Sunrises, sunsets

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Matula Thoughts June 4, 2021

2883 words

SUNRISES AND SUNSETS

One.

Sunrise, sunset. Nearing the halfway point of the calendar year, a favorite yearly milestone is approaching – the summer solstice and the first day of astronomical summer. As a resident years ago I didn’t much notice this longest day of sunlight but, now getting on in life, it has gained greater attention. You don’t have to go to Stonehenge to understand the Earth’s shape and tilt (23.5 degrees from orbital plane), seeing how the “easterly” position of sunrise changes from winter to summer. The sun rises in true east and sets exactly in true west only on two days each year – the equinoxes on March 21 and September 21.

The 17-year cicadas are back. I saw and heard them on this past Memorial Day weekend. Sunrise and sunset for them span 17 years, a rather unusual existence.

Gray Michigan winters often obscure the daytime sun and we relish it when dominates in the spring. In northern Michigan summer sunsets after 10 in the evening are worth staying up to see. On Sunday June 20 summer solstice will happen at 11:31 PM EST [Below: summer sunset, Empire, Michigan.] 

Most people believe this is true: the earth is round and it revolves around the sun. These ideas seemed counter-intuitive to pre-scientific people and even recently have been contested, but Copernican evidence for heliocentricity and Hubble Space Station observations are good enough for most people, even though some doubters still exist. They may doubt because they truly haven’t figured it out – or they hang on to the belief because it is expedient to their interests, perhaps in the sense that Jaume Plensa’s figure, Behind the Walls, suggests in front of the UM Museum of Art.

Another point to celebrate in the June calendar is the 19th, a date I’ve just learned about from a book called On Juneteenth by Annette Gordon-Reed. This was a significant moment in time, when the actuality of the Civil War concluded in Texas, thatapp had continued to fight on months after Appomattox. There is reason to think that this date may grow into a full national holiday in recognition of the still-lingering conflict over the opening of the second paragraph of the Declaration of Independence

Two

Words cannot express … Pandemics don’t fit into calendar years neatly and it turns out that any expectations that Covid-19 would last only a year were naïve, now that we are well into a second year. Yet, incredibly in this relatively short time, have developed vaccines and better skills at managing the active disease. Few of us have not seen covid up front in friends, family, patients, and neighbors – whether in acute disease, long-haulers, or death. While covid death has largely spared the UM urology family, mortality at-large has not. [Above: Eclipse, Alma Thomas, 1970. SAAM.]

In this past year of social submergence we have lost Ed Tank, Clair Cox, Dick Dorr, Ed McGuire, Bob Moyad, John Hall, Joe Cerny, and Bill Belville (shown in rows from top left, above) amidst other personal and patient losses, and certainly there will be more. Each loss creates a unique reconciliation for each of us, and when writing condolence notes the phrase “words cannot express …” often comes to mind, even if left unwritten. Some words, particularly those of poets, however, do come closer to the mark of replicating feelings. 

A recent web-based reading and discussion with two great American poets, Edward Hirsch and our UM colleague Linda Gregerson, was particularly rich in meaning. It was sponsored last month by The Book Stall in Winnetka, IL, to plug Hirsch’s new book, 100 poems to Break Your Heart, and it included a piece by Linda, For the Taking, that she read. She had sent me a link to the event and any chance to hear her perform a reading is worth the price of admission. Hirsch’s title is far from inviting, but the book contains much that gets close to the mark in expressing grief in words, authentically. The introduction offers a framework for an enabling understanding of grief. 

“Implicit in poetry is the notion that we are deepened by heartbreaks, by the recognition and understanding of suffering – not just our own suffering but also the suffering of others. We are not so much diminished as enlarged by grief, by our refusal to vanish, or let others vanish, without leaving a verbal record. The poet is one who will not be reconciled, who is determined to leave a trace in words, to transform oceanic depths of feeling into faithful nuances of art.”

This paragraph rings true, the process of dealing with grief, Hirsch says, not only reconciles but also painfully enlarges us. This point extends beyond personal needs to console ourselves with personal losses and express condolences to others for their personal losses – we also need to develop the vocabulary and nonverbal skills in our medical students and residents because dealing with grief is a life skill that physicians need and cannot be delegated to our few palliative colleagues. Maybe some of us know this implicitly, but I for one really didn’t fully comprehend this idea until Hirsch’s book.

Three. 

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Heliocentricity was believed a factual truth by some people in classical antiquity, ancient India, the medieval Islamic world, and Renaissance thinkers (da Vinci: “The Sun does not move.”) but it was Copernicus in 1543 who largely settled the question, or so it seemed. Galileo’s observations and calculations made him a champion of Copernican heliocentricity although leaving the Italian astronomer at odds with the Roman Church. An Inquisition in 1615 supported the Church’s defense of faith against science, but Galileo continued to challenge authority.  His book in 1632, Dialogue Concerning the Two Chief World Systemscompared the Copernican system with the traditional Ptolemaic system and was construed as a challenge to the Pope the final straw to bring the Church down on Galileo. An Inquisition in 1633 confined Galileo to house arrest for the last years of his life. [Above: Andreas Cellarius (1596-1665) illustration of the Copernican system, from the Harmonia Macrocosmica.]

Even after the Church gave up the fight against heliocentrism, others took up the ignoble battle. In 1859 Commander A.J. Morison published a book The New Principia; or True System of Astronomy, in which Earth is proved to be the Stationary center of the Solar System … while the Sun travels yearly in an ellipse around the Earth. He wasn’t the last to hold this retrograde notion, an author with the curious pseudonym Parallax in 1873 published Zetetic Astronomy, Earth is not a globe. An Experimental Inquiry into the true figure of the Earth, proving it a plane … and the only known material world. The 20th century began in 1901 with more support for these enduring memes, with Wardlaw S. Scott’s, Terra Firma: The Earth is Not a Planet, proved from Scripture, reason and fact.

False claims of Morison, Parallax, and Scott – whether delusional beliefs or blatent commercial propoganda – were out of step with the accumulated world view and evidence of science. Yet, as testimonies to free speech, they were offered fairly to the public that in turn rendered public opinion and scientific evidence that deemed the Flat Earth claims ludicrous then, a century past  –  and even more so in this day and age. Nevertheless, as the human population nears eight billion it is no surprise that some small minority will embrace these ancient delusions as a startling reality. Autocracies protected from free speech can demand such delusions for its nation.

            The recent phenomenon of instantaneous global social media clouds the issue, allowing deliberate false claims of rumors, conspiracy theories, or alternate realities to infect huge swaths of the population within minutes, imperiling truth. The matter of free speech, held so dearly until now by liberal democracy, is in question today as never before – yet, as always, some limits to free speech have always been recognized, such as “yelling fire in a crowded theater,” an example hard to come by in Covid times. 

Four.

Politics – local and larger. The Covid Pandemic of 2020 continues to diffuse into 2021, further disrupting lives, businesses, economies, education, health care, and so on but just as any crisis this one brings some old problems into focus with new clarity. Health care disparities, in the grossest sense of greatly increased death rates in disadvantaged communities, is one salient example. Less glaring, but no less concerning, is the rampant spread of misinformation (whether imagined or malign) and the inability of wide swaths of the population to comprehend a proper and reasonable scientific argument. These two matters (among others) are serious threats to the human future. 

If a democracy is to reflect the corporate beliefs and aspirations of a populace in maintaining its rules and regulations, it stands to reason that the populace must be reasonably literate – holding, forming, and reforming beliefs that are reasonable, drive toward truth, and promote the civilized behaviors upon which civilization depends. In past centuries when civilization was primarily a local phenomenon and information was finite, autocratic governance worked well enough, until it didn’t and was replaced by new authorities. When enough of the population was fed up, or not fed enough, change happened as after Marie Antoinette said to her hungry subjects, “Let them eat cake.” The will of the people tipped her off the throne. Some sort of quorum-sensing formula, driven by hunger, inequity, abuses, or other outrages turns a compliant population into an angry one that demands change. This biological behavior transcends the animal kingdom.

It’s gotten more complicated for human civilization that has progressed from a three-dimensional world to a world with a fourth dimension of information that accelerated after Gutenberg and jumped into warp speed with the digital revolution and the internet.  – information, and that information is infinite. The Shannon number comes to mind, a calculation by Claude Shannon indicating the number of possibilities of the game of chess. This number far exceeds the number of number of atoms estimated in the observable universe, an enormously huge number itself, and yet the Shannon calculation represents only a single game in the incalculable pantheon of human knowledge.

Civilization today is largely experienced globally, with a mix of inter-connected governmental systems, although all governments ultimately, in one way or another, depend on some corporate consensus of belief in them, whether the ruling authorities are autocratic, sectarian, democratic, military, “divinely ordained” royalty, or otherwise in the position of authority. Nevertheless, regardless of the fourth dimensionality and globalization, the basic biologic determinants prevail and quorum sensing of pain and outrage continue to tip the scales of political equilibrium, but with more destructive consequences than machetes, guillotines, or guns.

Five.

Literacy. This idea relates to two papers sent to me – one by our colleague Cliff Craig, UM Professor of Orthopedics and the other from his 1965 UMMS classmate Mike Johns, now in Atlanta after stints at Johns Hopkins, Emory, and back at UM as interim EVPMA. 

The first, a JAMA paper by neurologist at Indiana University Bruce Miller, discussed false responses to the Covid pandemic. [B.L. Miller. “Mechanisms and Possible Responses.” JAMA. 2020;324 (22): 2255-2256.] Miller rightly stresses the importance of Science Literacy, but as I read the story that term Science Literacy jumped out at me. It’s not a new term, having been around for a century in various forms, but it became prominent in conversation and literature after around 1970, when it was viewed as an extraordinary form of literacy. Paul de Kruif, a UM Ph.D. and assistant professor in microbiology, in microbiology was one of the early “science writers” for general audiences.

            At the most basic level, literacy is the ability to read and write, uniquely human skill sets and arguably the product or cause of civilization. Very quickly in the course of civilization literacy came to mean three things, the “three Rs,” reading, writing, and arithmetic.  St. Augustine of Hippo , writing in Latin around AD 400 confessed the importance of  “legere et scribere et numerare discitur” (learning to read, and write, and do arithmetic). Now, 1700 years after St. Augustine, it is no less appropriate to exclude Scientific Literacy from the core properties of literacy than it would have been to exclude “numerare discitur” from “reading and ‘riting’”.

            Our Western educational systems have largely failed, making scientific literacy a deliberate exclusion from the vast majority of educational products. We graduate students from universities with literacy in literature, performance, art history, accounting, business, law, world history, music, marketing, packaging, political science, languages, and even in engineering, scientific, and health care professions without a firm basis in scientific literacy in its largest sense: how do we hold, form, and reform beliefs based on science and general human values. 

The second paper was more complex and required deeper reading. In fact, that’s what it was about – deep reading. This paper by Adam Garfinkle in National Affairs, in fact required a couple of runs through it myself and while it dealt with literacy, it approached the topic through a consideration of neural pathways.   [National Affairs, Spring, 2020.] Deep literacy, Garfinkle claims, builds capacity for abstract thought, analysis of difficult questions, imagination, creativity, clarity, and empathy. Language is at the core of this phenomenon of deep literacy, that goes far beyond its basic platform of the “three Rs.”  The author ties this into biology, culture, and political systems.

“Deep reading has in large part informed our development as humans, in ways both physiological and cultural. And it is what ultimately allowed Americans to become ‘We the People,’ capable of self-government. If we are losing the capacity for deep reading, we must also be prepared to lose other, perhaps even more precious parts of what deep reading has helped to build.”

            The risk to deep literacy seems to come from the loss of quality attention –  some call this “cognitive patience.” The digital revolution is blamed for this, but it may be a larger 20thcentury phenomenon tied in with its faster pace of culture, manifested in work, entertainment, news cycles, and travel. The search engines have increased the pace, and with smart phones, tablets, and computers by our sides we may not need to teach memorization of multiplication tables or speeches such as the Gettysburg Address. Yet something happens in the human brain when the tables are learned and when the speech is memorized – internalized, as it is. By off-loading or sub-contracting the mental work of processing facts, ideas, and narratives, we may lose the ability to synthesize from them. 

            Musical literacy and that of visual art differ from the art of numbers and narratives. Knowing the multiplication tables and Gettysburg Address, for example and for most people, require mental work – the brain must expend calories to accomplish those tasks. Somehow it takes less work to internalize a tune or recall a picture. American Pie and Mona Lisa are carried around by most people of my vintage and in my region of space. A musician or painter can build upon them, consciously or subconsciously, when they create something new. The same is true for someone who really knows the Gettysburg Address, but it’s one thing to really know all 172 words and another thing to call it up from Wikipedia or Alexa.

Postscript.

Sunrise, Sunset was the wedding song written in 1964 by composer Jerry Bock and lyricist Sheldon Harnick for the musical play, Fiddler on the Roof. It hit close to the mark as Harnick recalled at age 90 in an NPR interview April 30, 2014.

“I do remember when we wrote “Sunrise Sunset,” the first person we played it for was Jerry Bock’s wife. And when I perform a song for someone I try not to look at them. It makes me a little upset if they’re not paying attention. So I look above them or to the side of them.

Anyway, I sang “Sunrise Sunset” and when I finished, then I looked at Jerry’s wife Patti and I was startled to see that she was crying. And I thought my goodness; this song must be more effective than we even know. And the same thing happened – I am not a pianist but the music to “Sunrise Sunset” is easy enough so that I could learn the piano part – and I played it for my sister.

And when I finished I looked and she had tears in her eyes. And that was a very unusual experience.” 

The song still rings true. [Below: Summer sunset, Empire, Michigan.]

Matula Thoughts began about 20 years ago in the form of a monthly email What’s New from the Medical School Dean’s Office of Faculty Affairs and transitioned to a Urology Department monthly communication around 2007. In 2013 the personal essay took the form of Matula Thoughts, on a web site called Word Press, and this essay is around the hundredth in that form. There is a time for all seasons and this seems the right time to “sunset’ this public effort, but with great appreciation to the readership that motivated me for the past two decades. The monthly discipline of producing Matula Thoughts has been invigorating but this seems the right time to let it go.

Thank you if you’ve been following Matula Thoughts over these years.

David A. Bloom, June 4, 2021

I know this much is true

Matula Thoughts May 7, 2021

2,986 words

May2021

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One.

People are out and about this spring in sharp contrast to last year when Ann Arbor’s sidewalks, streets, and parking lots were virtually empty. If you happen to walk on State Street near the UM Art Museum you may see a large-scale sculpture by Jaume Plensa called Behind the Walls. This made its debut at Rockefeller Center in 2018 and then had a stay in Mexico City, before settling here at UM. [Above: Plensa’s Behind the Walls.]

I first noticed the monumental face during a “covid walk” last spring – actually, a friend pointed it out to me. The sculptor’s intent of updating the “see no evil” meme of the three wise monkeys seemed clear but, as I returned to Behind the Walls on other walks, deeper nuances of the self-blinded face expanded. After a year of sightings and casual thoughts regarding Behind the Walls, I was prepared for the documentary about Jaume Plensa shown by the UM Penny Stamps School of Art Series in collaboration with the UM Art Museum and its director Tina Olsen. Plensa had this to say, using the metaphor of “a message in a bottle”:

“In a world full of injustice, disasters and suffering, it seems banal to speak of beauty, frivolous even. I am convinced that beauty has an extraordinary force, an extraordinary capacity for regeneration. It has an obligation to illuminate us.” [Approximately 56 minutes into the film.]

 “I’ve spent my whole life trying to construct a language, an alphabet, an ideology, a … thought that would help me understand others better. I suppose there is also a search that is related to the message and the bottle, my message. I try to write it with more precision but especially I also try to make even stronger bottles, more stable so they can get as far as possible.”

“The things around us, the people, the objects, are sleeping like children who suddenly fall asleep in a car. Sculpture, creation, has this enormous capacity for waking us up again.”

“I believe that in my case there has been a thorough search for something I haven’t found yet, which is to understand how I relate to the outside, my relationship with the world, the community, others, especially my relationship with myself. Me myself, towards myself, because I know if I reach that distant point in myself, I will understand it in others.” [1:16]

Behind the Walls goes beyond the cynical monkeys who chose not to observe anything that they expected to be unpleasant or “evil.”  Plensa says something more. The hands over the face – disconnected from the arms, shoulders, and torso –  are naturally assumed to be self-directed to cover the eyes, although it is just as easily imagined that external forces – culture, society, peer pressures, politics, or sectarianism –  as likely to be the levers positioning the hands.

Ty Seidule’s book, Robert E. Lee and Me (mentioned on these pages in March), is a case in point of how personal world views are built by the cultures that raise, educate, and sustain us. Col. Seidule, whose childhood and education were framed by the monumental legacy of Lee, became a career officer in the U.S. Army and completed his service with a Ph.D. in history from Ohio State University and position as chair of the history department at West Point. At the Military Academy he noticed a striking absence of confederate memorials on the campus (in stark contrast to the rest of the country) and his life-long adulation of Lee vaporized as he came to understand the myth of the “lost cause of the south” and the sad painful fact that Lee betrayed his country.  (Thanks to Professor Victor Garcia, University of Cincinnati College of Medicine, who sent me the book.)

Two.

Empty places. Just as Ann Arbor streets were empty last May, so too were its classrooms from pre-school through graduate school. A second school year has now begun under the Covid cloud and the fighting over “open vs. virtual” schooling continues. [Below: Ann Arbor parking lot at West Huron and North Ashley on Saturday May 2, 2020 at mid-day, normally full at this time of year, but startlingly empty in the second month of the pandemic.]

May 2 parking

School closures for infectious diseases are nothing new, we recently uncovered a similar situation more that 100 years earlier – even before the previous great pandemic. Reed Youmans, grandson of Reed Nesbit, recently sent us a box of clippings, photos, and notes retained by the family, and one newspaper clipping referred to Reed Nesbit’s uncle, Dr. Otis Nesbit of Valparaiso, Indiana. One October night in 1913 the Superintendent of Gary Indiana Schools visited the general practitioner at home and asked him to “come over to Gary and help me keep my schools open” because of “a regrettable situation common to most school communities of the day.”

“People then had the fanciful idea that if they locked up their schools, they’d have no infantile paralysis, no diphtheria, no scarlet fever, or smallpox or whatever, Dr. Nesbit said on occasion of his retirement last week, following nearly 28 years as head of the Gary Schools Medical Department.” [“School chief voices praise of Nesbit,” The Gary Post – Tribune. Tuesday, August 5, 1941.]

Even then the idea of closures to mitigate communicable diseases was contested. Nesbit’s uncle turns up in the UM Urology story and will be explored in our second book, A Century of Urology at the University of Michigan. The first book, The Origin Story of Urology at UM, is available electronically and we expect hard copies soon. The open access link:

https://doi.org/10.3998/mpub.11693324

Recurrent infectious diseases plagued schools and communities a century ago, even though the principles of vaccination had been well-established for more than a century. Furthermore, the germ theory, recognized then for five decades, wasn’t understood well enough to apply to the finer details of respiratory droplet contamination, although many sensible people understood the value of wearing masks in surgical situations and epidemics. The big Influenza Pandemic would begin only four years after Otis Nesbit was recruited to the Gary schools and the story continues to repeat – as the past year has shown.

Three.

1932. The microcosm of UM urology can be claimed to have begun in 1919 when Hugh Cabot arrived in Ann Arbor. Urology residency training began in Ann Arbor in 1924 when Charles Huggins followed Cabot from Boston and Reed Nesbit came from California the next year as Cabot’s second trainee to become a urologist. Cabot was fired by the regents in 1930 and his virtually unknown protege Reed Nesbit became the head of the tiny urology section.

Nesbit quickly began making a name for himself and for Michigan Urology. By 1932, he had published papers (Annals of Surgery, Archives of Surgery, JAMA, J. Mich. Med Soc.) and that year joined the American College of Surgeons (ACS), a younger organization than the AUA, and one that would bring him to a high point of his career three and a half decades later.

Yet in 1932, two years after Cabot’s dismissal, the Medical School was still adrift without a dean. The nation too was adrift – the Depression and Dust Bowl were torturing millions of Americans. Millions more worldwide were suffering from worsening geopolitical and economic conditions. The Dow Jones Industrial average reached its post-Depression nadir of 41.22 in 1932. Brave New World by George Orwell was published. Motion pictures were a pleasant distraction from the dreary times; the film Arrowsmith, based on the Sinclair Lewis Novel (centered around a fictional version of UM Medical School) tied with The Champ for most nominations at the fifth Academy Awards but lost out to Grand Hotel for best picture.

Jack Lapides, a studious young man from Rochester, NY, came to the Ann Arbor campus in 1932 as an undergraduate. So too did Arthur Miller, an aspiring writer from New York City. Each travelled different paths to success with their UM educations, although they must have passed each other on campus, we found no evidence that they interacted.

In 1932 the federal role in health care was directed to public health, rather than individual health care. The U.S. Public Health Service Syphilis Study of Untreated Syphilis in the African American Male at Tuskegee was initiated this year in Alabama to study the natural history of untreated syphilis and the study continued until 1972, attracting little national attention, particularly in its early years. A decade later effective antimicrobial therapy became available (penicillin) in the U.S. however the study failed to offer that possibility to its subjects – a terrible mistake. [Below; Doctor injects subject with placebo. Tuskegee Syphilis Study, administrative records (1929-1972), National Archive. Wikipedia.]

Tuskegee-syphilis-study_doctor_injects_subject_with_placebo

The gratuitous Nazi human experimentations around that time were becoming public and would show the darkest side of humanity. Few people then recognized the parallels of the two programs; even though the motivations were different, it is a slippery slope from one to the other. Ethical concerns over Tuskegee were raised within the Public Health Service (PHS) in 1955 and over the next decade, but it took a whistleblower within the PHS, Peter Buxtun, to bring the national attention that ended the experiment in 1972.

Four.

Prescientific vs. scientific medicine. Clinical experimentation has been part of medical practice for much of human history; trial and error is at the root of the observation and learning that underlies the scientific process – trying to find out what’s true. Just as our clinical analytical sense has sharpened over time, so has our ethical analytical sense – trying to do what’s fair.

Systematic and statistical analysis of clinical trials with groups of people entered the mainstream of medical education and practice in Paris with the clinimetric approach of professor Pierre Charles Alexander Louis (1787-1872) (see Origins p. 30, 30n) who debunked the use of bloodletting in pulmonary tuberculosis, culminating in his 1836 book and the Society for Clinical Observation of his students, including Bostonians Samuel Cabot III and Oliver Wendell Homes. [P.C.A. Louis, Researches on the Effects of Bloodletting in Some Inflammatory Diseases, Boston Hilliard, Gray, 1836.]   [D. McCullough, The Greater Journey, Simon and Schuster, NY, 2011.]

Holmes, back in Boston in 1843, proposed the idea that another infectious disease, childbed fever, was transmissible from patient to patient.

In 1847 Ignaz Semmelweis (1818-1865) utilized a clinical trial in a Vienna Hospital – “randomized” by assignment (according to hospital admission on an odd or even numbered day) to one of two public maternity clinics – to study childbirth fever. The two clinics historically had marked disparities in death rates, that was widely attributed to the fact that the First Clinic was the teaching service for medical students whereas the Second Clinic was the teaching service for midwives. [Below: Puerperal fever death rate by years, Vienna General Hospital 1841-1846, Wikipedia, Ignaz Semmelweis.].

Yearly_mortality_rates_1841-1846_two_clinics

The medical students divided their days between the autopsy room and the First Service, while the midwives mainly spent their time on the Second Service. Semmelweis postulated that the medical students were transferring some sort of “cadaverous material” to their patients and he instituted a policy of hand rinsing in calcium hypochlorite solution between the autopsy room and examination of patients.

The experimental work of Semmelweis showed that “cadaverous poisoning” via uncleansed hands not only caused the higher mortality in the First Clinic but could be downgraded significantly by hand-cleansing between patients. His work was mocked, his ideas were unpublished at the time, and he was dismissed from his job. His career and life went downhill and he died of unclear reasons after forced hospitalization and mistreatment in a mental hospital at age 47 in 1865.

In contrast, Lister’s clinical experiments, just around the time of Semmelweis’s death were widely published, showing that sepsis (of another origin) could be prevented using carbolic acid to prevent limb gangrene and generalized sepsis after open fractures, applied on a patient-by-patient basis.

Five.

Bush_signs_in_ADA_of_1990

Disabilities constitute a disparity in health care just as in most other public goods of society. The documentary Crip Camp mentioned last month on these pages centers around a camper who became a writer, producer, and director of the film. James LeBrecht was born with spina bifida. His disability prevented ambulation and his parents told him he would need to be very outgoing to be accepted in life by “normal” people, explaining that he had to approach other people because “they are not going to come up to you.”  He become an extrovert in his neighborhood, but attendance at Camp Jened in the Catskill region of New York in 1971 offered LeBrecht his first chance to live and play without embarrassment among other (also disabled) kids. A nucleus of those campers later became major participants in the Disability Revolution that led to the American Disability Act (ADA) of 1990. [Above: George H.W. Bush signs ADA June 26, 1990 on White House South Lawn. Pictured (left to right): Evan Kemp, Rev. Harold Wilke, Pres. Bush, Sandra Parrino, Justin Dart.]

LeBrecht unabashedly recalled how urinary incontinence forced him to contend with diapers until a urinary diversion freed him from them, although still left him dependent on stomal supplies and vulnerability to leakage mishaps. Four medical advances were changing the lives of spina bifida children around that time LeBrecht went to camp:

a.) Safe and effective post-natal repair of open spinal cord and cutaneous defect by pediatric neurosurgeons became routine after the midpoint of the 20th century;

b.) The Holter Shunt for hydrocephalus;

c.) Urinary diversion, most specifically the Bricker ileal conduit diversion that came into major use in the 1950’s in conjuncture with extirpative cancer surgery but within a decade found routine application to spina bifida children to prevent urinary incontinence, infections with sepsis, and upper tract damage;

d.) The work of Jack Lapides in Ann Arbor.

In 1971 the American Academy of Pediatrics recommendations for infants and children with spina bifida recommend “after urinary diversion” followed by intravenous pyelograms to keep track of the upper urinary tracks. Routine urinary diversion, the standard of care, was life-changing for LeBrecht and thousands of other spina bifida children.

A major change coming into play in 1971 changed life even more greatly for spina bifida folks and many other people. The Jack Lapides methodology of clean intermittent catheterization was first publicized then, initially for adults with lower urinary tract dysfunction but within a few years extended into the spina bifida cohort. Papers with Diokno and Kass, eliminated the need for surgical urinary diversion and gave spina bifida children a better and safer way to manage their urinary tracts.  [A.C. Diokno, J. Lapides et al, “New approach to myelodysplasia,” J Urol 116.6 (1976): 771-772.]   [E. Kass, J. Lapides, “The significance of bacilluria in children on long-term intermittent catheterization,” J Urol 126.2 (1981): 223-225.]

Crip Camp was one of the five nominees for best documentary film last month, but My Octopus Teacher won the Oscar.

Postscript

I know this much is true is the name of a book (Wally Lamb, 1998) and an extraordinary motion picture miniseries (HBO, 2020) depicting two brothers, one with terribly disabling mental illness although both boys were tortured by their perceptions and misperceptions of reality.

What we each know to be true is limited by what we are taught, what we chose to see, and what we chose to evaluate. Just as science and medicine depend on truth, the imaginative worlds of art, literature, and motion pictures at their best and most enduring seek to portray the veracities of life and society. A recent PBS documentary on the writer Flannery O’Connor quoted her as refuting the idea that fiction was an escape from reality, saying that good fiction was “a plunge into reality.”

It should be no surprise that households of scientists and healthcare workers may yield artists of one sort or another – or vice versa. These pages last month noted that the TV series House (2004-2012) portrayed a brilliant Sherlockian diagnostician, counter-intuitively misanthropic and dependent on pain medication. Dr. House was played by actor Hugh Laurie, son of a well-known English physician, Ran Lurie. The actor later said he felt guilty for being paid more money to present a fake version of a physician than his father ever earned as a doctor.

The classic urologic example of this is Katharine Hepburn (1907-2003), daughter of a Connecticut urologist, Thomas Norval Hepburn (1879-1962) for whom an endowed lectureship exists in Hartford. Her career spanned 60 years on stage and screen, achieving 12 Best Actress Nominations and four Oscars. [S. Berg, Kate Remembers, 2003.] The next Hepburn lecturer is set to be our Nesbit alumna Ann Gormley (1993 fellowship with Ed. McGuire).

Hugh Bonneville, son of legendary British urologist J. P. Williams (1926-2020), allegedly took the surname of a favored automobile model to spare his well-known father any notoriety. Bonneville’s Earl of Grantham in Downton Abbey certainly reached many more people than the skilled hands of Mr. Williams, even if less viscerally. J.P. Williams was a respected consultant at the Institute of Urology in London, an acclaimed Harley Street practitioner, and author with John Blandy (an important teacher in Ed McGuire’s training) of the History of the British Association of Urological Surgeons. J.P., as he was known, founded the Chrysalis Club, an informal monthly forum for trainees in urology.

Vanessa Kirby was brilliant in the recent film, Pieces of a Woman. She is the daughter of prominent London urologist Roger Kirby (b. 1950), an early pioneer of robotic prostatectomy, founding editor of several journals, and director of the Prostate Center on London’s Wimpole Street. Vanessa just missed out on a best actress Oscar award last week to Frances McDormand of Nomadland – both works being keen observations on human pain and suffering.

These coincidences remind me of my friend and colleague, Ian Thompson, Jr., who once hoped write a book called, How Urology Changed the World. Thomas Hepburn, J.P. Williams, and Roger Kirby (and surely others) would figure strongly in it, as their children in entertaining us through theater help us understand it.

state-st.

Behind the Wall, tucked away between the old and new portions of the UM Museum of Art, is ironically obscured by a large red figure as well as the busy pedestrian and vehicle activity of State Street. But you will see it if you look.

Thanks for reading Matula Thoughts this May 7, 2021.

David A. Bloom

Expectations and epistolaries

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

 

Origin stories

WN/MT July 3, 2020
Origin stories
2518 words



One.

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

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

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

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


Two.

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

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

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

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



Three.

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

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

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

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


Four.

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

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

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

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



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

Polio testing children, May, 1954.


Five.

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

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

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

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

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


Postscripts.

Another Shimomura. 

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

 

Ed Tank reminiscences.

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

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


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

Back on the road to contagious hospitals

Matula Thoughts 1 May 2020
2430 words


Back on the road to contagious hospitals

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


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

One.

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

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

 

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

Two.

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

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

Three.

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

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

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

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

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

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


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

Four.

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

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


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

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

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



Five.

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

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

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

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

 


Postscript.

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

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

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

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



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

April, perhaps the cruelest month

WN/MT 3 April 2020
2356 words

This April, perhaps the cruelest month



One.

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

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

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



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





Two.

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

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

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

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

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


Three. 

 

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

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


Four.

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

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



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

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

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

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




Five.

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

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

“Hello babies.

Welcome to Earth.

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

It’s round & wet & crowded.

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

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

God damn it, you’ve got to be kind.”

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

 

Postscript.

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

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

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

Influenza H3N2 1968 killing 1 million

Influenza H2N2 1956-58 killing 2 million

Influenza H1N1 1918-1920 killing 20-50 million

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

Influenza H3N8 1889 – 1890 killing 1 million

Third cholera pandemic 1852-1860 killing 1 million

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

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

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

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

David A. Bloom
Department of Urology
University of Michigan

March thoughts, idle and otherwise

WN/MT 6 March 2020

March thoughts, idle & otherwise
2102 words

 

One.

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

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

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

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

 

Four.

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

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

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

 

Five.

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

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

 

Postscript x 2: peas and war.

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

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

 

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

David A. Bloom

November one

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

October incongruities and congruities.

 

Matula Thoughts 

Oct 5, 2018

October incongruities & congruities.
3813 words

 

One.

October is an odd month, not just with its odd number of days and shortening hours of daylight, but with unpredictable weather shifts including tropical cyclones, the Atlantic hurricanes and Pacific typhoons. Autumn is already in progress and Michigan is fortunate to witness spectacular foliage displays that peak this later this month. October lacks much in the way of major national holidays. Columbus Day, October 8 this year, is observed variably, in some states, Puerto Rico, banks, school districts, the Postal Service, federal and state agencies, but not generalized nationally or celebrated at Michigan Medicine.

Columbus Day had its start when the Tammany Society in NYC and the Massachusetts Historical Society in 1792 celebrated the 300th anniversary of the Columbus landing. A century later, President Benjamin Harrison similarly highlighted the 400th anniversary. Harrison, notably, was the only president (so far) who was the grandson of a president. Columbus Day became a state-level holiday in Colorado in 1907, in 1934 Franklin Roosevelt designated October 12 a national holiday, and since 1971 it has been set on the second Monday of October. The ambiguous details of European “discovery” of America, problematic from the indigenous people perspective, makes it unlikely that Columbus Day will have a long future as a national holiday. Alternatively, Hawaii celebrates Discoverer’s Day and Vermont declared it Indigenous Peoples’ Day. Native American Day is celebrated by California and Nevada on the fourth Friday of September, while in South Dakota on October’s second Monday. Tennessee observes American Indian Day on the fourth Monday of September and other countries in the Americas have their own origin celebrations.

University homecoming events provide other respites in October, although our Urology Department held its Nesbit Alumni reunion prematurely last month, nearly colliding with our biennial Dow Health Services Research Symposium due to coordination with autumn scientific meetings, religious holidays, and the dominating effect of the home football schedule relegating the 2018 Nesbit Meeting to September’s Nebraska game.

October ends with Halloween, an ancient Celtic harvest tradition, now centered on costumed children prowling their neighborhoods for treats, ostensibly as bribes to withhold pranks. Carved pumpkins or turnips become jack-o’-lanterns signaling target-rich households. Pumpkins are more octagonal than spherical to my eye and Halloween face-carving liberates pumpkin fruit for pies and pepita snacks. [Above: Irish Halloween turnip lantern, Museum of Country Life, Turlough Village, County Mayo, Ireland. Courtesy, Wikipedia. Below: October 2, 2018, Dee Fenner and Red Maple tree, outside Dean’s wing.]

 

 

Two.

Recollections of last month include the opening of Michigan Medicine’s Brighton Specialty Center, a large organizational effort led by John Wei, yielding 300,000 square feet of new clinical space. Anne Cameron did three of the first cases in the Brighton Center for Specialty Care operating rooms. [Above: John Wei at pre-opening ceremony. Below: Anne & OR team September 24.]

Our Dow Health Services Research Symposium #4, directed by Chad Ellimoottil and Lindsey Herrel, featured TED-style talks at Power Center.

[Above: Matt Nielsen University of North Carolina with slide congratulating Lindsey and Chad. Below: Greg Auffenberg (Nesbit 2017), Brent Hollenbeck, Chris Saigal of UCLA, Jim Montie.]

The featured speakers and short abstracts and lightning presentations were first rate, including Preeti Malani and Ken Warner (below).

The flying microphone, shown below with Rod Dunn, livened up the atmosphere. Jim Dupree discussed the successful Michigan Urological Surgical Improvement Collaborative (also below).

The following week Chris Sweeney, of Harvard Medical School/Dana Farber Cancer Institute, gave the Jerry Weisbach Lecture, speaking on clinical trial insights regarding prostate cancer heterogeneity. [Below: Chris & Ganesh Palapattu.]

The Nesbit Reunion, later in the week at NCRC (above), featured Toby Chai, Professor of Urology at Yale (Nesbit 1994) as Nesbit visiting professor who gave two excellent talks.

Our own Matt Davenport was the Nesbit guest speaker. John Wei did a superb job, as Secretary-Treasurer, organizing the program and event. [Above: Toby & Matt. Below: John Wei & Sherman Silber N’73.]

Sherman Silber spoke on “Progress making sperm and eggs from skin.” We also heard Kevin Stone and Brian Stork from West Shore Urology. [Below: Dave Harrold N’1978, Surendra Kumar N’81, Dan Piazza N’79, C. Peter Fischer N’79.]

[Below: Utah Pete Fisher N’06 & son Mitch.]

The Nesbit Tailgate entertained alumni and friends from around the country and the victory over Nebraska completed the weekend. Next year, around this time, we will launch the Centennial of Urology at Michigan. [Below top: Meidee Goh, sister Lindee from Boston, husband David Fry; bottom: Yuting Fan, Sherman Silber, David Burk N’89 & brother-in-law Rupert Baily from North Carolina.]

Next year’s Nesbit Reunion, 2019, will open up the year-long Michigan Urology Centennial.

 

Three.

Octopus, octagon, octogenarian, and October come from the Proto-European h₁oḱtṓw stem for eight, an odd fact given that this is the tenth calendar month of the year. How this came to be is a curious quirk of calendar history.

Lunar phases provided the first “calendars” throughout most of human history, marking time between solar days and solar years using the moon’s regular phases. Lunar phases are still essential for fishermen and sailors to predict tides, noting big swings in tidal amplitude during full and new moons (spring tides) and lesser differences during the quarter phases (neap tides). Etruscans and Romans approximated 8-day weeks to lunar cycles to coordinate commercial markets, political affairs, and holidays, although some fudging was necessary each year to match the solar cycle. An early Roman calendar ran from March through December with lunar cycles that filled up 304 days, exclusive of 51 winter days during an “unorganized expanse” of slack time. [Wikipedia entry Nundinae.] The ten calendar months of Romulus were then: Martius, Aprilis, Maius, Iunius, Quintilis, Sextilis, September, October, November, and December.

Julius Caesar gave us the Julian calendar, bringing Roman calendar years into closer agreement with solar years. He implemented the new system on January first in a year that he had no way of knowing would be 45 BC. The Julian Calendar offered three normal years with 365 days and an intervening leap year of 366 days, to make up for the inexact match of solar days to solar years. The leap day was doubled every fourth year to maintain solar synchrony, but nevertheless the calendar gradually lost its alignment with the solar year and by the time of Pope Gregory XIII in 1582, the asynchrony had drifted to 10 full days. Lawyer and law teacher in his earlier career, Ugo Boncompagni was summoned to Rome by Pope Paul III and served Paul IV and Paul V before election to Pope himself. His term was one of church reform, largely in response to the Protestant Reformation. [Below: Pope Gregory XIII portrait by Lavinia Fontana in list of extant papal tombs. Wikipedia.]

Gregory XIII refined the Julian Calendar by advancing the calendar that year so that 4 October was followed, the next day, by 15 October and using leap year spacing to make the average year 365.2425 days long. The Gregorian Calendar, fixing the 10-day drift and shortening the average year by 0.0075 days, is widely used throughout the world today for business and government. Because of Gregory XIII, the October of 1582 lacked a 5th day and nine others in between. The credit for the math involved belongs to Aloysius Lilius, an Italian physician and astronomer, and Christopher Clavius, a German Jesuit astronomer and mathematician.

Science has proven the actual length of solar days vary, due to tides sloshing around and slowing rotation of the Earth. The solar year (tropical year) in 2000 was 365.24219 ephemeris days, ephemeris time (ET) being defined by orbital period rather than axial rotation of Earth. The Système International (SI) divides an ephemeris day into 86,200 SI seconds. For most landlubbers lunar phases have limited utility, although they still show up on modern wrist watches, that keep us on time.

 

Four.

The regular weekly focal point of our department is 7 AM Thursday, regardless of month, when residents and faculty assemble for conferences where each summer a tide of 4th year medical students begins as rotating “clinical clerks” begin to audition for residency training slots. Students spend a month with us in clinics, hospital rounds, operating rooms, and then make individual presentations at Grand Rounds, having been directed and mentored by residents, fellows, and faculty. The tide recedes when nationwide formal interviews begin in October. [Above: Thursday 7 AM conference.]

Out of around 340 students who apply, around 20 clinical clerks, and 47 who interview, we will match 4 students who will spend their next five years or more with us. The candidate pool is very strong academically and in terms of individual personalities, life experiences, drive, and talents, these students are the best of the best of medical students. The proof is seen in our residents.

It is a tough time to be a medical student and entering medicine. Most students have accumulated egregious debt in the form of student loans. This fact is a black mark on our society. There is little excuse for a large medical school tuition bill, students create enough personal debt with living expenses alone during medical school. Society, particularly that of advanced industrialized nations, can afford to teach its next generation of health care workers. As it is, young doctors spend large fractions of their income paying back their debt (with interest) to banks and other funding sources – money that they would otherwise pump back into the economy through local stores, car dealers, home purchases, and Amazon. Philanthropy too would be served because former trainees in their first years of practice would be more likely each year to give a hundred bucks or so to the institutions that taught them (and even to the Nesbit Society), thus developing “a habit of giving back” rather than trying to stay afloat in the tsunami of educational debt.

The uncertainty of health care economics adds to the difficulty for students, and massive regulatory changes coming from the federal government place academic medicine and all of health care at risk, perhaps the greatest risk in our time. Yet, all times have been tough, and many of the best and brightest people continue to choose medical careers.

 

Five.

Political campaigning heats up in October with elections next month for governor, state legislators, other regional officers, one third of the US Senate, and the US House of Representatives. Voter turnout in the US tends to be around 58% of eligible voters in national presidential election and 40% in mid-term elections. Even less turn out in odd years, primaries, or local elections, indicating that Americans take the responsibility of democracy far too lightly. This fact should disturb us at least as much as the idea of foreign governments messing with our processes (that’s what rough opponents do – so why are we surprised and apparently so defenseless?) Below is a chart from the U.S. Census Bureau.

Our predecessors worked hard and against odds to create a government of the people, by the people, and for the people. The Declaration of Independence is a beautiful and aspirational document that explains why people should be entrusted to their own destiny, The Constitution creates a working framework for government, and its Bill of Rights presents a list of individual protections from authority (with some nonsense that politics mixed into it). A greater cynic might argue, given the voter turnout data, that today’s citizens are not working hard enough to protect foundational elements of western society.

On the other hand, deception has its moments and admits many self-serving hucksters and bad actors to the corridors of power. Voters are often attracted to bright shiny celebrities, single issue extremists, or deceptive campaigns. Trickery is part of the human confection, one classic example being the Trojan Horse of Homer’s stories, although new technologies magnify the possibilities of deception and crowd manipulation. Technology aside, our society has failed to properly educate an informed citizenry capable of critical thinking. Biologic trickery takes many forms, and the octopus is one of the most versatile masters, using camouflage, mimicry, threat, shape-shifting, and environmental opacification. While octopi (scientific order Octopoda) may be the biologic champions, humans are good learners.

[Jens Petersen. Image of greater blue-ringed octopus, Hapalochlaena lunulata. Tasik Ria, North Sulawesi, Indonesia GFDL license. Wikipedia.]

 

Six.

Octoberfest. Beer and political campaigning mingle in October. Octoberfest, as a celebration, dates back to 12 October 1810, when citizens of Munich attended festivities around the royal marriage of King Ludwig I to Princess Therese. Münchners, Munich’s community-folk, gathered peacefully to drink beer, watch horse races, and enjoy a day off work, unless they were helping with the crowd, distributing the food and beer, or organizing the races. Civilization requires organizers, workers, and leaders.

Octoberfest has spread around the world as a respite from routine of work and a chance to celebrate as a community. For some people this is simply an excuse to drink beer, but others enjoy some civic sensibility. Beer and other spirits may help navigate the politics that necessarily attend all communities and the periodic stress of politicking to elect around 500,000 state and national public officials.

Leadership is an unfortunate necessity of human affairs, and over the course of documented history it is evident that most leadership has been self-serving, foolish, and extended the sum total of human misery. Nevertheless, seven billion humans need forms of leadership to organize sports, workplaces, community events, local governments, geographic regions, religions, and nations.

The U.S. Congress on 23 January, 1845 passed “An act to establish a uniform time for holding elections of President and Vice President in all the States of the Union.” The Tuesday after the first Monday of November was selected and that date continues to this time. Federal elections occur only in even-numbered years, and presidential elections take place every four years. October, the heaviest month of campaigning, is exhilarating for many people as evidence of the aspiration of “government of the people, by the people, and for the people.” Election day is a public holiday in some states and territories, but not Michigan. November 5 is our next election day.

 

Seven.

October fiction. October Country, the name of a 1943 Ray Bradbury collection of stories, conveys a sense of the oddness of October. The introductory “mini-story,” The Grim Reaper, in the modern paperback version, is a stark commentary on modern humankind in the mid-20th century. [Bradbury. The October Country. Del Rey Ballantine Books, NY. 1996.]

Bradbury used the title, The October Country, as a metaphor for that time of the year when people and places become melancholy with thoughts and preparations for winter. His dystopian novel, Fahrenheit 451, imagines the dark winter of an authoritarian society where free speech no longer exists. The 1966 Francis Truffaut film version with Julie Christie was a classic in its own right. Bradbury (1920-2012), along with Isaac Asimov, Arthur Clark, Robert Heinlein, and Stanislaw Lem carried science fiction into the literary mainstream according to a 2012 obituary [Gerald Jonas, NYT, June 6, 2012.]:

“The futuristic world envisioned by Bradbury among others is coming fast upon us, compelled by the erosion of democracy and the ascendency of technology. We not be able to curtail the latter, but we should be shamed by our pathetic efforts as a species to build and disperse democratic institutions and human rights.”

Machine-learning algorithms, even those multi-layer “neural” networks capable of “deep learning,” in my opinion can ever equate to human intelligence. Programs and systems are built by people susceptible to particular ideologies, biases, “isms,” greed, and other intoxications that plague everyone and their clever systems invariable reflect some, but not all particularities. These algorithms are already in play in our lives and will become increasingly pervasive with autonomous capabilities in many sectors of our lives, however we must be cautious of accepting artificial intelligence (AI) as a substitute for human authenticity. How can AI distinguish between fact and true facts, given the mutability of fact and truth and their continual arbitration, in “real time,” by human values, science, and consensus? A cynic might argue that AI shouldn’t be expected to distinguish between facts and true facts if most humans can’t do so.

Ian Fleming’s final James Bond book, the 14th in the series, Octopussy and the Living Daylights, was a collection of short stories published posthumously in 1966, originally with just those two stories, but later including The Property of a Lady and also 007 in New York. The first story and provided the backstory for the film Octopussy, with Roger Moore in 1983. A pet octopus, owned by the villain, give that story its name and elements of the other stories found their way into other Bond films.

 

Eight.

October tides. Back in the times of the earliest wine and beermakers, days were defined by sunrises and sunsets, tides and lunar phases framed the weeks, and sun and star positions marked out months and years. It must have taken a leap of faith for early thinkers to convince themselves that something as far away as the moon could physically move the massive oceans of earth, but the tidal relationships to moon and sun were recognized as early as the second century BC by Hellenistic astronomer Seleucus of Seleucia who linked tides to lunar position, with height of tides depending on the position of the moon relative to the sun.

Tide tables were made for tourists in China in 1056 so that they could coordinate visits to the legendary tidal bore of the Qiantang River. Due to the mismatch in size between the Hangzhou Bay and Qiantang (Tsientang) River, this daily occurrence with 30 foot tides moving at 25 mph, can double in size when the moon and coincidental typhoons align. This has been celebrated for thousands of years during the 8th month of the lunar year, known as the Mid-Autumn Festival. [David K. Lynch. Scientific American. January, 1982. Alan Taylor. The Atlantic. Sept. 20, 2016.]

Newton may have been deemed a tidal bore when wrote the essay Discourse on the Tides, in 1616 in a letter to Cardinal Orsini and later used calculations and his theory of universal gravitation in Principia in 1687 to explain the tidal influences of sun and moon. Great Lakes tides at their greatest reach 5 centimeters, although much larger standing waves called seiches, caused by wind and atmospheric pressure, are mistaken for tides.

 

Nine.

Tecumseh, Harrison, and the Battle of the Thames. The Thames River in Ontario comes to mind in relation to a famous Native American who died on this day, October 5, 1813. We have many referrals for patient care from our neighboring town, Tecumseh, and while I vaguely recognized this as a Native American name, I knew little until I looked it up and learned this day is the anniversary of a battle in 1813 when Chief Tecumseh was killed at the age of 45. An American Shawnee, he was born in Ohio Country and he grew up amidst the American Revolution and the Northwest Indian Wars. He became a great leader, compelling orator, and staunch advocate for tribal unity.

Tecumseh’s War in Indiana Territory between his American Indian confederacy and the U.S. began with a confrontation in 1810 at Grouseland, the home of William Henry Harrison, governor of the territory. Conflict continued with a defeat for the multi-tribal confederacy at the Battle of Tippecanoe in 1811, and spilled over into the War of 1812 after Tecumseh formed an alliance with Great Britain that helped capture Fort Detroit. After the fledgling U.S. Navy gained control of Lake Erie in 1813, the British and multi-tribal confederacy retreated into Canada, where American Forces engaged them at the Battle of the Thames (also known as the Battle of Moraviantown) and Tecumseh was killed.

[Above: Tecumseh, attrib. Owen Staples. Toronto Public Library. Below: Tecumseh’s War map by Kevin Myers, Wikipedia.]

[Below: Battle of Tippecanoe. Alonzo Chappel Collection, Smithsonian Institute.]

With the death of Tecumseh, the confederacy collapsed and Detroit returned to American control, where only four years later the University of Michigan would be established. Most native Americans were eventually pushed west of the Mississippi.

Harrison considered Tecumseh remarkable, once calling him a genius. With soaring popularity after the War of 1812 Harrison became U.S. House Representative in 1816 and Senator in 1825, truncated by appointment as Minister Plenipotentiary to Gran Columbia in 1828. He returned to private life in Ohio at his farm, but was prompted to make a few runs for presidency, ultimately winning and becoming ninth American President in 1841, the last president born before the Revolution.

Harrison’s term was short-lived as Harrison was sworn in on 4 March 1841 and died of pneumonia a month later. Vice President John Tyler assumed office, but a constitutional crisis concerning succession lingered for more than a century until resolution by the Twenty-fifth Amendment of 1967. Tyler was the son of Founding Father Benjamin Harrison V and the paternal grandfather of 23rd U.S. President Benjamin Harrison, who nationalized Columbus Day.

It might be argued that the choice of our ninth president was a risky one from the point of health vulnerability, at age 68 he was the oldest sworn into office until Ronald Reagan in 1981 at 69. On the other hand, far younger presidents and major political leaders have been cut short by disease or assassination, so perhaps age should be a minor consideration for long range leadership. Representative democracy seems a far better method of leadership selection than royalty, birthright, or sectarian succession, but genetics (or epigenetics) always seems to be lurking behind the scenes as the American presidency has shown through Adams, Harrison, Roosevelt, and Bush.

 

Ten.

Octopus traps and Halloween spiders. Matula Thoughts often seeks threads or themes, sometimes risking belaboring a point or putting too fine an edge on a detail, such as comparing pumpkins to octagons, or relating October to medicine. Of course, October 16, 1846 was the first demonstration of general anesthesia.

A stretch to the octo stem brings in Takotsubo cardiomyopathy, a non-ischemic heart crisis of sudden temporary weakening of the muscle also known as stress cardiomyopathy, transient apical ballooning cardiomyopathy, or the broken heart syndrome, and leading to acute heart failure, lethal ventricular arrhythmias, or ventricular rupture. Most cases (85%) are set in motion by severe physical or emotional distress that causes myofibrillar degeneration. The first studied case was by Sabo et al in Japan, reported in 1991, and the name came from the traditional octopus traps used by Japanese fishermen, setting them out when the tides were favorable. [Yoshihiro YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy. Circulation. 118:2754, 2008.] [Below: octopus traps, Wikipedia, public domain.]

Octopi aside, eight doesn’t have a heavy presence in biology, Stedman’s Dictionary expends barely a half a page to words beginning with oct. Although spiders and ticks (larger category = class, Arachnida) have eight legs, octo hasn’t tainted their names. Spiders rank seventh in species diversity among all organisms, with nearly 90,000 species compared to 300 species of octopi, and our single human species. Spiders (biologic classification order, Araneae) have enormously complex genomics and have a universal ability to make silks and venoms. [Pennisi. Science. 358:288, 2018.] Spiders scare kids and are completely congruous with Halloween, so be prepared with shock, awe, and a basket of treats when permutations of 8-legged creatures knock at your door at the end of this month. [Below: Marvel Spider-Man symbiote suit.]

 

Thanks for reading Matula Thoughts.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

Gaps

Matula Thoughts Feb 2, 2018

 

Gaps, stories, & authenticity

3707 words

 

(Above: MIA this February)

One.         

Minding the gap. February is a gap month, adjusting for the tiny discrepancy between solar years and calendar years by an awkward change that lengthens the month once every 4 years. The next 29-day adjustment will happen in 2020.

Missing this month is the full moon like that which happened two days ago and coincided with a super moon, a blue moon, a blood moon, and a total lunar eclipse (the picture above was taken last year). Full moons usually happen monthly, sometimes even twice a month, with the second of the full moons called a “blue moon,” although having no blueness whatsoever. The super moon refers to the optical effect of the moon being “super close” to the Earth. The blood coloring  relates to lighting effects from the lunar eclipse.

Given lunar periodicity of 29.53 days, February is the only month in which a full moon gap can happen. This last occurred in 1999 and will happen next in 2037.  A similar gap occurs in occasional Februarys with the new moon, as last in 2014 and next in 2033. [Macdonald. J. Brit. Astron. Assoc. Dec 1998. p. 324.]

February, in the Midwest, also provides a gap between the celebratory early days of winter and the promise of spring rejuvenation in March or April, before May contingent perhaps on today’s groundhog forecasts from Punxsutawney, Pennsylvania. If you are in Punxsutawney today and travel east along Interstate 80 near the interface between Pennsylvania and New Jersey you will encounter another type of gap, the Delaware Water Gap, where the Delaware River cuts through a ridge of the Appalachian Mountains.

Last summer I passed through a second geological gap after being stuck in traffic in the Rockies along with cars, trucks, and Greyhound buses backed west of an accident on Interstate 70 (below).

I had been returning from a continuing medical education course that Quentin Clemens, Brent Hollenbeck, and Jeff Montgomery had organized conveniently close to excellent fly fishing opportunities that would be warmly relished this cold month. This summer, by the way, will likely be a gap year for their course, but with encouragement they might reprise it in 2019, the year Michigan Urology begins its Centennial celebration.

The specific phrase, mind the gap, came into play exactly fifty years ago, in 1968, when London Underground leadership automated and standardized the warnings that drivers and local station attendants had been giving to passengers regarding the gaps between the station platforms and train doors. Because the gaps were sometimes dangerously large, an automated short announcement was planned with digital technology. The AEG Telefunken Company supplied the equipment and sound engineer Peter Lodge recorded test phrases intended to read later by an actor. After the actor demanded royalties, the thrifty London Underground deemed Lodge’s own test readings of “Mind the gap” and “Stand clear of the doors please” good enough and ultimately implemented them in stations in 1969.

Minding the gap is a useful metaphor for medical professionals and residency trainees. The gap between conjecture and truth is the workplace of the health sciences and the rapid advances of knowledge and technology create new inevitable gaps. Additionally, complex systems, health care economics, and divided loyalties create tensions that force ethical and moral challenges. An editorial in JAMA by Donald Berwick last year highlighted some of the moral choices confronting today’s doctors, explaining that the gaps between choices come in three tiers, personal, organizational, or societal. [Berwick. JAMA. 318: 2081, 2017.]

 

Two.

London Underground dates back to 1854 when the Metropolitan Railway gained permission to build a subterranean system and began to evaluate digging methods in test tunnels, but it wasn’t until January, 1863 that it opened the world’s first underground railway, which ran between Paddington and Farringdon Stations. Steam locomotives hauled wooden gas-lighted carriages. A second line, The District Line, between Kensington and Westminster, opened in December, 1868. The first underground lines were trenches that were “cut and covered,” in a manner like the setting of the Terra Cotta Army of Qin Shi Huang 2100 years earlier. Newer methodology of deeper bored circular tunnels, avoiding the need to involve surface property owners, began with electric locomotives on the City and South London Railway between King William Street and Stockwell in 1890. The deep tube system expanded and by the time of the “Mind the gap” recorded announcements, the London Underground map had become one of the iconic graphics of the 20th century. Some versions of the map noted the distances involved, vertically and horizontally, for the more egregious gaps.

Composite_Beck_and_2012_tube_map

[Wikipedia. The left side shows the 1933 Beck map and the right side the Underground map as it appeared in 2012.]

The Darkest Hour, a new film about the gap between England’s meager armed forces in 1940 and Hitler’s military advance in Europe shows a fanciful scene where Churchill takes the Underground to Westminster one day seeking to understand the “will of the people.” His imagined conversation with the working people on the train bolsters his courage to resist rather than capitulate to the overwhelming and imminent threat. Churchill goes on to deliver his first galvanizing wartime speech. In the film two political opponents grouse: “What just happened?” one asks as parliament erupts in patriotic cheers. “He [Churchill] mobilized the English language,” comes the reply, “and sent it into battle.” Creative devices of the cinema notwithstanding, it’s hard to imagine what today’s world would be like without Winston Churchill’s leadership in that precarious year.

 

Three.

Fictional views of the world help us understand it more accurately and deal with it more effectively. When fiction artfully imagines facts and relationships and renders them in coherent stories with enough historical fidelity and realism the past, present, or even the future become clearer. The Darkest Hour did this effectively for those dark days of 1940, when England found itself unprepared for a re-armed and hostile Germany. Although the Underground scene was fiction, it gave substance to the reality that Churchill was able to tap into the will of the English people, understanding that their values, hopes, and dreams were quite distinct from the views of the rarified aristocracy that surrounded him and had ruefully shaped English policy until that moment. Churchill, like his peers and advisors, had limited contact with ordinary, working people, but he had enough sense of them to gain an imagined understanding of their aggregate intent on the choice between surrender or fight. Furthermore, his inspiring speeches at the right moments tilted the scale further against appeasement and surrender. While the Underground scene might make historians grumble, the fictional device artfully illuminated Churchill’s likely state of mind.

The 1993 film, Groundhog Day, offered more outlandish fiction, giving an imaginative spin to the Punxsutawney myth. A successful musical version premiered in London at the Old Vic in 2016. This story is a fiction about a fiction. Yet, who hasn’t wished for moments like Bill Murray’s Groundhog Day where time repeats itself, offering us another chance, or like “a glitch in The Matrix,” and as Yogi Berra is reputed to have said: “Déjà vu all over again.”

 

Four.

Our species, Homo sapiens, is not only defined by its stories, but stories shaped our emergence from the earlier members of our genus Homo, if you accept a Darwinian point of view. Allen Lichter, former UMMS Dean, sent me a book recently that elegantly consolidates our specific human story. Aptly named Sapiens and written by historian Yuval Harari, the account tells how our genus, Homo, evolved 2.5 million years ago from an earlier and now-extinct genus of great apes in East Africa and set out to see and change the rest of the world. Some kindred species, Homo neanderthalensis, evolved in western Eurasia of the Ice Age while others, Homo erectus appeared in Eastern Asia and survived for 2 million years. Homo soloensis evolved on the island of Java, Homo floresiensis on Flores, and Homo denisova in Siberia were also members of our category of biologic classification, the genus. Evolution also continued in East Africa with other competing species in our genus: Homo rudolfensis and Homo ergaster, along with us, Homo sapiens.

Harari gives reasonable evidence that storytelling was central to the emergence and dissemination of Homo sapiens, who eventually replaced all the other species of the Homo genus, although collecting bits of their DNA along the way. All hominoid species existed in communal groups that must have depended on some form of verbal communication, but Harari indicates the language skills of H. sapiens were superior and in time gave total competitive advantage to our species of humans: “The ability to create an imagined reality out of words enabled large numbers of strangers to cooperate effectively.” [Harari p. 32]

The earliest storytelling logically was a matter of gossiping and rumors related to clan folk, hunting, competing clans, predators, seasons, and climate. Storytelling expanded, perhaps around campfires, into durable tales of myth, history, and fantasy. Without the advantage of scientific thought and verifiable information early story tellers undoubtedly relegated competing some clans to barbarian enemies. Some of these may legitimately been other human species, although as opposed to traditional ideas that different species could not breed, evidence is clear that successful interspecies mingling occurred in the last 100,000 years before the other human species became extinct.

For the last 10,000 years Homo sapiens has been the sole human species. Historical ideas of polygenesis have been effectively debunked – there is only one human kind, although 7 billion of us have myriad ethnic origins, ideas, experiences, hopes, and dreams. Diversity is an uncontestable true fact, and equity and inclusion are mandatory to our survival as a species. John Kennedy once was reported to have said: “Our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s future. And we are all mortal.” [Commencement Address at American University, Washington, DC. June 10, 1963]

Today’s world is cosmopolitan in fact and by necessity.

 

Five.

Today, February 2, has interesting links to the past. Notably, in 1887 in Punxsutawney, Pennsylvania, Groundhog Day began on this day. February 2 in 1901 was the day of Queen Victoria’s funeral. My grandfather recalled that he watched part of it from a rooftop in London, guessing that he was around seven years of age at the time. On this day in 1922, the book Ulysses by James Joyce was published, resetting the line between pornography and “acceptable” literature. In 1925, on February 2, dog sled relays carrying life-saving diphtheria antitoxin reached Nome, Alaska when all other access was impossible. This superhuman feat, a half-century later, inspired the Iditarod Race. Balto, the most celebrated of the original relay dogs, is immortalized in a statue in New York’s Central Park and his remains, preserved by taxidermy, are at the Cleveland Museum of Natural History.

These curious bits of information are facts that can be authenticated, for the most part. The late Don Coffey used to tell his students to learn to distinguish facts and true facts. What he intended with that admonishment was the recognition of authenticity in the pursuit of truth, authenticity being a state of worthiness of acceptance or belief by conforming to true fact.

Facts (and data) have some degree of relativity as Coffey knew well, they may change as new information is gained. Truth is something greater than fact, a higher degree perhaps of accuracy or authenticity. Something authentic is genuine, factual, truthful, or honest. As fanciful as the idea that a groundhog could predict the remaining length of winter or the notion that someone could be trapped in a repetitive time cycle, there is something authentic in the human aspiration to find easy ways to forecast the future (much like ancient uroscopists) or to have a chance to repeat a day in one’s life to achieve a better outcome.

 

Six.

Human nature seeks truth and its embodiment in personal conduct, integrity, is the basis of successful social interaction. The line between authenticity and inauthenticity can be difficult to discern and it can change. As we become informed that facts we had previously taken for “true” are found to be inaccurate, we are playing the intellectual game of science. More generally, this is the game of life as Homo sapiens. New information – observations in life – reasonably cause us to reset beliefs and values. It is no moral lapse or inauthenticity to discard facts when better facts are discovered based on new information, rather this is the natural human arbitration of the world.

Inauthenticity is another matter, being usually deliberate deception with antonyms that include counterfeit, inaccuracy, infidelity, deception, exaggeration, erroneousness, falseness, miscalculation. For a physician, nurse, PA, MA, researcher, other health care worker, or patient, the presumption of absolute authenticity is the basis of daily transactions. This is no less true for a historian, English professor, geologist, or physicist. Yet facts and stories are likely to have different interpretations or aspects to them. We arbitrate “truth” through collaboration with knowledgeable peers, or other sources of information. Such calibration is the nature of the scientific process, but it is more generally at the heart of all the social and intellectual interactions of human civilization.

A storyteller’s success is a matter of telling an authentic story. The story may be fact or fiction, but in either instance, the ability to make it ring true to a discerning ear is the hallmark of success. A successful factual writer, such as a journalist, will collect facts and study relationships in order to weave them coherently and artfully. The writer must strip away non-essential information or information perceived as inaccurate or misleading to create a story that is clear, accurate, and authentic to the reader.

The distinction between authenticity and inauthenticity is more complex for the writer of fiction, the value of which is to entertain and inform. Good fiction is authentic when it creates a story that rings true to readers in terms of realistic dialogue, details both relevant and accurate, and narrative that is clear. In the best instances, good fiction not only illuminates reality, but it distills it to capture and enhance its essence.

 

Seven.

Churchill’s language. Years ago, when the Society for Pediatric Urology was held in New York City and Bernie Churchill was president of the group, a well-known Winston Churchill authority and impersonator, James Humes, appeared as the surprise dinner speaker. When Humes described Churchill’s approach to speechwriting, the ideas resonated enough to write them down. Curiously, I’ve been unable to verify these in anything I’ve read of Churchill since then, so I can’t promise them as “true facts.”  Nonetheless, they ring true to me:

  • Start strong
  • Simple language
  • One theme
  • Paint a picture
  • End with emotion

In his own writings, Humes himself is the source of some good quotes.

  • The art of communication is the language of leadership.
  • Every time you have to speak you are auditioning for leadership.
  • Most speakers speak ten minutes too long.

If you want to explore Churchill and Humes further, a book Humes wrote in 2001, Eisenhower and Churchill: The Partnership That Saved the World, is well worthwhile.

 

Eight.

The Tet Offensive began fifty years ago and should be recalled for many reasons, but none less than it offers important lessons in leadership. Last year on these pages we told some of the story of Larry Hawkins, a young man from Detroit, who was one of the thousands injured during the Tet Offensive and how he came to the Ann Arbor Veterans Hospital paraplegic and deteriorating from urosepsis due to a neuropathic bladder. Jack Lapides saved his life by performing a vesicostomy, that also gave Larry personal independence. Larry went on to become a lawyer and influential public servant in Florida. After a distinguished career that included advocacy for the rights of the handicapped, Larry passed away a year ago and was buried at Arlington National Cemetery last summer. We had come to know of Larry through the efforts of his sister in contacting us for stomal supplies, that were becoming harder and harder to obtain for the Lapides vesicostomy, an operation that was life-saving in its day, but has been largely replaced by other management techniques.

Fifty years ago, in January 1968, when the combined forces of the Viet Cong and the North Vietnamese People’s Army of Vietnam launched surprise attacks on dozens of cities, towns, and hamlets throughout South Vietnam, the tide of the war began to shift. My professional education had begun amidst the Vietnam War, when we still had a national military draft, but my service was deferred via the Berry Plan until I completed my training. By then the draft and war had ended, but my service was still mandated and I was assigned to Walter Reed Army Hospital.

For the next few decades the collective American consciousness wanted to forget Vietnam and its many lessons, something that was easy to do for most people whose bodies, minds, and families had escaped the war’s sequelae. Nevertheless, occasional great memoirs gained public attention, including the Things They Carried by Tim O’Brien and Robert McNamara’s book In Retrospect. That latent period passed with the recent Ken Burns encapsulation, The Vietnam War. These books should be required reading for every American citizen. Continuing with the de facto “movie review theme” this month, we call attention to The Post, a current film that combines fact and fiction to tell an important and authentic story about The Washington Post and The Pentagon Papers.

 

Nine.

The_General_(C-1._S._Forester_novel)_book_cover

Leadership. A much older book recently came to public attention as a favorite of General F. John Kelly, Chief of Staff for the President. The General, by C.S. Forester is described as the classic example of leadership during WWI, but its lessons transcend any era. Written as fiction in 1936, its authenticity made it a best-seller and it tells the timeless tale of leaders who fail by fighting this year’s war with the tools and tactics of the last decade’s war. This book impressed Churchill, as well as Hitler according to Forester. Kelly singles The General out as an example of the importance of what he calls “Professional Reading,” a necessity for anyone aspiring to competence in their work. An article in Foreign Policy quotes Kelly:

“When I came back in the Marine Corps as an officer — close to my first days as a second lieutenant — I ran into a fellow named Capt. Ed Wells, a Harvard-educated, upper-crust guy. That first day I knew him he started talking to me about professional reading and how the real professionals read and study their professions. A doctor who doesn’t read peer articles and stay attuned to the developments in his field is not the kind of doctor you would want to go to, and the same is true for officers in the Marine Corps. He got me going on reading, specifically focused on military things, and I just never stopped. When I read a new book I wrote a notation in the front of the book what billet I was in, the date I finished reading it, and where in the world I was…

I’ve read this book [The General] every time I got promoted just to remind myself of the effect. I’ve noted where I was when I finished reading it the last time, then when I read it again I will try to remember what it meant to me as a major and, depending on as you get older and higher in rank, it’s a different book every time you read it. When a lieutenant reads that book it’s different from when a lieutenant general reads it. And I think the same is true for every book. So it’s just kind of a fun thing I’ve done over the years and with this book in particular just to remind me of the critical importance of thinking.” [Ricks. Foreign Policy. April, 2017. Reprinted, by permission, from Adm. James Stavridis, USN (Ret.) and R. Manning Ancell, The Leader’s Bookshelf (Annapolis, Md: Naval Institute Press, © 2017).]

 

Ten.

The Greyhound bus line company. Travelling through the Delaware Water Gap this winter on Interstate 80 or stalled in traffic last summer on Interstate 70 along a cut through the Dakota Hogback west of Denver I saw a number of the ubiquitous Greyhound buses. Greyhound is as synonymous for intercity travel in North America as the Underground is for intracity transportation in the United Kingdom. Greyhound’s first route traces back to 1914 in Hibbing, Minnesota when Carl Eric Wickman, a failing Hupmobile car salesman, used his last remaining 7-passenger vehicle to transport iron ore workers from Hibbing to the town of Alice, known for its saloons, at 15 cents per passenger. The next year Wickman teamed up with Ralph Bogan who had a transport service between Hibbing and Duluth. The newly named Mesaba Transportation Company had a positive margin of $8000 that first year. Through mergers and acquisitions of networks, Mesaba grew.

The Greyhound name appeared informally on the inaugural run of a segment from Superior, Wisconsin to Wausau, Wisconsin when the local operator of the affiliated Blue Goose Line run, Ed Stone, saw a reflection of his bus as it passed by a shop window and the moving image reminded him of a greyhound dog. Stone later applied the name to his entire network. By 1927 the entire Wickman system was transcontinental and by 1930 it had consolidated 100 bus lines into the Motor Transit Company, that was soon rebranded the Greyhound Corporation. In 2007 Greyhound became a subsidiary of the British FirstGroup transportation company, although Greyhound itself remains based in Dallas. While most large metropolitan subway systems have consolidated into public utilities the interurban bus lines have remained private.

Old Depot

The Bus depot in Ann Arbor serviced interurban bus lines including Blue Goose, Greyhound, and Shortway from a little building (above) until September, 1940 when it was replaced by a state-of the-art facility with 62 seats, a telegraph booth, a ticket office, a baggage room, and a 12-seat lunch counter.

Depot Story

Over the years, as Greyhound became the dominant carrier, the art deco building lost its luster through a number of renovations until 2014 when it was taken down to build the Marriott Residence Inn. The historically attuned developer, First Martin Corporation, retained the façade (below) and encapsulated the story of the bus station on the lovely visual displays, seen above.

Bus depot facade

Residence Inn

……………………………………..

It’s been a challenging winter, but spring is not far away.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor