Matula Thoughts Dec 7, 2018

3930 words

 

One.

Tiny Tim Cratchit and Ebenezer Scrooge come to mind in December when seasonal good cheer expands the possibilities of latent human kindness, turning some Scrooges into their better selves, exemplified by Charles Dickens’ 1843 tale. The author played the story well, for who can’t empathize with Tiny Tim, whose disability reminds us of the Americans with Disabilities Act (ADA), signed by GHW Bush in 1990? The late president said, at the signing, that he was glad to help take down “that shameful wall of exclusion,” little knowing that the ADA would help his own access to public spaces during his wheelchair years 25 years later. [Above, upper Liberty Street, cold afternoon. Below: Tiny Tim & Bob Cratchit. Fred Barnard illustration for 1870 ed.]

We don’t need Marley’s ghost, to exercise our philanthropic nature this month. [Above: Scrooge enlightened by Marley’s ghost. John Leech Illustration in A Christmas Carol, Chapman & Hall, London. 1843. British Library.]  Tax advantages, to a dwindling extent, also enter the philanthropic calculus as people evaluate well-constructed requests for their dollars. Pleas for out-of-pocket “spare change” from panhandlers is a complex matter, sometimes linked to homelessness, but just as likely separate and multifactorial. Like most human enterprises, it grows if supported. Solicitations on the streets are often more a business rather than a solution to hunger, homelessness, poverty, mental illness, or substance abuse. Panhandling makes downtown spaces a little uncomfortable, and although handing over a buck provides momentary satisfaction, it doesn’t further the greater good of the truly needy or the public.

The community of Ann Arbor has come together for excellent programs such as the Delonis Center, Ozone House, Alpha House, Salvation Army Shelter, Dawn Farms, Home of New Vision, Packard Clinic, Hope Clinic, and Neutral Zone, but these don’t fill all the needs of homeless or otherwise at-risk people. Spare change gifting has a doubly negative effect: it encourages the business of panhandling, and it relieves guilt of panhandled individuals, who preferably could expend constructive efforts on durable solutions to the causes and needs of the people who seek help. Shelters, food banks, health care, public safety, job programs, education, and low-income housing, need political support, public policy solutions, volunteerism, and philanthropy. If you encounter a panhandler and feel guilty, consider pointing out a nearby shelter or offering a nutrition bar.  [Below: Sidney Paget illustration, The Man with the Twisted Lip. Arthur Conan Doyle, 1981.]

 

Two.

Galens Medical Society, founded in Ann Arbor in 1914 as a liaison between students and faculty, began charitable Tag Days in 1927 and solicits funds on the streets the first weekend in December.  Medical school became costly in the 20th century and in the 1930s Galens established scholarships and a loan fund. Galens now targets its funds to children’s needs in Washtenaw County.

Salvation Army kettles usually decorate December streets, although I saw few this past weekend. This evangelical church began in 1865, when Methodist circuit-preacher William Booth and his wife sermonized at the notorious Blind Beggar tavern in East London. The Salvation Army is best known for its crusade against alcoholism, as portrayed in George Bernard Shaw’s 1907 play, Major Barbara. The organization uses military titles, the CEO is referred to as General, and the kettles began in 1891 when Salvation Army Captain Joseph McFee placed one at San Francisco’s Market Street Ferry Landing to collect Christmas dinner money for impoverished members of the community. Disaster relief is another function of the organization.

Homelessness also applies to pets, and the Huron Valley Humane Society is another consideration for your generosity. Philanthropy, or anthrophilia, is a restricted form of biophilia, a term embraced by E.O. Wilson, who wrote:

“… to explore and affiliate with life is a deep and complicated process in mental development. To an extent still undervalued in philosophy and religion, our existence depends upon this propensity, our spirit is woven from it, hope rises on its current.

There is more. Modern biology has produced a genuinely new way of looking at the world that is incidentally congenial to the inner direction of biophilia. In other words, instinct is in this rare instance aligned with reason. The conclusion I draw is optimistic: to the degree that we come to understand other organisms, we will place a greater value on them, and on ourselves.”  [Wilson EO. Biophilia. Harvard University Press, 1984. p. 1-2.]

 

Three.

The urology chair will transition next year as the Michigan Urology Centennial approaches, and the first part of the Michigan Urology story should be in print at next year’s Nesbit Society meeting, October 3-5, 2019. The early history of UM reveals the foundational role of philanthropy, beginning as a partnership of community, state, and generous people who wanted to create something worthy and great in Ann Arbor. The same was true for its first hospital. With declining support from local and state government, philanthropy becomes mission-critical, evidenced by the recent University of Michigan campaign with $1.5 billion dollars for Michigan Medicine, celebrated last month at the North Campus Research Center. [Below: Becky and Randy Tisch flanked by Harry and Natalie Mobley.]

Endowments and endowed professorships impact our department greatly. The Babcock Fund jump started dozens of research projects and bolstered our residency and fellowships for 80 years. The Lapides endowment affected my career, Stuart Wolf’s small renal mass data set changed the worldwide approach to kidney cancer with the Brain and Mary Campbell family gift, and the professorship from George Valassis very positively helped the careers and academic work of Jim Montie, Dave Wood, Ganesh Palapattu, and Khaled Hafez. The Brandon survivorship gifts have been of inestimable value to hundreds of patients and the career of Professor Daniela Wittmann. The Chang, Nesbit, McGuire, and Moyad professorships followed, as did the Complementary/Alternative Medicine Program under Mark Moyad, initiated by Phil Jenkins, Bob Thompson, and Josh Pokempner. We are still short by ten of the need to match professorships to the expanding ranks of senior faculty.  Endowed professorships will be the essential structural elements for any great clinical department of the future.

Jerry May, UM Vice President of Development, steps down after 30 years of bountiful leadership (above, during a tough day in Columbus). Eric Barritt (below with John Copeland) has effectively led Michigan Medicine development for four years and we have enjoyed Vince Cavataio as urology’s development officer over the past two years. Endowment-building requires diligent work with a good measure of luck. In this sense, it is both stoichiometric (assembly with the right elements and proportions) and stochastic (random).

[Below: at Nesbit tailgate Vince and Tonya McCoy.]

 

Four.

Moral dilemmas of health care were explored in another Shaw play, The Doctor’s Dilemma, first produced November 20, 1906. Its Preface provides an even sharper dissection of the medical profession than the play itself. Parsing of scarce medical resources was exemplified in the story by a new cure for tuberculosis (TB) that its physician-inventor, Sir Colenso Ridgeon, could only provide to ten patients at a time. From his first group of 50 TB patients Ridgeon had to select ten “most worthy” of cure. Personal foibles added to the doctor’s dilemma when an irresistable young woman asks him to cure her dissolute husband. Around the same time a poor but noble colleague of Ridgeon’s with TB also appeals for help. Suddenly, Sir Colenso has 52 patients in need, but still only resources for ten. His other dilemma was the timeless conflict between medicine as a profession and a personal business.

Shaw modeled Ridgeon on Sir Almroth Wright (1861-1947), British bacteriologist and immunologist (below) who was one of the first to predict that antibiotics would create resistant bacteria, an idea Shaw used in his 1932 comedy, Too Good to Be True. Wright was opposed to women’s suffrage and their entry into professions, writing a book in 1913, The Unexpurgated Case Against Women Suffrage. Wright’s contrary nature probably made him suitable for Shavian friendship and earned him the names “Almroth Wrong” and “Sir Almost Right.” Wright would have raised his eyebrows had he visited Ann Arbor when the Galens Society began and found women included in the Michigan medical school class since 1871.

An essay by Michael O’Donnell in the British Medical Journal, might inspire you delve further into Shaw’s play and its Preface. O’Donnell recently adapted the play “as if for radio” and had performers read their parts, on the 100th anniversary of The Doctor’s Dilemma. O’Donnell’s essay concluded with a barb directed toward the banal teaching of “communication skills” rather than venturing into the “richer territory explored by dramatists”:

“If doctors are to treat illness as successfully as they treat disease they have to enhance their medical experience with some understanding of the world in which they and their patients struggle to survive. Their need, I suggest, is not ‘communication’ but the empathy and understanding that, thanks to Shaw, we and our audience shared on that memorable evening. And we never knowingly deployed a key communication skill.” [BMJ. 333:1338-1340.]

The years immediately following Galens origin and Shaw’s heyday severely tested Ann Arbor and the world beyond. The First World War, a catastrophe for millions, rearranged global geopolitics. The influenza epidemic, known as the Spanish Flu, infected one third of the world population with one in ten (50 million) dying from it. Spain can’t be blamed, for the disease didn’t originate there. As a neutral party in WWI Spain freely reported news of flu activity while other nations restricted information to maintain public morale and to mask information about troop illness. The War spread the flu through close quarters, troop movement, and hygiene disruption. The first U.S. flu wave commenced in the spring of 1918 in military camps and cities. A second wave emerged that September at U.S. Army Training Camp Devens outside Boston. A third and final wave in 1919 ran through the spring. When President Wilson collapsed at the Peace Talks in Versailles, Paris was still in the throes of the flu, and it has been speculated that Wilson was suffering from it. The flu was gone by summer, but H1N1 virus persists.

 

Five.

December 7, 1941, jolted Ann Arbor, like the rest of the country, with the Pearl Harbor attack. Wayne Dertien of Hudsonville shows the December 8, 1941 edition of the Grand Rapids Press, the day after Pearl Harbor (above). This picture (online from 12 June 2013 MLive.com) demonstrates how people saved newspapers or magazines to memorialize a milestone event and, presumably, return to it from time to time. How this will happen now that Gutenberg has gone digital is anyone’s guess, although it should be noted that the convenience of the internet brought me to Mr. Dertien’s picture. We located Wayne and spoke to him recently to get permission to repeat his picture and story, and he commented on how he found the article in a basket his late mother had kept with other articles and magazines that she valued, including an article on the Kennedy assassination.

For urological reasons, 1941 was also noteworthy: a paper that year by Charles Huggins, one of Michigan’s first two urology trainees, led to his Nobel Prize in Medicine in 1966. The other original trainee, Reed Nesbit the first titular head of urology at Michigan, was extraordinary in his own right, as a formative figure in urology practice, education, and research.

In 1941 Nesbit brought two young men to Ann Arbor for residency in his 13th class of residents: Dolphus Compere and Robert Plumb. (Nesbit would eventually have 36 “classes” of trainees.) I got to know Dolph through the tireless work of Maureen Perdomo, one of our development officers in the earlier years of my term as chair. Maureen was totally devoted to our urology alumni and had tracked down Dolph to a retirement home in Fort Worth. Dolph Compere (1916 – 2012) was raised by his mother in Texas after his father, a physician, died of injuries suffered in WWI. Dolph graduated from the University of Texas in 1937 and got an MD from Baylor in 1941. He came to Reed Nesbit and UM for residency in the summer of 1941 and returned to Texas to get married during his December vacation. WWII had broken out just days before the wedding. Returning to Ann Arbor Dolph asked Nesbit for permission to enlist, but Nesbit said he “wasn’t ready.” In 1943 Nesbit released him for duty. We have Dolph’s story of his time in the Pacific Theater and will include it in the Michigan Urology story. Dolph’s co-resident, Bob Plumb, is another story we are pursuing. [Below: Dolph Compere welcoming me and David Miller to Dallas in 2010.]

 

Six.

Events that conspired to cause the two world wars of the past century centered around national misunderstandings among governments that had been high-jacked by extreme points of view. Great efforts were made after WWI to minimize the chance of another great war by promoting international cooperation. Going through papers of University of Michigan president Hutchins at the Bentley Library, I found documents asking him to support a League of Nations, that was established January 10, 1920, and resulted in a Nobel Prize for Woodrow Wilson. The United States never joined and, whether related to that fact or not, a second World War broke out twenty years after ‘the war to end all wars” had ended and the League was dissolved in 1946. With these thoughts in mind, it should give us pause that international cooperation has given way to the deal of the moment. This may reflect a post-truth attitude in human society where are facts are relative or utilitarian, without shared belief in objective truths that transcend nations and disciplines. We see this in politics, in the news industry, and in entertainment. This attitude is infecting journalism, academia, science, and medicine.

Urology makes the world small because of collegial friendships, belief in inquiry, and collaborations connecting us around the world in spite of oceans, borders, walls, or professional turfs. I took this picture a year ago on the Great Wall (above), after a meeting at the home base of one of the most innovative pediatric surgeons and urologists of our time, C.K. Yeung (below).

Whatever the Great Wall divided or protected is long gone. Our guide said it may be the largest cemetery of our species, as fallen workers were buried in or alongside it as they died.

Intellectual walls are equally puzzling. One example is the deep resistance to Lister’s solid evidence for the effectiveness of antisepsis, presented so clearly in The Lancet in 1867. Resistance to that compelling evidence was plainly obtuse. Many iconic leaders of the time were defiant, notably Samuel David Gross, claimed by many at the time to be “The Father of American Surgery,” and immortalized by Eakins with a bloody bare hand during surgery in The Gross Clinic (1875). The year following the painting Gross wrote: “Little if any faith is placed by an enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister.”

An educated mind is literate in science as well as the humanistic thought of past millennia. You can’t have one form of literacy without the other to develop the critical thought necessary to understand the important issues of our time. Many are existential concerns, if not for us, then for those who follow us. [Below: paradigm shifts, Hong Kong Harbor, December, 2017.]

When paradigms shift, as they always and inevitably do, walls don’t serve us well.

 

Seven.

Charles Dickens dealt with many existential concerns of his time, poverty, environmental deterioration, ignorance, crime, violence, malnutrition, and health disparities. These continue today. Born February 7, 1812 in Portsmouth, England, Dickens lived only 58 years, dying after a stroke in 1870. Most notably for my profession, pediatric urology, he was a supporter and philanthropic fundraiser for the fledgling hospital, Great Ormond Street (GOS), where modern pediatric urology began a century later with the work of Sir David Innes Williams (below, flyer for Dickens reading to benefit GOS). Imaginative literature produces colorful language for the medical profession.

Writing under the pseudonym Boz, in 1836, Dickens contributed to a publication called The Posthumous Papers of the Pickwick Club, eventually taking over the monthly periodical. The serialized story became Dickens’s first novel, The Pickwick Papers, and centered on the fictional Samuel Pickwick, Esquire, founder and perpetual president of the club. Kind, wealthy, and rotund, Samuel Pickwick’s phenotype informed a medical condition that came to light more than a century later, in the 1950s. Other figures in the Pickwick Papers included Nathaniel Winkle, Augustus Snodgrass, Sam Weller, and Alfred Jingle. Coincidentally two friends of mine in urology share surnames of those club members.

[The Pickwick Club. Charles Dickens 1838. NYPL Berg Collection.]

Pickwickian syndrome is the obesity hypoventilation condition in which some people, severely overweight, fail to breathe enough to maintain sufficient oxygen levels or low enough CO2 levels, causing sleep apnea. A BMI over 30 kg/m2, hypoxemia, and hypercapnia define the condition. [Kryger M. J. Clin Sleep Med. 8:333-338, 2012.] Other Dickensian conditions include Tiny Tim’s ailment requiring a crutch, perhaps due to Pott’s disease or renal tubular acidosis, and Major Bagstock who exemplified bronchoconstriction & cyanosis. Our own faculty colleague, Howard Markel, did a nice piece on the Public Broadcasting System (PBS, Feb 6, 2016) entitled Was Dickens the first celebrity medical spokesman?

 

Eight.

An essential, existential, meme. The philanthropic idea of Adam Smith was his first big idea. Philanthropy, a generalized warmth toward fellow creatures, extends beyond kith and kin. It is literally “a love of mankind.” This is the foundational condition behind education, health care, and the government of liberal democracy. Freedoms including journalism (“the press”), speech, religion, assembly, lobby, and personal enterprise within the constraints of law, derive from this intrinsic human characteristic of philanthropy.

At the end of a good run, I don’t want to hyperpersonalize my term as our department’s second chair and 9th urology chief, from Cabot to Montie, I was only as effective as the people around me: our staff, faculty, nurses, PAs, and residents are wonderful. I heard a recent interview on NPR that included an alleged quote from the film director Orson Wells, who said something to the effect that the role of a director was “to preside over accidents.” Whether I can trace this quote back to its origin and find it to be a true fact or not, is less important than the thought itself that any director, chair, administrator, or team leader is at the mercy of the randomness of the actions, performances, beliefs, or events that surround the stakeholders and bystanders of the enterprise.

Stochastic events are central to all parts of biology, whether genomic function, epigenetic determination, molecular assembly, behavior of any self, or teams. Life is attended by stochastic randomness, events and processes that may be explained by probability distribution, but are not precisely predictable. In this sense they are, perhaps, accidental or random. These events and processes may be mathematical, chemical, epigenetic, or social like an Orson Wells play or the management of an academic urology department. Ideas and memes, possibly the most complex biologic products, are also stochastic, as they arise. They may be good or bad, useful or destructive, true or false. We may think our dreams and ideas are accidental, stochastic as they seem to appear randomly, although they are not quite random – they have sources, coming from some conditions, memories, anxieties, wishes, or other places in the mind.

The idea of stoichiometry, so close in sound, is something quite different, intending a precision based on the chemical idea of conservation of mass. A film director or a leader of an academic clinical department needs people, props, and data. For the director, a film has a budget, it needs equipment, sites, actors, support teams (including those “best boys”), props, food, payroll systems, and a distribution plan. These are the necessary components of motion pictures. The many performances that comprise the final product, however, cannot be determined by numbers, data, or stoichiometry. Although performances may be studied, rehearsed, and coached, they are ultimately accidental. A director must provide milieu, and perhaps inspiration, but if good actors are on the scene, a good director might be most effective by getting out of the way of the characters and their art. A producer may go to an accountant to help manage the accounts, but not to direct a film. Academic units are not greatly different.

 

Nine.

Philanthropy is fundamental to humanity at the level of family and tribe, it is built into our DNA as it is in other primates and many other mammals. The love and philanthropy that we give to family and neighbors preserves and grows society, in that it is a specific and necessary component of the human condition. It is part of the stoichiometry of our species, it is a proportionate part of the mix, albeit expressed variably from person to person. It is at the heart of the early religions and cultures that defined humanity and in many cases tried to extend the idea beyond any specific family, culture, nation, or religion. Philanthropy is stoichiometric in that it is a specific and essential part of the mix of our species, but it is also stochastic or random, in the binary sense that it can happen or not happen.

Philanthropy in this sense, as a meme, had its most insightful articulation by Adam Smith, in the first sentence of his first book, The Theory of Moral Sentiments, when he wrote in 1759:

“How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though he derives nothing from it, except the pleasure of seeing it.”

As a meme, this particular thought of Smith’s was not totally random in that it was shaped by millennia of human thought, his personal upbringing and education, and the society surrounding him (the astonishing Scottish Enlightenment). But as a thought that inspired his book, it popped up in his brain and was shaped into a very compelling and durable meme – the generalization of philanthropy to all of humanity. While this aspiration had been set out in the great human religions long before Smith, his meme was not compelled by a deity or demanded by a social code.

Smith recognized that each person has some nugget of generalized philanthropy within. In this complex world of 7 billion people, interwoven with perhaps only a few “degrees of separation” from each other, the meme of Adam Smith, generalized philanthropy and its first cousin, global human cooperation, is more than just a meme, it is now an existential necessity. Our genes compelled familial and tribal philanthropy that have carried us this far to human domination of the planet through the powerful tools of education, science, and technology. However, we can’t go much further without full deployment of the memes of philanthropy and global human cooperation.

 

Ten.

Leadership change is around the corner for our department and it comes at a fortuitous time with the Michigan Urology Centennial about to start later next year. This will signal a change in the weekly What’s New email communication of the Department of Urology, as that communication format and paradigm should be a choice of the next administration. On the other hand, the web-based monthly version, Matula Thoughts, will continue as best it can by this writer at the web site matulathoughts.org. The quirky title derives from the uroscopy flask that identified the entire medical profession for many centuries. Laennec’s invention of the stethoscope in 1816, supplanted the matula and is a far better symbol for the medical profession, epitomizing the idea of listening. Furthermore, the stethoscope is far more portable and durable than glass flasks, and contains little in the way of biohazard, except for an occasional bit of wax.

 

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