harnish, Nis Nørgaard, Yazan Rawashdeh.]

Danish and Michigan faculty produced a superb collection of talks over the 2.5 days and planning is already underway to return this symposium to Ann Arbor in 2021 was given the chance to give one talk about anything I wanted, in addition to assignments of more usual urologic topics. Reverberating from the dozen years of Chang Lectures on Art and Medicine we concluded in Ann Arbor last year, I returned to that theme to talk about the role of art in dealing with the “TMI” (too much information) of our medical world. Our arts compress, abstract, or replicate things artists find beautiful, meaningful, or otherwise worthy and those windows onto the world help the rest of us expand our own windows. Matula Thoughts, What’s New, and CopMich last month provide opportunities to delve into these matters, not from any learned perspective as an art historian, but only from the simpler framework of a citizen and physician deluged by the constant typhoon of TMI. [Below: a.) Mette Schmidt, Cea Munter, Klara Ternov, Marie Erickson; b.) Jens, Hans Jørgen Kirkeby, & Dana; c.) Ganesh Palapattu.]

[Below top: Maiken Bjerggard “Queen of Jutland”, Erik Hansen, Pernille Kingo, Anna Keller. Bottom: CopMich ensemble 2019]a

 

 

Postscript.

This is hurricane or typhoon season for much of the world. Cabot may have hit Michigan metaphorically like a hurricane in 1919, but real mega-storms regularly challenge eastern and south central states at this time of year and today Hurricane Dorian is running itself down after a week of devastation and terror. The Waffle House Index comes to mind. This informal metric was conceived of in 2011 after the Joplin tornado when FEMA noticed that two Waffle House restaurants in Joplin stayed open during the storm, eliciting the idea of a measure of community robustness – that is, its ability to function in the face of overwhelming forces. This “index” abstracts from all the noise (all the overwhelming “information” of the hurricane and its effects) some measure of community functionality. The Waffle House, unlike most other restaurants and businesses that close when environmental conditions deteriorate, is reputed to do its best to remain functional for its communities, following the lead of the first responders, police departments, fire stations, and hospitals. The Waffle Health Index, unlike abstruse statistical measures, is simple, understandable, and meaningful to most people. An abstraction of regional disaster to a useful metaphor, or a meme, that brings some clarity to mass confusion and facilitates useful response.

One could hope for similar indicators of biodiversity, local or global environmental integrity, generalized human well-being, or academic health center viability, to give clear appraisals of complex conditions as a basis for appropriate responses. The individual biologic response to threat may be prompt, as we recoil from fire, but the systemic response of the human species to impending disaster is woefully inadequate.

 

September & centennial greetings,

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

Matula Thoughts August 2, 2019. Impressions

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Matula Thoughts

August 2, 2019

Impressions & metaphors:

Thoughts from a UMMS faculty member
2224 words/20 minutes

 

One.

As a medical student, my first impressions of children’s surgery imprinted on my brain much like a duckling gets imprinted when it initially sees its mother, or whatever creature first walks by. I went to UCLA for surgery residency in 1971 and then to London for a year in 1976 to learn from David Innes Williams, a founder of pediatric urology (above, Shaftesbury Hospital, 1976). The experience was rich. At first I was as an observer and later served as a registrar, the UK version of my status in the U.S. Mr. Williams was the consummate professional and his attitude was reciprocated by patients, trainees, and staff. My first impression of “DI,” as we called him, was one of the perfect English gentlemen, with unparalleled expertise and skill in one’s field. I noticed that even the poorest families coming to see him dressed for the occasion, the men often wearing a coat and tie, and the children well-scrubbed up and disciplined. Formality was echoed by kind and polite staff (Sister Fay and Sister Val) and by Mr. Williams himself who invariably offered a proper English greeting.

Mr. Williams was always addressed as “MR. WILLIAMS”– the appropriate title for a surgeon in the British world of medicine since the days of King Henry VIII who chartered the Barber Surgeons Guild in 1544. The physicians (internists) had been chartered in 1522 and were addressed as “Doctor” and the surgeons, a very distinct class of practitioners were “Mr” back then and remain Mr. to this day. Additional medical customs and traditions persisted in the National Health System and when I was a clueless young American, a colleague then ahead of me in training, Mr. Robert Morgan, took me under his wing and kept me out of trouble. Just as British ways sometimes confused foreigners like me and American ways tended to befuddle the British who, for example, couldn’t understand why Henry Kissinger came to be addressed as Doctor.

I returned to London in 1986, as a young UM faculty member on leave under Ed McGuire, to serve as a locum tenens for several months. Sir David Innes Williams (above, recently knighted) had retired from a large administrative post in the National Health System (NHS) and his successor Phillip Ransley was the sole pediatric urologist in London. American colleagues were taking sequential turns filling the spot that soon became formalized with a second NHS pediatric urologist, who turned out to be Patrick Duffy, the registrar working with me those months in 1986. I was self-conscious to be sitting in the same chair and at the same desk Mr. Williams had used to see patients, but I seemed to be tolerated by staff and patients.

In the decade between my times working for the NHS, the dress code and sense of formality of the clinic visits had relaxed. Families were more causal in dress, perhaps reflecting acceleration in the pace of life, only occasionally putting on their Sunday best for clinic visits, more likely quickly assembled from work and school to rush to Great Ormond Street Hospital by tube, bus, or cab (rarely by car, because where could they park?). Nevertheless, greetings were not rushed, but rather were moments of catching one’s breath on both sides of the table, with casual inspection, mutual taking measure, and kind acknowledgements. Those first impressions the parents and children have of the physician/health care provider are lasting.

 

Two.

Life is a social business and medical practice and education are especially social. That’s why we have frequent visiting professorships, like the Duckett Lecture last month, with Chester Koh from Baylor. Chester spoke on medical devices and discussed cases with residents, who also observed his professionalism and communication skills.

[Above: Pediatric uroradiology conference with Chester; Below: Kate Kraft, Chester, John Park.]

The first words patient hear often set the stage for their entire relationship with a health care provider. It is no surprise that one of the more offensive introductory phrases patients report is: “Why are you here?” Clinicians never intend any offense, and I myself may have cluelessly used those words in past days, trying to figure out the needs of a patient. Health care providers have many pressures for excellence, self-education, relevance, academic productivity, and equanimity. Furthermore, they are belabored by systemic pressures that are, perhaps, the greatest drivers of professional burnout: organizational metrics, throughput demands, rigid schedules, mandatory web-learning programs (fire safety, compliance, “high reliability training,” new chaperone rules, opioid regulations, and other modules every year). Electronic health record systems set the stage – demanding entry of a chief complaint at the outset of each “encounter.”

To many patients, however, that first question, Why are you here, is a slap in the face, interpreted by some as an accusation (“why are you wasting my time?”) or is evidence of an unread letter of referral or poor preparation. Patients may be anxious, looking for reassurance, expertise, and kindness. Parents with sick children will be especially distressed and for them, “Why are you here?” is a poor choice of the starting position for the physician or provider. If you put yourself in the place of the mother in Gari Melchers’ painting after the hassle and expense of getting to the clinic with your baby, you might not respond favorably to that question. If the provider was, perhaps, “burned-out” from a busy clinic schedule, the electronic health record, systemic mandatory demands, and short ancillary staffing, it is very likely that the mother with the sick baby was equally stressed, if not more so.

[Mother and Child. Gari Melchers. C, 1906. Institute of Art. Chicago.]

 

Three.

White Coat Ceremony. The stethoscope, invented in 1816 by René Laënnec in Paris, is not just an effective tool for auscultation, it is an equally effective metaphor for listening, which is itself a metaphor for seeing, hearing, or otherwise sensing the needs of a patient and family. [Below: Laënnec, National Library of Medicine. Below: Laennec’s 1819 monograph.]

Laënnec died of cavitating tuberculosis at age 45 on August 13, 1826 in Kerlouanec, leaving a wife but no children. [Ariel Roguin. René Theophile Hyacinthe Laënnec (1781-1826): the man behind the stethoscope. Clin Med Res. 4(3):230-235, 2006.]

The meme of the physician as a listener and observer is worth preserving, especially in this day of corporate medicine and formulaic encounters based on electronic medical record work flow. To institutionalize this idea of listening, our medical school began giving all entering medical students top-of-the-line stethoscopes on their first day of school at the White Coat Ceremony on 2004. The instruments were gifts from the clinical departments and some friends of the medical school interested in the actual and metaphoric listening skills of our “next generation” of physicians. Some of the best listeners in health care are themselves hearing-impaired and have trained themselves to go beyond casual vocal encounter with patients to discriminating perception of their patients with all senses.

[Above & below: UM White Coat Ceremony July 27, 2019.]

White Coat Ceremonies date back only to 1989 when, at the University of Chicago, a professor complained that first-year students “were showing up in shorts and baseball caps … where the patients are pouring their hearts out.” Dean of Students Norma Wagoner responded by starting a ceremony where students were supplied with white coats and instructed: “for any session where we have patients present, we expect you to look like professionals, wear the white coat, and behave appropriately.” [Peter M. Warren. “For new medical students, white coats are a warmup. Los Angeles Times. October 18, 1999.]

In 1993 Dean Linda Lewis at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor a white coat ceremony that is mirrored in medical, dental, and osteopathic schools today, among many other health professional schools. (Today, many of these medical schools bear the new names of their modern benefactors.) The white coat as a uniform of a health care provider is importantly a symbol of personal hygiene and responsibility. [Below: White Coat Syndrome, 2008, by Pat Curry, RN.]

The matula was the most prominent symbol of the medical profession for 650 years, as evidenced in art of the times, until Laënnec’s stethoscope in 1816 and the white coat even more recently. What the prominent symbols of the healing professions will be a century from now remains to be seen, but with luck regarding human destiny they won’t revert to the Aesculapian staff and matula.

 

Four.

The moral universe. The compelling imagery of a moral universe is a comforting metaphor. In 1958 Dr. Martin Luther King wrote “Let us realize the arc of the moral universe is long, but it bends toward justice,” in The Gospel Messenger, noting it to be a known aphorism. He used it again in 1964 for commencement exercises at Wesleyan University. The phrase has a deep history, traceable to 1853 and “A Collection of Ten Sermons of Religion” by Theodore Parker, Unitarian minister, American transcendalist, and abolitionist. A book in 1918, “Readings from Great Authors,” quoted Parker. A columnist in the Cleveland Plain Dealer reiterated the phrase, but omitted the word “moral” in 1932. The phrase has been since repeated on many occasions such as in a 1940 New Year version by Rabbi Jacob Kohn in Los Angeles: “Our faith is kept alive by the knowledge, founded on long experience, that the arc of history is long and bends toward justice.” President Obama used the phrase and credited Dr. King in 2009. [Above: Chagall Windows. Art Institute of Chicago.] Whereas some things in life are described as “soul-crushing,” this phrase is soul-compelling.

The physical universe and the universe created by the collective brains of Homo sapiens overlap and the human one increasingly changes the other, at least for the present in the Anthropocene moment. The change is simultaneously creative and destruction – think Mona Lisa or the miracles of contemporary health care versus genocide and environmental deterioration. But if we accept the fact that the human universe is ours to create, then we must recognize that it is (it should be or it can be) a moral universe, thus validating the aspiration of King and those who came before and after him with this belief.

The idea of a universe is a human construction and belief in a moral universe is a particularly human invention. Not eager to invite liturgical criticism, few can deny that Homo sapiens has built extensively around concepts of spiritual faith. But such is the nature of our species to imagine, discover, plan, and pass the information we find and create along to successive generations. In that sense, it is up to us to build that moral universe within the gargantuan amoral physical universe around us.

 

Five.

Ann Arbor August. In much of the northern hemisphere, August is a time for vacation, although the modern workplace of 52 weeks and 365 days per year, and 24 hours per day, requires some people at work every minute such that August is no longer a month of universal leisure time. I recall that when the yearly calendar was unveiled to my surgical internship group at UCLA in July, 1971, the first vacation assignment (namely July), went to the most hyperactive of our class, who was expecting to dive immediately into the world of operating rooms, intensive care units, conferences, and clinics.

That intern was very displeased at being told to “stand down” for his first month. The rest of us, I suspect, would have been more accommodating. In the end, he accommodated just fine, and over the course of a distinguished career, Ron Busuttil ended up as chair of the surgical department at UCLA himself. Summer or winter today, the life of a resident provides more downtime and one expects that our new PGY1s will have time for the pleasures of Michigan this month and next.

The Ann Arbor Farmers’ Market (above), operating since 1919, is a lovely feature of our community – a perfect example of Adam Smith’s second-best quotation (a favorite of John Wei):

“It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest. We address ourselves not to their humanity but to their self-love, and never talk to them of our own necessities, but of their advantages.”

[Below: top, local farm sales; local idiosyncrasy – Wolf Man; bottom, Sweet Dirt – Melissa Richard’s Ann Arbor ice cream]

 

Michigan Urology has its own centennial this year. We begin this celebration next month, 100 years after Hugh Cabot came to Ann Arbor, recruited by Dean Victor Vaughan, and will conclude it in the autumn of 2020, to coincide with Cabot’s first academic year at the University of Michigan. Cabot brought modern urology to Michigan in the multiple dimensions of clinical care, education, research, and the international stage.

 

Postscript

Gari Melchers (1860-1932), whose Mother and Child was shown earlier, originally from Detroit, was awarded an LL.D. from UM in 1913. His impression of Victor Vaughan was presented to the university in 1916.

Melchers’s Theodore Roosevelt, originally in the Detroit Freer Collection, is now at the Smithsonian Freer-Sackler Galleries. [Donaldson BM. An Appreciation of Gari Melchers (1860-1932). Michigan Alumnus, Quarterly Review. 1934. P. 506-511.]

As you enjoy August we prepare for the Michigan Urology Centennial, marking the start of modern urology in Ann Arbor under Hugh Cabot.

 

• Centennial Celebration launch, Nesbit Society Annual meeting October 3-5, 2019, Ann Arbor.
• AUA Nesbit Society reception May 17, 2020, Washington, DC.
• Centennial Gala Celebration. Nesbit Society Annual Meeting, September 24-26, 2020, Ann Arbor.

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

Independence

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Matula Thoughts July 5, 2019

Independence Day

2055 words

Above: American flag. Copyright: Sticks Object Art & Furniture, Des Moines, Iowa.
Private collection, with permission.

“Paul Revere? Ain’t he the Yankee who had to go for help?” – old Texas joke. [DH Fischer. Paul Revere’s Ride. Oxford University Press, 1994.]

 

One.

July 4, 1776, meant different things to different people of the time. The British Parliament, indigenous peoples, enslaved workers in colonial states, southern planters, northern industrialists, loyalists of King George III, colonial rabble rousers, federalists, antifederalists, abolitionists, France, Spain, Irish Protestants, or Irish Catholics – to consider just some of the stakeholders – each had their own view of the matter.

Paul Revere’s midnight ride on April 18, 1775, was an iconic event leading up to Independence Day the following year, although its role as an actual tipping point between colonial discomfort with Britain’s royal authority over it and explosion into full-blown revolutionary action is beyond this essay. Causality aside, Revere’s ride inspired popular imagination, legend, and poetry. Henry Wadsworth Longfellow’s poem, published nearly 85 years later in January, 1861, in The Atlantic Magazine, reverberates in my brain, having learned it in my grade school yet another century later: “Listen my children and you shall hear of the midnight ride of Paul Revere …” That meme had legs and the idea of 13 United States of America became a reality and eventually transformed into the idea of a nation.

American regionalist painter Grant Wood (1892-1942) imagined the midnight ride from a bird’s-eye perspective in 1931 (above). You can view the original in Washington DC at the SAAM. The tiny detail in front of the church repeats the once-common misperception that horses gallop with all four legs in the air, extended front and back (below, top). Grant Wood either didn’t know better or else was deliberately naïve in using the archaic style. He was not really a student of the art of motion, his work only occasionally depicting moving objects such as the impending calamity in Death on the Ridge Road, painted in 1935 (below, bottom).

 

Two.

We celebrated independence for our chief residents and fellows  last month at the Art Museum of the University of Michigan. [Above: chiefs, courtesy Ankita Shah] The Museum had its origin in 1910 as Alumni Hall and I have fond attachments to it, not just because of the appearance, the contents, and its generous uses to the university and the public, but personally as well because our youngest daughter was married there, the Shirley Chang Gallery is housed there, and my late friend Helmut Stern left much of his great collection there as well.

Most graduations are moments of personal liberation and independence. Residents and fellows usually jump from an intense paradigm of responsibilities, schedules, and education to the freedom of their practices of urology, although that world has become more constrained than a generation ago. The idea of the “private practitioner” in health care, especially for surgical specialists is ancient history, although even back in those old days when most urologists entered small groups, they carried the discipline and professionalism of their training mentors and programs with them, out into the world.

Our graduation at the Art Museum was much more about character and culture than personal liberation. Junior residents presented the life stories of the graduating chiefs with grace and humor. Ella Doerge (story told by Rita Jen) will go to London for fellowship with Tim O’Brien at Guy’s Hospital. Ted Lee (story told by Matt Lee) will undertake a three-year Boston Children’s Hospital Fellowship. Zach Koloff (story told by Chris Russell) will also go to Boston to a first-rate Lahey Clinic – affiliated practice. Parth Shah (story told by Michael Fenstermaker) will join the excellent USMD Urology group in Dallas-Fort Worth. Over the five years these chiefs spent with us they became physicians, surgeons, and urologists that I’d trust in a heartbeat with the care of friends, family, or myself.

Our fellows were profiled two weeks ago in What’s New. Deborah Kaye (Society of Urologic Oncology/Health Services Research Fellow) will join the Duke faculty. Nnenaya Agochukwu (Global Health Services Research/RWJ Fellow) will undertake a second fellowship, this being at the University of California in San Francisco in reconstructive urology. Irene Crescenze (Female Pelvic Medicine Reconstructive Surgery Fellow) will join the Ohio State University faculty, under chair Cheryl Lee (Nesbit 1977).

Faculty awards went to Professors Matt Davenport and Jim Shields of the Department of Radiology and Chris Sonnenday of the Department of Surgery who have been essential collaborators with urology. Professor Alon Weizer was recognized as the Team Player of the Year. Among his many gifts, Alon is both a great virtuoso surgeon and a selfless team player, a very rare combination of talents. Vesna Ivancic, the embodiment of professionalism, was recognized for that crucial characteristic of a physician-teacher. The residents presented two awards to faculty: Sapan Ambani was given the Silver Cystoscope Award and Khaled Hafez was given the Julian Wan Award for Excellence in Resident Mentorship.

Chair Palapattu supervised a great evening and the new awards were wonderful additions. Kudos to Program Directors Kate Kraft and Sapan Ambani, Nesbit Society President Mike Kozminski, and Lora Allen. The evening was especially enjoyable for me, freed of responsibility for being sure all went well and the bill was paid.

 

Three.

New folks. Here in Ann Arbor we didn’t need a Paul Revere to announce the good news that our new residents and fellows joined us a few days ago and thankfully no calamities were encountered enroute. Joel Berends from San Antonio is the first-ever recipient of the American Urological Association and Urology Care Foundation Physician Scientist Training Award that will take him from now through June 20, 2027. Anna Faris from Cleveland Clinic, Mahir Maruf from Ross University in Florida, Catherine Nam from Emory, and Alexander Zhu from Des Moines University have also joined Michigan Urology and their program will go through 2024. The annual residency refreshment of July is always eagerly anticipated, although why it happens this particular month of the year and not at the beginning of the fall semester, as is usual in academics, is an interesting question, possibly due to coincidence with start of the common fiscal year of hospitals.  [Below: AA Farmers’ Market]

 

Four.

Chang Lecture. From 2007 to 2018 the Urology Department held a series of yearly lectures on art and medicine, to celebrate Dr. Cheng-Yang Chang for his educational and clinical roles at Michigan Urology and his work in pediatric urology. Dr. Chang’s father, Chang Ku-Nien, was a master painter of 20th century Chinese art and much of his work resides at the UM Art Museum. The Shirley Chang Gallery, named for Dr. Chang’s late wife, is a peaceful and beautiful refuge. [below: Shirley Chang Gallery]

Dr. Chang began training under Reed Nesbit and completed the program here under Reed Nesbit and Jack Lapides in 1967. His two Chang sons remain closely tied to Michigan Urology. Ted completed training in urology under Ed McGuire in 1996 and is now in practice in Albany, working near another great Michigan urology alumnus Barry Kogan. Ted’s older son, Kevin, recently graduated from UM, but is headed for the business/informational technology world. Hamilton, UM 1989, is an investment banker in Chicago and one of Michigan urology’s greatest advocates. [Below: Ku-Nien Chang. Taiwan Cross Island Highway, 1967. UMMA.] While it seemed appropriate to sunset the yearly Chang Lecture series when the urology chair turned over to Ganesh Palapattu, the idea of intertwined art and medicine lives on in our department and periodic Chang art and medicine events are likely to appear.

The Chang Lectures had three objectives. The first two were: celebration of an important and worthy Michigan Urology family and the responsibilities of universities to offer “public goods” – open lectures on general topics (even from a specialized department such as urology). The third goal relates to a belief that discussions of the conjunctions of art and medicine belong in medical schools and health care training programs. Art and medicine converge at the human interior. For artists, that interior is a matter of intellect, soul, hope, aspiration, fear, grief, love, and beauty. For those of us who tend to the contingencies of physical bodies, the interior is a matter of brains, bones, organs, fluids, cells, systems, and naturally includes our visible integument. When we began the lectures, visual art took center stage, although no art form was out of bounds and Joel Howell’s inspiring talk in 2009 focused on music.

 

Five.

The Smithsonian American Art Museum (acronym, SAAM) is a favorite stop in Washington, DC. Once known as the National Portrait Gallery, SAAM is a wonderful place for a quick visit, something less feasible at most other Smithsonian museums, but you certainly can spend a day at the SAAM where Paul Revere’s Ride by Grant Wood resides. When you happen by there, the Daguerre monument on the museum’s Seventh Street side is worth a look. Daguerre’s work grew into modern photography that would show how horses actually gallop.

Leland Stanford, a horseman among other things, commissioned photographer Eadweard Muybridge (1830-1904) to study galloping horses photographically. The gallop is too fast for human eyes to analyze and for centuries visual artists depicted all four legs were simultaneously in the air, extended forwards in the front and backwards in the rear, during a gallop. On June 15, 1878 Muybridge depicted Sallie Gardner at a Gallop, a series of 24 pictures in rapid succession and its 24 frames constitute the first moving picture. The gait analysis showed that when all four feet were simultaneously in the air the legs were gathered below the belly of the horse rather than extended front and back. Sallie Gardner was Stanford’s Kentucky-bred mare and the jockey was named Gilbert Domm.

 

[May 4, 2019; Louisville, KY, USA; Luis Saez aboard Maximum Security (7) crosses the finish line during the 145th running of the Kentucky Derby at Churchill Downs. Mandatory Credit: Jerry Lai-USA TODAY Sports – 12643976]

Luis Saez riding Maximum Security crossed the finish line at the 145th Kentucky Derby at Churchill Downs, May 4, 2019, ahead of the thundering herd, but was disqualified for interference with other horses. [Above: Reuters photograph] One hopes the interference was accidental, but rules are rules, the photographic evidence of the interference was self-evident, and it’s reassuring to find occasional evidence that the end doesn’t always justify the means. The arc of the moral universe may be long, but sometimes we live long enough to see it bend toward truth.

 

Postscript

Independence Day celebrates the first days of the American nation, as proclaimed in the astonishing Declaration of Independence, a beautiful piece of prose hammered out by committee with compromises made. The Constitution, produced also by a team, is a clunkier set of rules and regulations that was amended more than a year later with some ideas many of its signers took for granted and assumed the original Constitution offered no constraints on essential freedoms in a democracy. James Madison, principal author, finally was convinced that certain amendments were necessary including explicit enumerations of specific freedoms that people needed from government. The original Bill of Rights listed explicit protection for freedom of speech, religion, the press, assembly, and the right to lobby the government for redress of grievances. These were listed in the Third Article of the Bill of Rights that became incorporated in the First Amendment of the first ten amendments to the Constitution. The original First Article of the Bill of Rights dealt with the formula for representation in the House of Representatives and the Second Article specified details of laws related to compensation of the representatives.

Historian Gordon Wood, who once taught at Michigan and was popularized in a scene of a Harvard Square tavern argument in the 1997 film Good Will Hunting, once wrote: “… it was Madison’s personal prestige and his dogged persistence that saw the amendments through the Congress. There might have been a federal Constitution without Madison but certainly no Bill of Rights.” [Representation in the American Revolution, University of Virginia Press (Charlottesville, VA), 1969. (ISBN 978-0813927220)]

Human potential – with its science, technology, knowledge, and truth – is severely deformed and stunted when government restricts freedom of speech. Freedom of religion, the press, assembly, and the right to petition actions of government necessarily follow freedom of speech. Truth, equality, and the rights of The First Amendment come close to being the most basic secular principles of humanity and are always at risk and threatened in every civilization.

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

Ga-ga now and then

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DAB Matula Thoughts June 7, 2019

Ga-ga then and now

2172 words

[Above: Nesbit reception at 2019 AUA Annual Meeting in Chicago. Ice sculpture.]

 

One.             

Senior medical students are getting ready this month for the next big stage in their lives and careers, just as I did in June of 1971 heading west from Buffalo to Los Angeles, to start nine years of training at UCLA. I don’t recall much of the drive along the evolving interstate highway system, a vision of President Eisenhower only 20 years earlier, but the exhilaration of beginning something totally new with surgical residency under William P. Longmire certainly dominated my thoughts on the road. The intellectual and conjoined physical capabilities of surgery as a profession excited me. The first day of internship, in line to check in, I met fellow intern Doug McConnell and quickly befriended John Cook, Erick Albert, Ed Pritchett, Ron Busuttil, Arnie Brody, John Kaswick, Dave Confer and the rest of our 18 at the bottom of the UCLA training pyramid. Over the five-year process, we learned the knowledge base, skills, and professionalism of surgery through experience, teaching, study, and role models. In the blink of an eye 1971 has become 2019 and, suddenly I’m near the end of my career.

Reading Arrowsmith and the recent story of the Theranos debacle in John Carreyrou’s Bad Blood, I saw those protagonists wanting to change the world. My hopes in 1971 were not so grand, I just wanted to find my own relevance and hoped to become good in my career. Most people similarly want to make their mark in one way or another, through job, family, art, or community. Some, however, actually intend to change the larger world, although their idea of “change” may be someone else’s deformation.

Last month a large cohort of our University of Michigan urology residents, faculty, nurses, PAs, and staff met in Chicago at the annual AUA national meeting to learn, teach, exchange ideas, network, enjoy reunion, and circulate word of our new chair Ganesh Palapattu. The Michigan brand was strong with hundreds of presentations from our faculty, residents, and alumni. The MUSIC and Nesbit Alumni sessions were great gathering points. [Below: UM podium events with alumni Cheryl Lee, Jens Sønksen, Barry Kogan, and Julian Wan.]

Cheryl has been back in Ann Arbor this week as visiting professor.

A group of our residents and one incipient PGY1 were ga-ga at the AUA Museum booth. [Below in front: Juan Andino, Catherine Nam; back row: Adam Cole, Scott Hawken, Rita Jen, Ella Doerge, senior faculty member, Colton Walker, Matt Lee, Kyle Johnson, Udit Singhal.]

 

Two.

Surgery, the word, derives from Greek, kheirourgos, for working by hand and the term moved through Latin, Old French, and Anglo-French to become surgien in the 13th century. The epicenter of that world was the doctor/patient duality, based on an essential transaction as old as humanity with exchange of information, discovery of needs, and provision of remedies and skills. The knowledge base and tools are far better since Hippocratic times, but the professional ideals are much the same. It seemed pretty awesome to my 21-year-old self that I might one day be able to fix things with my hands like Drs. Longmire and Rick Fonkalsrud. History mattered to our UCLA professors who insisted that trainees know the back stories of each disorder and treatment.

New interns arriving next month, called PGY1s for their postgraduate year status, may have parallel thoughts to those of mine 48 years ago as they start their journeys. Pyramidal training models no longer exist – PGY1s can reasonably expect to complete their programs. Their experiences will be replete with contemporary expectations, notably patient safety, value propositions, clinical outcome assessments, co-morbidities, social determinants of disease, personal well-being, attention to patient experience, and teamwork with diversity, equity, and inclusion. Acronyms have proliferated, tools are more powerful, and regulation grows more burdensome. Nevertheless, essential transactions remain at the center of health care with needs of patients addressed by the knowledge, skills, and kindness of healthcare providers, one patient and one provider at a time.

While taking pride in the labels doctor, physician, surgeon, nurse, and physician’s assistant we realize now that teams of providers with many types of expertise congregate around each single patient, either immediately physically as “bedside teams” (in clinics as well), sequentially, or virtually (with office staff, coders, laboratories, or electronically). Teams offer exquisitely specialized expertise and “wisdom of crowds,” although patients often find no single person in charge of their care.

 

Three.

Patient safety was a given when I was a resident. It was wrapped up in regular Morbidity and Mortality conferences without explicit use of that phrase, patient safety. Around that time a young graduate student in sociology, Charles Bosk, embedded himself in an academic surgical team for 18 months to discover how surgery was learned, practiced, and lived at an unnamed “Pacific Hospital.” The result was his book in 1979, Forgive and Remember: Managing Medical Failure. Bob Bartlett, my friend and colleague in the Surgery Department, introduced me to it a few years later. A second edition in 2003 was reviewed by Williamson. [Williamson R. J Royal Soc Med. 97(3):147-148, 2004.]

Patient safety has grown since my internship from an obvious but unarticulated expectation to a distinct field of study modeled after other industries, notably aviation. Health care has learned much from other professions such as the concepts of safety culture, standardization of procedures, checklists, and so forth, although healthcare is more multidimensional and nuanced than those other worlds. Bosk recently reflected on the health care exceptionality in a Lancet article, “Blind spots in the science of safety,” written with Kirstine Pedersen, concluding:

“There is a science of safety to reduce preventable adverse outcomes. But health care also has an irreducibly relational, experiential, and normative element that remains opaque to safety science. The contribution of a kind and reassuring word; a well delivered and appropriately timed disclosure of a bad diagnosis; or an experience-based evaluation of a small but important change in a patient’s condition – all are difficult, if not impossible to capture in a performance metric. Accomplishing safety and avoiding harm depend on discretion, effective teamwork, and local knowledge of how things work in specific clinical settings. Finally, the successful practice of a science of safety presupposes in theory what is most difficult to achieve in practice: a stable functioning team capable of wisely adapting general guidelines to specific cases.” [Bosk CL, Pedersen KZ, “Blind spots in the science of safety.” The Lancet 393:978-979, 2019.]

 

Four.

The Michigan Urology Centennial is nearly here and the process of writing our departmental history has elicited many names and stories. Bookends demarcating any era may be discretionary choices and our starting point could easily be debated. Perhaps the first “urologic” procedure of Moses Gunn initiated this specialty at Michigan in the 1850s, or the first faculty appointments with the term lecturer on genitourinary surgery, held by Cyrenus Darling (1902) or clinical professor of genitourinary surgery by Ira Dean Loree (1907) might qualify. Unquestionably, though, the arrival of Hugh Cabot in the autumn of 1919 brought modern urology with its academic components to the University of Michigan. Cabot was the first to use the 20thcentury terminology, urology, at UM and he was Michigan’s celebrity in the field. He literally brought Modern Urology to Ann Arbor, as that was the name of his two-volume state-of-the art textbook of 1918, repeated in a second edition in 1924. Cabot probably didn’t anticipate becoming Medical School dean when he left Boston two years earlier, but his advancement was hardly accidental. A number of other prominent faculty members were well-positioned to replace Dean Victor Vaughan, but Cabot played his political cards well and won the job.

Frederick George Novy (1864-1957) was the strongest competitor. Born and raised in Chicago, Novy obtained a B.S. in chemistry from the University of Michigan in 1886. His master’s thesis was “Cocaine and its derivatives” in 1887. Teaching bacteriology as an instructor, his Ph.D. thesis in 1890 was “The toxic products of the bacillus of hog cholera.” After an M.D. in 1891 he followed the footsteps of his teacher Victor Vaughan as assistant professor of hygiene and physiological chemistry. Visiting key European centers in 1894 and 1897, Novy brought state-of-the-art bacteriology to Ann Arbor, rising to full professor in 1904 and first chair of the Department of Bacteriology. His studies of trypanosomes and spirochetes, laboratory culture techniques, anaerobic organisms, and the tubercle bacillus were widely respected. Our colleague Powel Kazanjian wrote a first-rate book on Novy.

 

Five.

Paul de Kruif (1890-1971), one of Novy’s students, bears particular mention. [Above: de Kruif, courtesy Bentley Library.]  de Kruif came from Zeeland, Michigan, to Ann Arbor for a bachelor’s degree in 1912 and then a Ph.D. in 1916. He joined the U.S. Mexican Expedition (“the Pancho Villa Expedition”) against Mexican revolutionary paramilitary forces in 1916 and 1917, then saw service in France with the Sanitary Corps, investigating the gas gangrene prevalent in the trenches of WWI. de Kruif returned to Michigan as assistant professor in 1919 working in Novy’s laboratory, publishing a paper on streptococci and complement activation.

Novy helped de Kruif secure a prestigious position at the Rockefeller Institute in 1920, to study mechanisms of respiratory infection. While there de Kruif wrote an anonymous chapter on modern medicine for Harold Sterns’s Civilization in 1922. The 34 chapters were mainly written by prominent authors, including H.L. Mencken, Ring Larder, and Lewis Mumford, so how de Kruif, a young bacteriologist (and non-physician), came to be included in this compilation is a mystery. de Kruif’s 14-page chapter, however, caused the biggest stir, skewering contemporary medical practice and doctors for “a mélange of religious ritual, more or less accurate folk-lore, and commercial cunning.” de Kruif viewed medical practice as unscientific “medical Ga-Ga-ism,” but his article was sophomoric at best.

Once de Kruif was revealed as author the Rockefeller Institute fired him in September, 1922. The newly unemployed bacteriologist came in contact with a newly prominent author, Sinclair Lewis (1885-1951), praised for Main Street (1920) and Babbitt (1922). Lewis was ready for his next novel and two friends, Morris Fishbein and H.L. Mencken, persuaded him to focus on medical research. Lewis, son and grandson of physicians, knew little of medical research, so Fishbein, editor of JAMA, connected Lewis to de Kruif. A bond and collaboration ensued for Arrowsmith (1925) in which a central character, Max Gottlieb, was modelled around Novy. Lewis gave de Kruif 25% of the royalties for the collaboration, but held back on sharing authorship, claiming that it might hurt sales. At the time de Kruif thought his share generous, but later became somewhat embittered as book sales soared with Lewis as sole author. [Henig RM. The life and legacy of Paul de Kruif. Alicia Patterson Foundation.]

Arrowsmith was selected for the 1926 Pulitzer Prize, but Lewis refused the $1,000 award, explaining his refusal in a letter to the Pulitzer Committee:

“… I invite other writers to consider the fact that by accepting the prizes and approval of these vague institutions we are admitting their authority, publicly confirming them as the final judges of literary excellence, and I inquire whether any prize is worth that subservience.”

Four years later, however, Lewis accepted the $46,350 Nobel Prize. His Nobel lecture was “The American Fear of Literature.”

Leaving lab behind, de Kruif became a full-time science writer, one of the first in that new genre of journalism. His Microbe Hunters, published in 1926, became a classic and inspired me when I read it as an early teenager, unaware of the controversies around it. [Chernin E. “Paul de Kruif’s Microbe Hunters and an outraged Ronald Ross.” Rev Infec Dis. 10(3):661-667, 1988.] Arrowsmith was re-published in 2001 by Classics of Medicine Library and Michigan’s Howard Markel provided the introduction. [Markel H. “Prescribing Arrowsmith.”]

 

Ga-ga notes

de Kruif’s adjective ga ga for American medicine in the 1920s intended to mean foolish, infatuated, or wildly enthusiastic. It can also denote someone no longer in possession of full mental faculties or a dotard. (Dotard recently came into play in the peculiar rhetoric of the North Korean and American leaders.) The ga ga origin may be from early 20thcentury French for a senile person based on gâteux, variant of gâteur and hospital slang for “bed-wetter.” Gateau, of course, is also French for “cake” and gateux is the plural. de Kruif himself was negatively ga-ga with his criticism of medical specialism. Lady Gaga brings the term to a new level of consciousness and a new generation.

The past week was big on three continents for those who go ga-ga over historic anniversaries. Two hundred years ago, on 31 May 1819, Walt Whitman was born on Long Island. His Leaves of Grass, among much else, had the intriguing phrase “I am large, I contain multitudes,” a prescient reminder of our cellular basis, microbiome, or the plethora of information that leads to TMI (“too much information”) or burnout. Seventy-five years ago, on 4 June 1944, Operation Overlord at Normandy, France, initiated the Allied invasion of Nazi-occupied Europe. Thirty years ago, on 4 June 1989, protests in a large city square between the Forbidden City and the Mausoleum of Mao Zedong turned violent and are now referred to as the June Fourth Incident in the People’s Republic of China.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

May 3, 2019. Sensations

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Matula Thoughts  May 3, 2019

Sensations

 

2180 words: twenty minutes to read, five to skim, or seconds to delete if TMI.

 

Appreciation. Leonardo da Vinci reverberates strongly, even five hundred years after his death on 2 May 1519. The Lancet commemorated yesterday’s anniversary with a cover picture of that great polymath who encompassed astonishing ideas, insights, and talents, leaving for posterity a multitude of works that amaze and delight. Anatomy, physiology, engineering, and visual art are just a few of the intellectual arenas his senses played with and his hands produced. Walt Whitman later wrote: we “contain multitudes…,” and you can fill in the words of what multitudes in particular might follow, such as atoms, cells, thoughts, physical creations, emotions, or other possibilities. da Vinci exemplified that human potential better than most of us, trying to make sense of the world.

 

One.             

Azalias 2019

Spring hits our senses. We can’t easily describe in words the perfumes of flowers or the pleasant rich scent of mulch, but we surely know them. Odors are important sensory inputs, although we don’t usually notice them much as they are less important for us than to most other creatures.  [Above: azaleas, spring 2019.]

Dogs, for example, discern far more olfactory notes than we do and that is probably a good thing, since dogs sequester significant cerebral space and energy for distinctions of specific urine scents or fecal aromas to understand who is in the neighborhood, skills that have been essential to millennia of canine culture, while humans have found other ways to evaluate their fellows and territories. [Below: Molly’s spring inspection.]

Molly

We surely would be confused by having to track of hundreds of scent variations. In fact, even a small amount of effluent odor from one of our neighbors is generally regarded as too much information. [Below: mulch delivery at Smithsonian Institution, Spring 2019.]

Mulch

Smell used to be important in medical diagnosis. Uroscopy relied on smell, color, sediment, feel, and taste of urine for clues to disease and prognosis. Historically, urine was inspected by all five senses (including the taste of urine and the sound of its stream), but now patients are told to leave a sample in the privacy of a bathroom for a medical assistant to label and send to a laboratory. Doctors rarely come close to the stuff. Even so, for any good diagnostician, a necrotic wound, uremic breath, fecal odor, or hint of tobacco, are valuable bits of information not just for a specific disease, but also relevant to the life and comorbidities of a patient. These and other points of data add to the medical gaze that transcends visual clues and once inspired the meme of clever detectives. That gaze has now been replaced by the digital gaze of checklists, smart phrases, and drop-down menus.

RueMorgueManuscript

Last month we commented on the first of the medical detectives in The Murders in the Rue Morgue, wherein Edgar Allen Poe in 1842 described how diagnostic senses could be marshaled in a process he called ratiocination to figure out crimes. The tale reflected on the odor of urine and double entendre of a name when detective Dupin explained to the narrator (Poe) how he seemed to read his mind, by making deductions from facial expressions:

“Perdidit antiquum litera sonum.

I had told you that this was in reference to Orion, formerly written Urion; and, from certain pungencies connected with this explanation, I was aware that you could not have forgotten it.”

The Latin phrase intended the loss or attrition of an old or previous meaning or sound of the word or its homonym. Orion referred to the celestial constellation (Poe called it a nebular cosmogony) and its similarity to urine became a play on words that Dupin noticed had popped into the narrator’s mind as he looked up at the constellation and smiled when the wordplay and associations came to mind. [Above: 1895 facsimile of Poe’s original manuscript for “The Murders in the Rue Morgue.” Susan Jaffe Tane collection at Cornell University. Public domain. Wikipedia.]

 

Two.

Five classic senses taught in my childhood – smell, sight, taste, hearing, and touch – have been updated to seven for my grandchildren with the addition of vestibular sense and proprioception. Technology extends the senses further, outsourcing them and merging their inputs to provide unprecedented amounts of information of the world around us and within us. Microscopy and telescopy carry sight far beyond the unaided eye, while modern imaging with CT scans, MRI, and radioisotope labeling visualize our own living interior bodies. Sound, too, allows inspection of our interiors due to the discovery of Pierre Curie and his brother in 1880 of the piezo-electric principle in crystals that underlies ultrasonography. Extending the seven “basic” senses through technology, we see the world in new ways, although at the cost of diminished acuity of our original senses.

Today’s versions of the medical gaze and the detective’s ratiocination, are powerful: the sum-total of sensory inputs (enhanced by technology) and mental heuristics of scientific thinking.  Intellect integrates the physical senses. This larger sense, the sense of making sense of everything, is the wisdom, judgment, and mental capacity that creates meaning from immediate or recalled sensory input. This may be the most important and defining human sense, but even that is challenged by impending extension or replacement with so-called artificial intelligence.

 

Three.

Ghost_In_The_Machine_cover 

Incidental or relevant? Recently, I was asked to comment on a paper regarding incidental findings of renal cysts in children and that got me thinking how far ultrasonography has come in my career. Genitourinary imaging by ultrasonography came of age as a practical urologic tool in the 1980’s. I recall those early days when, at Walter Reed Army Medical Center, we experimented with crude B-mode ultrasonography to interrogate testes for tumors or viability. Coincidentally, it was around that time, 1981 to be specific, when Gordon Sumner wrote the lyrics to a song called Too much information (TMI):

“Too much information running through my brain,

Too much information driving me insane…”

The world is even more replete with information since Sting and The Police recorded that song in their album Ghost in the Machine. Yet, one might argue that TMI is a sophomoric complaint, as if the infinite information in the cosmos should be curated for our personal capacity of the moment. The actual problem is not too much information, but too little human capacity for processing and our technologies have made this situation worse.

Kandel

Perhaps this is the essence of abstract art, that Eric Kandel expressed in Reductionism in Art and Brain Science, explaining that functional MRI shows human brains process representational art differently and in different cerebral pathways than processing abstract art (Columbia Press, 2016).  Representational art gives viewers very specific images that relate to things immediately understandable. (Below: American Gothic by Grant Wood (1930), courtesy Art Institute of Chicago.)

 

“Abstract art” seems to contain less information (perhaps less craft – or even no craft, at first glance) than representational works. Kandel finds that abstractions can in fact contain far more, calling on you to search everything you know to understand the piece. Abstract artworks invite you to inspect the world to discover their meaning, although a particular artist may not necessarily know or understand the world any better than you. The artist, however, creates a door for you to imagine the world differently than you did a moment before viewing the work. Abstract images may open up, in an informational sense, far more than a given representational scene or a moment you will readily comprehend. Abstraction is a window into far larger and stranger worlds of information, associations, and imaginations. (Below: Composition No. 10. 1939-1942, (Piet Mondrian. Private Collection. Wikipedia.)

Piet_Mondriaan,_1939-1942_-_Composition_10

edu-meet-me-volunteers

[Above: UM Silver Club members attend Meet Me at UMMA program at the University of Michigan Museum of Art. Image courtesy of UM Silver Club. The untitled painting is by Mark Bradford, 2005.]

 

Four.

The Shannon number, named for UM graduate Claude Shannon (1916-2001), represents a lower bound of the game-tree complexity of chess, 10120.  This is an enormous number, unimaginably large, given that the number of atoms in the observable universe is estimated at 1080. The point here is that human imagination (and in this instance, for only one human game), in a measurable sense, is far larger than the real world. Walt Whitman (1819-1892) may not have known the celestial math, but he wasn’t exaggerating when he wrote Song of Myself.

“Do I contradict myself?

Very well then I contradict myself,

(I am large, I contain multitudes.)”

[Whitman W. Song of Myself. Section 51, 1892 version.]

Whitman imagined that he and each of us is unimaginably large, in imagination. This is sensory overload at its most. It is ironically, unimaginable, far beyond TMI.

Whether an incidentaloma discovered by ultrasonography, computer-assisted tomography, or magnetic resonance imaging, is important to the well-being of a person or is too much information (TMI) is one of the dilemmas of modern medicine. The quality and precision of ultrasound interrogation, reveal increasingly tiny anatomic details, anomalies, and imperfections that may cause great anxiety for patients, regularly driving parents of children with simple renal cysts to near-insanity with unnecessary worry. While technology seemed to promise humans better control of their lives, it may be just the opposite, whereby technology becomes the ruling agent. [Below: the promise of technology, Life Magazine, September 10, 1965.]

life_c2

 

Five.

An article and a book expand these considerations of gaze, ratiocination, and information. Roger Kneebone, in The Lancet, offered perspectives on “Looking and Seeing,” comparing a physician’s observational skills to those of an experienced entomologist, Erica McAlister at the Natural History Museum in London. The article begins with these resonating sentences, quoted with his permission:

“Medicine depends upon observation. Yet we are changing the way we look and that alters what we see. As a medical student, I was schooled according to a rigid mantra. Inspection, palpation, percussion, auscultation – always in that order … The aim, I think, was to ensure that we directed our attention to the person in front of us, that we didn’t jump to conclusions before assembling all the information we needed. That fell by the wayside as we turned into junior doctors. Nobody seemed interested in what we had seen or how we described it. Instead, it was all about blood tests, x-rays, scans – all about results.” [Kneebone R. “Looking and seeing.” The Lancet. 393:1091, 2019.]

Kneebone says it beautifully. The last word in his phrase could easily be data as well as results. The results becomes a proxy for the patient. The physicians of the next generation have learned excellent key-board skills, data collection, acronyms du jour, and navigation of electronic health records with drop-down menus, check-lists, and cut-and-paste artistry. The artful skills taught to me and Kneebone – inspection, palpation, percussion, and auscultation – seem rendered obsolete by data. One worries if the talents to navigate technology and its data come at the expense of the medical gaze, the medical sniff, and the ratiocination Edgar Allen Poe and Arthur Conan Doyle brought forth in their detectives. The model of the astute clinician is giving way to Watson, not Conan Doyle’s Watson, but IBM’s Watson.

Information or data, if you prefer, is a false deity. We may use data but should not worship it. Too many leaders say “show me the data,” believing that data will perfectly direct essential actions. Data should inform key decisions, of course, but data needs human wisdom for good decisions – using, tweaking, discarding, or reformulating data for human needs, not for the self-serving “needs” of algorithms. Self-learning algorithms can accomplish much, but can never replace human wisdom.

The book of relevance is Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, by Eric Topol, reviewed by Indra Joshi in The Lancet and I look forward to seeing if it convinces me in its promise. [Joshi I. “Waiting for Deep Medicine.” The Lancet. 393:1193-1194, 2019.]  The concern with “artificial intelligence” is its easy confusion with human wisdom, the wisdom of crowds that tends to bend toward truth and overarching human values. Self-learning algorithms that constitute AI are ultimately constructed by individuals with their own values, biases, and agendas. Furthermore, they are susceptible to intrusion and perversion. Finlayson et al warned of this recently: Adversarial attacks on medical machine learning, emerging vulnerabilities demand new conversations. [Finlayson SG, et al. Science. 363:1287–1289, 2019.]

 

Short story.

Truth is often stranger than fiction. Poe’s story in 1841 revealed the perpetrator of The Murders in the Rue Morgue was an orangutan smuggled to Paris by a sailor. The actual murders were unintentional, the escaped animal was frightened and responding as its genes, millions of years of environmental selection, prescribed. Most readers probably found that part of the story a bit outrageous, it didn’t quite make sense that a sailor could or would smuggle such an animal. But truth is often as strange or stranger than fiction: a recent report from the Associated Press of Russian tourist Andrei Zhestkov, discovered on the Indonesian resort island of Bali trying to smuggle a 2-year old drugged orangutan in a rattan basket to Russia on March 22. The smuggler also had seven live lizards in a suitcase. [Mike Ives. New York Times, March 25, 2019.]

Orangutan

 

Thanks for reading Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Spring

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Matula Thoughts April 5, 2019

Calendar1

Spring considerations

20 minutes to read, two minutes to scan, one second to delete.

2341 words

Note of Passage

Mark C. McQuiggan, University of Michigan triple graduate, passed away last month leaving his beloved wife Carolyn (Brunk). Mark was the son of the late Dr. Mark R. McQuiggan and Dr. Catherine (Corbeille) McQuiggan, internists who had trained at the Mayo Clinic and worked together in an office in Detroit’s Fisher Building. Mark C. was born on May 15, 1933 and was 85 years old at the time of his death. He was thoroughly a Michigan Man with a BS from LS&A in 1954, an MD in 1958, and urology residency under Reed Nesbit, completed in 1964. Mark’s co-residents were Karl Schroeder and Dick Bourne, and other particular friends from residency were Clair and Clarice Cox and Dick and Jane Dorr.  Mark practiced urology with excellence and devotion in Southfield, Michigan, on the staff of North Detroit General Hospital and Ascension Providence Hospital. Mark and Carolyn were lovely and loyal presences at our yearly Nesbit Society Alumni Reunions. (Below: Mark in October, 2010, at the Nesbit Scientific Session.) Mark loved the University of Michigan, and Michigan Urology, along with Michigan athletics. Michigan Urology will miss Mark, who seemed to always have a smile and was a wonderful link to Michigan Urology’s past.

Urology at Michigan undergoes its own passage, this being the transition to Ganesh Palapattu as chair, who is already bringing exciting and substantive change to the department just around the fortuitous time of the Michigan Urology Centennial. He is continuing the weekly Urology What’s New aimed at departmental specifics along with this monthly set of Matula Thoughts on the first Fridays, and simultaneously available on the web site matulathoughts.org.

 

One. 

April brings spring, so welcome after a rough winter’s polar vortices reached down to our geography and innermost bodily cores. Flowering dogwoods, photographed last year (above), will return soon and that’s much of the attraction of photography – preservation of meaningful moments with fidelity to the momentary truth. We want to hold on to things we value as best we can and photography allows us to keep them, in a way, by replication. Words can also replicate those moments and truths with fidelity and beauty.

Last spring this column referred to Dr. William Carlos Williams and his book, Spring and All, a title mysterious in its promise. [Above: Williams and Ezra Pound at their last meeting, photographed by Richard Avedon in July 1958, Wikipedia.] The central piece in Williams’ collection, On the Road to the Contagious Hospital, speaks to facilities that that have faded away, the leprosaria, tuberculosis sanitaria, and other such places. New diseases and antibiotic-resistant resurgence of the old ones may resurrect those institutions. Leprosy, by the way, is not a disease of the past. The Lancet recently had a photoessay “Picturing health new face of leprosy.” The authors noted: “… leprosy impairs and society disables.”  [Kumar A, Lambert S, Lockwood DNJ. The Lancet, 393:629-638, 2019.]

The University of Michigan once had its own contagious hospital after the citizens in Ann Arbor in 1914 voted for a bond issue of $25,000 for an isolation hospital to be maintained by the university. [Below: UM Contagious Disease Hospital, courtesy Bentley Library.] It was placed on a ridge behind the Catherine Street Hospital and looked over the Huron River. Horace Davenport’s book (Not Just Any Medical School, 1999) tells how in the first year the 24-bed hospital housed patients with chicken pox, diphtheria, necrotizing ulcerative gingivitis (Vincent’s angina), pneumonia, tuberculosis (TB), and whooping cough. [Davenport HW. Not Just Any Medical School. University of Michigan Press. 1999.]

 

Two.

Photography, as a neologism meaning drawing by light, may have had a number of separate origins between 1834 and 1839. Previous methods to capture images by means of cameras obscura or shadow images on silver nitrate-treated papers were novelties, but didn’t scale up in terms of utility, until Louis Daguerre announced his sensational process on January 7, 1839. The rest is the history of the Kodak moment, motion pictures, Polaroids, and now the cell phone camera with its albums of thousands of pictures and videos.

Anesthesia, in contrast to photography, had a specific origin in time, place, and originator. Anesthesia was the neologism of Oliver Wendell Holmes in Boston, 1846. Just as photography was coming of age, medical practitioners were starting to bring science and new technology to their art. Large metropolitan hospitals, notably the Napoleonic legacies in France, afforded large numbers of patients that inquisitive physicians studied and compared. Evolving tools of measurement and investigation allowed new clinical skills and a slowly growing sense of hygiene would bring a greater level of safety to medical care.

Professor Charles-Alexandre Louis (1787-1872) in Paris at the Pitié-Salpêtrière was among the best of these physicians and his comparison of patients with pulmonary TB who were treated with leeches against those untreated patients was one of the earliest clinical trials. Young people from around the world came to Paris for weeks, months, or years to watch Louis at work. He stressed the idea of critical clinical observation (including the medical gaze), measurement, and analysis to improve understanding of disease and therapy, forming a Society of Clinical Observation that many young American trainees joined.

The idea of clinical material as the milieu for medical education and the improvement of health care through careful observation, inquiry, and research, received as great a boost from Louis as anyone. The medical gaze went beyond a quick visual glance. Deep inspection by an experienced physician was something new, a gaze that would discover clues to a diagnosis, understanding of co-morbidities, and other relevant facts to the case, the story, and the truth of a clinical situation.

The medical gaze, like the photograph, was novel and they complemented each other. Photography became a teaching and documentary tool. The informed gaze discovered a condition, an attitude, or a moment that the photograph could replicate and preserve. The medical gaze also inspired a new genre in literature – bringing the idea of astute medical discovery by observation, listening, and reasoning to crime solving.

One wonders if the medical gaze, once a desirable clinical skill, has now been eliminated by modern imaging tests, laboratory studies, biomarkers, and check lists? This begs the question whether or not tomorrow’s masters of those technologies and processes will quickly succumb to nonhuman purveyors of “artificial intelligence”?

 

Three.

The Murders in the Rue Morgue, Edgar Allen Poe’s famous short story in 1841, initiated a new genre of crime literature and the clever reasoning, Poe called “ratiocination,” necessary to solve crimes. [Poe 1809-1849, above] Curiously, Poe’s story included a brief speculation on uroscopic clues, specifically the odor of urine.

This scientific crime solver genre continues to gather cultural momentum. The picture above, made in the last year of Poe’s life, is the “Annie” daguerreotype, the best known of the eight known Poe daguerreotypes and named for Mrs. Annie Richmond of Lowell, Massachusetts who commissioned and owned the picture. Poe was just a little ahead of his time with ratiocination, his take on the medical gaze, where careful observation and trained reasoning could discover the truth of a situation. Over the next decades up to the fin de siècle a scientific corpus of knowledge, bringing new technology, would expand the medical gaze into a powerful capacity to produce data and evidence for both health care and criminal investigation.

Future detective author Arthur Conan Doyle (1859-1930) was barely ten years old when Preston B. Rose started teaching Ann Arbor medical students urinalysis and scientific methods of forensic investigation in the Chemical Laboratory just behind the University of Michigan Medical School. Only 17 years later, as a 27-year old ophthalmologist with a struggling practice, Conan Doyle created a powerful blend of ratiocination and scientific analysis in the intellectual superhero, Sherlock Holmes. The detective was modeled on a real-life medical role-model of Doyle when he was a medical student and the name Doyle selected coincided with the real-life medical superhero Oliver Wendell Holmes, one of the most prominent Americans Abroad, who studied with Louis in Paris, as explained in David McCullough’s book. After return to Boston, Holmes presented one of the first convincing hypotheses for the germ theory to explain puerperal fever. [Below: Sir Arthur Ignatius Conan Doyle by English photographer Herbert Rose Barraud. Carbon print on card mount. Courtesy of the National Portrait Gallery, London.]

Doyle SS

 

Four.

Holmes embraced the new technology of photography, writing essays about it, making his own pictures, inventing a stereoscopic camera, and studying human ambulation with it. In the June issue of The Atlantic Magazine in 1859 Holmes commented on the improbability of the technology of capturing an actual moment in time totally on a single surface:

“This is just what the Daguerreotype has done. It has fixed the most fleeting of our illusions, that which the apostle and the philosopher and the poet have alike used as the type of instability and unreality. The photograph has completed the triumph, by making a sheet of paper reflect images like a mirror and hold them as a picture.”

It is a universal truth that pictures tell stories more immediately than words, and we humans have been practicing this art since cave-dwelling days, inspired by beauty in the natural world, fantasies, or unnatural horrors. Photography offers realistic images of faces, scenes, or situations, and complements the older visual arts of drawing or painting.

Earlier, in the inaugural Atlantic Monthly (above) Holmes had written:

“The next European war will send us stereographs of battles. It is asserted that a bursting shell can be photographed… We are looking into stereoscopes as pretty toys, and wondering over the photograph as a charming novelty; but before another generation has passed away, it will be recognized that a new epoch in the history of human progress dates from the time when He who

Never but in uncreated light

Dwelt from eternity –

Took a pencil of fire from the hand of the ‘angel standing in the sun,’ and placed it in the hands of a mortal.”

[“The stereoscope and the stereograph,” Atlantic Monthly, November, 1857.]

 

Five.

Guernica. Pablo Picasso (1881-1973) while living in Paris was commissioned by the Spanish Republican Government to make a work in response to the destruction of Guernica. This  Basque town in northern Spain was bombed for two hours by Nazi Germany and Italian warplanes in their support of Spanish nationalists on 26 April 1937. [Above: Picasso working on the mural. Wikipedia.] The town was at a major crossroad 10 kilometers from the front lines between the Republican retreat and Nationalist advance to Bilbao. The target was a minor factory for war materials outside of town. The bombers missed the factory, but destroyed the town.

Picasso completed the large oil painting on canvas in June, 1937, after 35 days of work. The specific disputes of the Republicans and Nationalists, and the justifications of their supporters and suppliers are nowhere evident in the mural, only the grotesque mangled forms and anguished expressions of the victims. Guernica may be Picasso’s greatest work and one of mankind’s iconic images of the horror of war. The event itself was miniscule in the grand scale of 20th century conflict, but Picasso made it a transcendent moment for humanity.

No single painting, photograph, or narrative can capture the full and terrible story of Guernica, although together they give a fuller sense of the horror than any one work alone. [Above: Museo Reina Sofia, Madrid, Spain. ©Picasso. Below: ruined Guernica. German Federal Archives.]

Guernica, Ruinen

Picasso had commissioned three full-size tapestry reproductions of the work by Jacqueline de la Baume Durrbach and her husband René in 1955, weavers in Southern France. Nelson Rockefeller purchased one of these and it hangs on loan in the United Nations at the entrance to the Security Council room. A blue curtain strategically covered Guernica for televised press conferences of Colin Powell and John Negroponte on 5 February 2003. [Kennedy M. “Picasso tapestry of Guernica heads to UK.” London: The Guardian, 26 January 2009.] Picasso entrusted Guernica to the Museum of Modern Art in New York, pending re-establishment of liberty and democracy in Spain. After Spain became a democratic constitutional monarchy in 1978 the painting was ceded to Spain in 1981, although not without dissent that the ruling system was still not quite the republic stipulated by the artist in his will.

 

Short bits.

Morbidity and Mortality (M&M) conferences, discussed here last month, brought M&M candy to mind. The story goes that the Spanish Civil War inspired Forrest Mars, Sr. to create an American version of the British confection Smarties. Mars was working in England in the candy business at that time, estranged from his father, Frank Mars of Mars candy fame. Forrest had created the Mars Bar in Slough in 1932 and was looking for another product. Rowntree’s of York, maker of Chocolate Beans since 1882, had recently tweaked the name to Milk Chocolate Beans in 1937, and changed it to Smarties the following year. These oblate spheroids were sold in cylindrical cardboard tubes, with a colorful lid that contained a random alphabet letter, designed to encourage children to learn. The chocolate center was protected by a shell of hardened sugar syrup to prevent melting, a convenience enjoyed by soldiers in the Spanish Civil War.

The Spanish Civil War (17 July 1936 – 1 April 1939) engendered strong international sympathies, involving anarchists, communists, nationalists, aristocratic groups, and religious factions, although largely became viewed as a contest between democracy and fascism. British volunteers, likely including George Orwell, carried Milk Chocolate Beans and Smarties into battles and Forrest Mars might have noticed. Just as likely one of his children brought some home.

Returning to the U.S. and working with Bruce Murrie, son of Hershey Chocolate’s president, Mars developed their button-shaped variant, patented it on 3 March 1941, and began manufacture that year in New Jersey. M&M derived from Mars and Murrie, with a small “m” stamped on each button. The first big customer was the U.S. Army and during WWII M&Ms were sold exclusively to the military. “Melts in your mouth, not in your hand,” was first used as a tagline in 1949. Peanut M&Ms were introduced in 1954, and the rest is history.

Thanks for reading Matula Thoughts

David A. Bloom, M.D.

University of Michigan, Department of Urology, Ann Arbor