University of Michigan

Politics, as usual?

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Matula Thoughts March 5, 2021

2987 words

Politics, as usual?

One.

Last month was Lincoln’s birthday and a new biography, Abe by David Reynolds, merits comment. Fundamental issues of Lincoln’s times remain fundamental issues today and Reynold’s book permits you to be a “fly on the wall” in the rooms where consequential things happened. You need not be historian, constitutional lawyer, or elected politician to weigh in on these issues – literacy in today’s complex world is an existential necessity, political literacy for health care professionals in particular. 

Lincoln took office at an extraordinary moment of bitter partisanship and threat to the nation. His first inauguration was preceded by ugly political fighting amidst divisive and turbulent social conditions that Lincoln navigated deftly, although sometimes uncertainly. Many ideologies, “isms” and factions created a toxic climate that divided the nation into uncompromising strongholds of opinions as to which way the country should go. Lincoln was the consensus choice of the voters, but his perceived ideology was contentious to a vocal minority.

A recent article by historian Ted Widmer tells how on February 13, 1860 (a day after Lincoln’s 51st birthday) a mob tried to enter the Capital to disrupt the confirmation of the election. The mob, lacking passes to enter the Capital (and ignoring how American democracy was intended to work with peaceful transfer of presidency), was blocked by soldiers and protested loudly outside the building. Tempers also flared inside House and Senate chambers but American democracy and Lincoln won that day at the Capital. [T. Widmer, NYT, Jan 10, 2021.]

Reynolds argues convincingly that Lincoln distilled the toxic climate of opinions and centered his political course on the central defining idea of the nation as he saw it,

“.. Slavery, he declared in August 1856, ‘should be not only the greatest question, but very nearly the sole question.’ Noting the diversionary tactics of the proslavery side, he stated, ‘Our opponents, however, prefer that this should not be the case.’ He again drove home his main point: ‘The question is simply this – should slavery be spread into the new territories or not? This is the naked question.

Along with the naked question went a central idea. ‘Our government rests in public opinion … Public opinion, on any subject, always has a central idea, from which all its minor thoughts radiate. That central idea in our political public opinion, at the beginning was, and until recently has continued to be, the equality of men.” [D. S. Reynolds, Abe, Penguin Press, 2020, p. 434-435.]

This was a historically sound and prescient argument. Lincoln boiled down the entire national acrimony to the single organizing (and aspirational) principle of the Declaration of Independence – human equality.

Inasmuch as the Declaration was the primary justification for the new nation, it was an obvious corollary for Lincoln that the nation could not be divided, leading him to the famous biblical reference in his House Divided speech of June 1858. 

“ ‘A house divided against itself cannot stand.’

I believe this government cannot endure, permanently half slave and half free.

I do not expect the Union to be dissolved – I do not believe the house to fall – but I do believe it will cease to be divided. It will become all one thing, or all another.” D.H. Donald, Lincoln. Simon & Shuster, NY 1995. p.206.]

For all the subsequent debate over the conflict between the aspirations of the Founders and the ugly facts of “state’s rights” to hold human beings as “property,” the reality is that neither the Declaration nor the Constitution provided for such personal rights to own property in human beings – a concept totally dissonant from the foundational mandate and words of the Declaration.

Both documents had required consensus among all 13 colonies. Three provisions of the Constitution reflected the wills of slave-holding states, yet the document deftly steered clear of asserting any claim to the noxious idea of human slavery itself – “property in man.”

The first Constitutional provision (Article I, Section 2) allowed for congressional representation and apportionment of taxes for the states based on their “respective Numbers” of “free Persons” (these were assumed to be white men only, although that was never explicitly stated) plus:

“…those bound to Service for a Term of Years, and excluding Indians not taxed, three fifths of all other Persons.”

This cynical inclusion gave the slaveholding states the extra edge of additional votes and tax reapportionment for three-fifths of all enslaved persons. Ultimately these provisions were obliterated by the Thirteenth and Fourteen Amendments.

The second provision, another bone thrown to the slaveholding states, came in Article 1, Section 9 but it was time-limited.

“The migration of Importation of such Persons as any of the States now existing shall think proper to admit, shall not be prohibited by the Congress prior to the Year one thousand eight hundred and eight, but a tax or duty may be imposed on such Importation, not exceeding ten dollars for each Person.”

The final provision is in Article IV Section 2:

“No person held to service or labor in one state, under the laws thereof, escaping into another, shall, in consequence of any law or regulation therein, be discharged from such service or labor, but shall be delivered up on claim of the party to whom such service or labor may be due.” 

The framers of the Constitution clearly expected “property in man” to wither away, little expecting the Missouri Compromise of 1820 would allow the inclusion of a new slaveholding state and the Kansas-Nebraska Act of 1854 would allow the “popular sovereignty” of new states to make their own decisions on the matter. Rather than withering away slaveholding was resurgent in the days leading up to Lincoln’s first term and civil war was inevitable.

Lincoln set a course for the war with principle and perseverance, although as it ground on undecidedly, the Union will flagged and Lincoln feared for his reelection. By July 1863 the tide turned, in spite of draft riots in NYC, and Union victories in Vicksburg and Gettysburg fueled optimism. In August the president decided to sit for a picture.

Photographs in those days required long exposures, lasting many seconds or minutes and, as Lincoln sat for a glass plate portrait in August 1863 at Alexander Gardner’s studio in Washington, a fly alighted on the president’s trouser leg below his right knee. Lincoln was unperturbed and continued to sit still for the photograph, without troubling the insect. [Above: Gardner’s photo. Below: detail of the famous fly under Lincoln’s knee on the posterior crease.] 

 

Two.

Health care in Lincoln’s time hardly compares to health care today, but the matters of human inequality in terms of life, liberty, and the pursuit of happiness underpin our modern acrimony just as they underpinned the great national dilemma in 1860, especially so today in matters of health care. [Above: Harper Hospital, original hospital complex in an 1884 drawing  710 of The history of Detroit and Michigan or, the metropolis illustrated …, by Silas Farmer p. 710. British Library.]

In Lincoln’s lifetime it was unusual for a person anywhere in the world to go into a hospital. Medical care was delivered in doctor’s offices, people’s homes, or on battlefields. Hospitals offered very little to their unfortunate patients, aside from a bed. Lincoln died just when the germ theory emerged from Ignaz Semmelweis, Louis Pasteur, and Joseph Lister. The medical world was starting to change. During the Lincoln presidency, Ann Arbor had no hospitals, while Detroit had several, the newest being Harper Hospital, built in 1863, largely to attend to soldiers injured during the Civil War. 

Health care reflects the values and aspirations of economic and political systems of any given community and society. Modern nations seem to be see-sawing between democratic rule and authoritarian/central rule. Yet this is not a simple bipolar contest. Democratic rule provides elected representatives to express “the will of the people” but requires significant central/federal authority that may verge toward authoritarian leadership (as was claimed during FDR’s presidency on numerous occasions). Authoritarian control of a society responds poorly to the needs of the people, stifling education, inquiry, and innovation but is ultimately (and ironically) contingent on acceptance of that authority by enough people in the society (as revolutions have proven again and again). As Lincoln said, our government rests on public opinion. And public opinion should be informed by basic Constitutional literacy. 

A scathing critique of modern hospital care is recounted in the recent small book by noted historian Timothy Snyder, Our Malady. Lessons in Liberty from a Hospital Diary. He offers the provocative opinion that liberty in the political sense and health care in personal terms are directly linked, gleaning that perspective from his near-fatal illnesses and suboptimal hospital care.

“America is supposed to be about freedom, but illness and fear render us less free. To be free is to become ourselves, to move through the world following our values and desires. Freedom is impossible when we are too ill to conceive of happiness and too weak to pursue it. The word freedom is hypocritical when spoken by the people who create the conditions that leave us sick and powerless. If our federal government and our commercial medicine make us unhealthy, they are making us unfree.”

 

Three.

Freedom of enterprise and thought have brought great accomplishments in medicine and science but not a unified system of heath care. We often are told “Our health care system is broken” but the  complaint is not quite right. No purposeful system exists, rather a variety of organizations and systems that have evolved in response to the myriad needs and challenges of healthcare. Each system may work well enough for its purposes and stakeholders, but they function independently, often in competition with other systems and their stakeholders. The common good of the public, individually and at-large, tends to be a secondary concern. The “broken system” complaint, although misconstrued, is relevant and global. The individual patient is the ultimate stakeholder, but gets lost in the systems. 

Health care should be many things – accessible, equitable, effective, efficient, timely, safe, kind, and universal. But it usually falls short. This is obvious to 7 billion people –  advantaged and disadvantaged populations alike. Local, regional, and global inequities are visible every day on public streets or in countless newsfeeds. Even if your individual health care seems secure, it is precarious – predicated on a job, a bank account, health status, social status or caste, location, family member, public safety, and other particularities.

The frameworks of healthcare organizations reflect the values that underpin them in each locality and their nations. Most perform adequately in terms of their business success, some excellently, but few do well in the matters of personal care, coordination, excellence, equity, and value. Business success (revenue optimization) is not the primary purpose of non-profit healthcare organizations. That’s not why society grants them no-for-profit status.

The State of California recently sued Sutter Health for anticompetitive practices that raised the cost of health care in northern California for little reason beyond increase in revenue. 

We, the public, should care about this. Most large health care organizations enjoy the benefit of “non profit” status. The public gives these organizations tax breaks that are not given to “for profit” organizations like Amazon, Exxon, or Johnson and Johnson, that have a central defining objective of maximizing shareholder value. “For profit” organizations of course have other protections carved out by the public, notably limited liability status, that enhance their abilities to succeed in the business world, but “not-for-profits” serve larger public values.

 

Four. 

Management by accounting uses performance metrics and these have spread into the non-profit sector, health care in particular. Metric domination tends to deform missions. When governing boards use performance incentives to inspire a CEO, CFO, or CMO to cut nursing positions, eliminate overtime, or decrease benefits, then those things are likely to happen even if they damage the quality of products, the performance of employees down the ladder, or the culture of organizations. The entire brand of any organization is at risk, not-for-profits especially. Governing boards optimally should govern and not manage (and micromanage) their organizations. They need wise management leaders with holistic (and accountable) reign over their domains in the organization to best advance the mission of the enterprise, which naturally involves financial responsibility but not to the detriment of mission or brand. [Above: bean counting. Illustration from Margarita philosophica, 1503, by Gregor Reisch (d. 1525). Houghton Library, Harvard University.] 

Financial responsibility in health care, essential as it is, cannot not be constrained to the next quarter’s balance between revenue and expenses. Immediate “financial margin” is important, but no less essential are quality, value, stakeholder satisfaction, financial liquidity, investment in enterprise strategy, investment in research and innovation, health care education, debt leverage, leadership succession, community responsibility, workforce health-retention-recruitment, organizational culture, policy development, public health, etc.

Health care is a huge and complex bucket of obligation in the modern world, far too complex for any of its myriad organizations to be primarily managed by key performance indicators or incentive directives.

 

Five.

Presidential inaugurations used to occur at this time of year because slow communications and clumsy political processes of this nation in its earlier history required at least four months from national elections to the peaceful transition of power that distinguished the American experiment in democracy.

The first inauguration, that of George Washington, took place on April 30, 1789, but subsequent ones occurred in March until March 4, 1933, the last March presidential inauguration, when Franklin Roosevelt replaced Herbert Hoover (above) – after a contentious election in the dark days of the Great Depression, but the two statesmen executed a graceful transfer of power in the finest tradition of American Democracy.

New technologies of communication and shortened news cycle in Roosevelt terms allowed inaugurations to be moved to January –  the second inauguration of Roosevelt was the first of these after the Twentieth Amendment to the U.S. Constitution moved the beginning and ending of presidential, vice presidential, and congressional terms from March 4 to January 20.

The past presidential election degenerated into fraudulent claims of voting irregularity, dozens of dismissed lawsuits to overturn results, and efforts to block the transition of power by congressional mischief or threat of armed force. The election results were counted, recounted, inspected, certified, and ligated over two months, but cynics may seek to restore that original prolonged interval between actual election and inauguration to allow more time for shenanigans.

Unfortunately, something so important as political leadership falls into the hands of all sorts of men and women called politicians, whom history proves again and again cannot be uniformly trusted to “do the right thing.”

This ultimately comes down to personal assessment, but what are the right things? Are they the right things for politicians, their constituencies, or the right things for society at large? The answers comes back to the Declaration and Constitution: life, liberty, and pursuit of happiness with Constitutional fidelity. This means fair and equitable education, justice, public health and safety, and opportunity.  Much of this is measurable with public health and safety data, poverty statistics, crime rates, equity in housing and education, and “happiness” ratings such as Likert score surveys.

Roosevelt’s four terms derived from democratic elections and he functioned with a strong hand, discovering new essential federal roles in rebuilding a nation from economic collapse and then guiding it successfully (along with much of the rest of the world’s nations) through a massive war. Hitler, in contrast,  manipulated his appointed position as chancellor into authoritarian rule that precipitated and lost that war, incurring unimaginable devastation in his 12 years as dictator.

Political systems, transcending individual leaders and terms, are essential to carry out the “will of the people” and protect them from threats whether they be human threats, economic threats, biologic threats, or environmental threats. Political literacy is an existential necessity. 

 

Postscript.

On the walls.

Metaphoric elevation of lowly and annoying houseflies (Musca domestica) to miniature sentient journalists imagines the precarious nature of the invertebrate, in imminent danger of destruction by authoritarian swat. [Above: Housefly, Wikipedia.] 

A related metaphor, the bugging of a room, came to life in the real world and literary genres of crime and spy stories. 

After President Obama successfully eliminated an annoying fly during a CNBC interview in June 2009 a number of journalists recalled Lincoln’s greater tolerance in August 1863. The organization People for the Ethical Treatment of Animals (PETA) chastised Obama mildly and sent him a “handy-dandy bug catcher” according to its newsletter Animals Are Not Ours. [Alisa Mullins, “Obama and the fly,” June 17, 2009.] 

This was not President Obama’s last public brush with the unruly insect order, it happened again in January 2013 during a White House briefing when he announced his selections to head the Securities and Exchange Commission and the Consumer Financial Protection Bureau. An emboldened fly briefly alighted on Obama’s forehead, but escaped to buzz another day, although journalists were quick to record the event. Vice President Pence, among countless others, also had his historic moment with Musca domestica, at the October 2020 Vice Presidential debate, once again showing that politicians sometimes tolerate flies on the walls and bugs in the rooms where things happen.

American re-enlightenment. The George Floyd moment of 2020 illuminated much of the American condition from its original sins to present disparities that so impact the aspirations of life, liberty, and the pursuit of happiness.

My friend and Army colleague, pediatric surgeon Victor Garcia, recently sent me a book by a teacher at his alma mater, West Point, Ty Seidule. Robert E. Lee and Me. A Southerner’s Reckoning with the Myth of the Lost Cause. This timely book, explains how attitudes are formed in cultures, how they persist, and how or why they can change. [T. Seidule, St, Martin’s Press, NY. 2021.]

The difficulty of changing beliefs and myths – through rational argument, historical analysis, and scientific process – is an existential challenge that our species seems to be failing. Flies on the walls watch and invertebrates may yet win the day on this planet, even though Homo sapiens is capable of doing so much better. 

Thanks for looking at Matula Thoughts, March 5, 2021.

David A. Bloom

University of Michigan, Department of Urology

 

 

Expectations and epistolaries

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Matula Thoughts
January 1, 2021
Expectations and Epistolaries

2941 words

One.

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

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

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

 

Two.

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

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

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

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

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

 

Three.

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

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

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

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

 

Four.

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

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

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

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

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

 

Five.

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

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

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

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

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


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

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

 

Postscripts.

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

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

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

Trees fall in forests. 

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

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

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

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

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

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

 

Flat vs. round

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WN/MT June 2020

Flat vs. round.

2949 words

[Blue Marble from NASA Terra at 438 miles.]

Last month, world attention was dominated by a disruptive virus, angered by ugly politics, briefly turned to a space station special delivery, and horrified by the retrograde murder of George Floyd. Michigan Urology also lost one of its foundational alumni, Ed Tank.

 

One.

A flat Earth was a reasonable belief for Homo erectus and their other hominin cousins, including Australopithecus sediba shown below in reconstruction at the University of Michigan Natural History Museum (visited just prior to the closure for coronavirus). The campfires, hunting grounds, and cave dwellings of early humans reinforced a sense that their environments were mainly two-dimensional landscapes of hills, valleys, and forests.

That mind-set changed when clever Homo sapiens, sailing the seas and studying the skies, figured out the true fact of the round Earth: sailors noticed mountain peaks well before they saw the shorelines as they approached land and astronomers, lucky enough to see eclipses, deduced that circular shadows on the moon could come from spherical bodies. Aristotle captured some of these ideas in writing and a few intrepid navigators had enough faith in a round Earth hypothesis to venture west across the Atlantic, millennia later. [Below: lunar eclipse, Wikimedia, with permission, Tom Ruen 14 October, 2014.]

John Cabot in 1497 was one of the first identified Europeans to navigate to the North American Continent. Unnamed Norse explorers and fishermen as far away as the Basque region fished the Grand Banks seas and set foot in present-day Newfoundland and Labrador centuries earlier, but it was John Cabot from Bristol, England, to whom the first name can be attached. Originally named Giovanni Caboto from Genoa, he worked his way to Venice, then Spain, and finally England seeking funding for an expedition. Bristol, the second largest city in England and a major port, was where he raised enough capital to build a three-mast ship of 60-feet and 50 tons and find a crew to follow his belief in a round Earth. King Henry VII gave Cabot a Royal Warrant (a “visa” of the time) to explore what was presumed to be Asia. Cabot’s single ship crossed the rough North Atlantic with a crew of 18-19 in 34 days, explored Newfoundland or Labrador, and accurately returned to Bristol in 15 days.  The journey was repeated successfully once, but the ship was lost in 1498 on a third try. [Below: traditional globe.]

Five years before Cabot’s journey, another immigrant from Genoa, then living in Spain, crossed the gentler southern Atlantic Ocean to Caribbean Islands with three ships. Christopher Columbus had obtained financing from King Ferdinand and Queen Isabella, making two other return trips, but never reached the mainland. In fact, no one from the Spanish contingent reached the actual North American continent until 1513. It is possible that Columbus and Cabot met in Spain between 1490 and 1494, but Cabot certainly knew about the travels of his fellow countryman. Columbus and his sons branded their enduring legacy effectively. Cabot, lost at sea on his third voyage, wasn’t so well represented by his son Sebastian who was more interested in his own opportunities than advertising his father’s accomplishments. The Cabot story was eclipsed until now. Was Giovanni Caboto an ancestor of Hugh Cabot? It’s quite possible.

 

Two.

Retrograde visions. Orlando Ferguson (1846-1911), a self-styled professor from Hot Springs, South Dakota, copyrighted his Map of the Square and Stationary Earth in 1893, subtitled “Four Hundred Passages in the Bible that Condemns the Globe Theory, or the Flying Earth, and None Sustains It.” He completely discounted two and a half millennia of recorded human history and verifiable knowledge in favor of his literal translation of the Bible and belief in a “square and stationary Earth.”

Born near Du Quoin, Illinois, Ferguson moved to Dakota Territory in the 1880s, opening a grocery store and hotel. After a fire destroyed the hotel, he built a bath house near Siloam Springs and became known as “doctor” to some patrons. Fergusson’s map never gained traction and fell out of sight until discovery more than a century later. The map was donated in 2011 to the Library of Congress by State Senator Don Homuth. [N. Jackson. Library of Congress Receives Rare Map depicting Earth as Flat. The Atlantic, June 22, 2011.]

Edwin Abbott Abbott (1838-1926; shown above, Wikipedia), English schoolmaster and clever satirist, poked fun at his stultifying Victorian culture with a book in 1884 called Flatland: A Romance of Many Dimensions. Perhaps not wanting to be identified too closely to the ancient idea, Abbot used the pseudonym “A Square.” One of its illustrations (below) may have served as a model for the gendered entrances to the original Michigan Union, when it was built in 1917.

One of Abbott’s students at the City of London School, Herbert Henry Asquith, became Prime Minister of the United Kingdom from 1908 to 1916. Later the Earl of Oxford, Asquith, didn’t take Abbott’s Flatland literally when he oversaw the dispatch of the British Expeditionary Force (BEF) to the Western Front in The Great War in 1914. (Hugh Cabot would join the BEF in 1916.) The Flatland story was picked up in a 2007 film and two shorter films, Flatland: The Movie (2007) and Flatland 2: Sphereland (2012). Abbott’s “romance” was a clever fantasy and is still an entertaining read (below), but The Flat Earth Society is a meme for people unfortunately stuck in obsolete versions of reality or obstinately clinging to it for self-serving reasons.

 

Three.

Hardy Hendren, an iconic presence in my clinical education and even more so for that of John Park, introduced me to the Flat Earth meme, once commenting: “If you stick around long enough, you’ll meet someone who believes the world is flat.” It was a good lesson and I didn’t have to wait long to find members of the Flat Earth Society. Hendren was one of the best early explorers of the round earth of pediatric urology, but warned his students that Flat Earther’s always try to block progress. [Above: Hendren as visiting professor at University of Michigan 2012.]  Luddite is closely synonymous for the frame of mind in which persuasive argument, careful observation and reasoning, or scientific evidence fail to release a person from primitive beliefs.

Hardy educated his trainees in many ways even outside the operating room, where his rigor of thought, innovation, and tenacity were unmatched and those disciples carried his ideas and philosophy around the world.

Hendren’s clinics, relationships to referring physicians, and care for his supporting team set powerful examples for generations of students, residents, and fellows. After his own diagnosis of colon cancer, publicly discussed for all to learn from, Hardy quit smoking and became evangelical in urging those he encountered to quit. Trainees, colleagues, and people on the street were lectured vigorously. So too were parents of the children he treated – I marveled at his bravery, holding out a trash can to astonished parents in clinic to dispose of their cigarettes and lighters. Some may have seen this as an affront to personal choices, but Hardy was on a mission to minimize comorbidities of his patients, dispelling Flat Earth views of the world, including that of the healthy cigarette. Alberto Pena, Mike Mitchell, Rick Rink, John Park, Joe Borer, David Joseph, and Craig Peters with so many others took notice and found their own ways to perpetuate Hardy’s work in their practices and carry his ideas around the world. (Below: modern version of Cabot’s journey.)

 

Four.

Debts of gratitude. Almost everyone I know in health care proudly carries debts to influential teachers and role models. While the term, debt of gratitude, raises eyebrows of grammatical purists it does seem to work for most of the rest of us, especially in terms of our mentors and role models. Hardy Hendren stands tall in my list. Although I didn’t train with Jack Lapides, only knowing him in his retirement years, Jack, too, is high on the list for the contributions he made to our field and his style of intellectual rigor was impressed on his trainees and disseminated throughout their careers to their own students and colleagues such as myself. I have heard Jack mentioned with reverence over the years by so many of those who came within his orbit including Bill Baum, Marc Taub, John Hall, Barry Kogan, Steve Koff, Evan Kass, Bart Grossman, Gary Wedemeyer, Jay Hollander, and Ed Tank to name just a few. Our role models, and so much more of what is good in humanity, get drowned out by the daily tragedies and evils that compel our attention to news cycles.

Last week’s UMMG Town Hall responded mainly to the covid disruption of our work and lives and something David Spahlinger said caught my attention. He offered the metaphor that in the present phase of our national and personal traumas many people are in the “valley of disillusionment.” In our UM health system David is in the tough position of being the daily lightning rod for complaints, anger, disillusionments, and expectations for solutions to extremely difficult problems. Yet as an internist and intensivist, working in the thick of things and as president of the health system making rounds throughout all corners of the medical center, he is eminently credible. His talk noted that some of our colleagues “bristle” when they are told that “we are all in this together,” because the reality is that the suffering is inequitable. People suffer in very different ways – from the front line maintenance worker to the ICU nurse to the junior emergency department resident to the exhausted hospitalist to the beleaguered phone line staffer to the senior administrator trying to do their jobs. Each person’s home and family situation is unique and it is perhaps presumptive when leaders presume cohesion of a group. Spahlinger wisely said:

“The financial impacts of no merit increase and suspension of retirement contribution are not felt equally by everyone. Likewise, not everyone is working on the front line risking their own health. Those at home are under stress as they wonder if they have a job to come back to. My point is that everyone is suffering in different ways. The reason I say we are all in this together is that I don’t think we can prevail as an organization and carry out our mission unless we face the challenges ahead together.”

From my point of view as a colleague of David Spahlinger over the past 30 years, we all owe a great debt of gratitude for his excellence as a clinician and credible leader in our health system.

 

Five. 

Ed Tank. Michigan Urology lost one of its most extraordinary alumni when Ed died in Portland, Oregon on May 13 at age 88, leaving his wife Rosalie, four children, seven grandchildren, and a three-year old great-grandson. Born on March 23, 1932 in New Rochelle, NY as the first of two children, Ed grew up in the midst of the depression admixed with the urban excitement of his region. As a young boy he recalled meeting the legendary Yankee baseball player, Lou Gehrig (1903-1941) in an elevator. The Tanks moved to Western Springs, Illinois, in the Chicago area sometime around 1938 and Ed attended public schools in the La Grange district. The east drew him back for college at Amherst where he dove deeply and enthusiastically into liberal arts, in addition to having an outstanding collegiate wrestling career. In college he fell in love with Dixieland Jazz and loved to travel to Jimmy Ryan’s Jazz Club on Manhattan’s West Side to hear Wilbur de Paris and his band.

Medicine attracted Ed late in his college years and after graduating in 1954, he returned to Chicago for a postbaccalaureate year at Loyola to fulfill medical school requirements. This got him into St. Louis University Medical School, graduating in 1959. Along the way on a road trip back to Amherst for his third year college reunion Ed reacquainted with a childhood friend, Rosalie Butterfield, in Philadelphia and the couple married six months later. In St. Louis the couple had their first child while Ed was coincidentally rotating on the obstetrics service where Rosalie gave birth to Ellyn Marie.

In July 1959 Ed began surgical internship and residency at the University of Michigan under Gardner Child, III. The couple remained in Ann Arbor for two additional years, living quite happily as Rosalie recalls living in converted wartime housing then still present in Pittsfield Village and growing their family, with Julie who was born at St. Joe’s.

A research year was necessary in the surgery program, unless a resident had served in the military – and if so they were forgiven the year. Ed chose to do his research in Boston 1962-1963, working closely with Bill Bernard on hyperbaric medicine and was inspired to pursue pediatric surgery. A third daughter, Katie, was born at Boston Lying-In Hospital.

The Tanks returned to Ann Arbor in the summer of 1963 through summer of 1965, as Ed completed his surgery training under Gardener Child and during Reed Nesbit’s last years of leadership in urology. In July 1964 their son Ted was born at University Hospital.

Ed took the family back to Boston at Children’s Hospital for two years of training under Robert Gross, whom Rosalie recalls more of “a name” rather than a strong influence in Ed’s training at that time. She recalls Arnold Colodny’s strong influence then and Ed’s “double dose” of pediatric urology rotations under Alan Perlmutter.

In the summer of 1968 Ed returned to the University of Michigan as its first pediatric surgeon, but encountered turf issues with other surgical disciplines, distrustful of the emergence of pediatric surgery as a discipline. Thoracic surgeons were unwilling to “relinquish” the chest to Ed. Jack Lapides, Michigan’s new chief of urology, offered additional training in the urology domain and Ed, therefore, spent two years as a urology “resident” under Lapides while still holding responsibilities as a faculty member. Ed Tank then became the first trained pediatric urologist at the University of Michigan and remained on the faculty until May 1973 when he took a job in Portland at Oregon Health and Science University. The University of Michigan then had no pediatric surgeon until Arnie Coran came in July 1974.

Portland had been selected after a “big family discussion,” according to Rosalie. Ed enjoyed his work there with Jack Campbell, but found he had to focus on pediatric urology exclusively, even though he had hoped to practice general pediatric surgery as well. Ed was a superb clinician, surgeon, and teacher and inspired a generation of students and residents, one of the earliest being Rob Kay who came from UCLA medical school to Portland for residency 1974-1979, before going to the Cleveland Clinic. Ed’s first associate in pediatric urology was Steve Skoog who came in 1992, having trained at Walter Reed Army Medical Center and the Washington National Children’s Hospital under Barry Belman in 1985-1986. Steve recalls his first case with Ed was a 7-year old with Mayer-Rokitansky syndrome who had a Young-Dees urethroplasty and bilateral reimplantation.

Ed, wanting to cut back somewhat clinically, left the university in the mid-1990s and joined the Northwest Urologic Practice with Tom Pitre, operating at Emanuel Hospital.

Ed was leader in pediatric urology nationally, serving as Chair of the Section on Urology of the American Academy of Pediatrics 1990-1991. Some of his papers stand as “classic” in pediatric urology literature. Ed loved the Northwest and continued his boyhood love of fishing. He and Rosalie explored the round earth from Alaska to Antarctica. Ed was a big reader – always carrying a serious (nonfiction!) book with him. Rosalie recalls that she couldn’t talk him out of lugging a large hardcover biography of Truman or Eisenhower with them as they trekked the Himalayas.

Ed and Rosalie then focused most of their time in Sunriver Oregon and on their grandchildren, but continued some work for a time at Madigan Army Hospital and Native Health in Alaska before it had regular coverage. His collegiate passion for Dixieland Jazz persisted throughout his life and he made Rosalie a convert to it, with “umpteen jazz trips” across the country and around the world.

Ed and Rosalie loved and supported local classical music and repertory theater. Ed was a cheerful and generous maverick and always a passionate teacher, whether the subject was pediatric surgery, fish anatomy, crabbing, or subjects of his wide-ranging reading. Ed Tank was the first bona fide pediatric surgeon and pediatric urologist at the University of Michigan – a wonderful physician, teacher, role model, and friend to those lucky to have known him.

[Below: the subtle arc of the horizon from Portland to Detroit on a Delta Airlines Boeing 737 five miles high.]

 

Postscript.

On this round and small Earth, everything and everyone is connected. Events and ideas that originate at one spot may reverberate widely and persistently around the sphere. Navigation of the round Earth was not universally beneficial, certainly not for indigenous peoples of the Americas, Australians, or enslaved Africans.

David Spahlinger’s point, quoted above, links a number of issues at this distressing moment in time, including our rattled workplaces at the University of Michigan and the death of George Floyd on a Minneapolis street. I took from David’s statement at the Town Hall, that a legitimate understanding of the diversity of suffering predicates any solution to any particular challenges of the moment (and any claim to unity, i.e. “we are all in this together”). This applies beyond UM to regional, national, and global predicaments of poverty, war, and human justice. If individuals of diverse perspectives and circumstances are to find solutions to existential problems, any effective leadership for them must be credible –  credibility built not only on respect for diversity but also commitment to fair amelioration of inequities as we rebuild from months of the covid economic crisis and centuries of retrograde human inhumanity.

 

Thanks for reading Matula Thoughts, this June, 2020.

David A. Bloom

University of Michigan

Back on the road to contagious hospitals

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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

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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

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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

Matula Thoughts February 7, 2020

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Matula Thoughts 7 February 2020 Leaps, literacy, & opinions 2142 words One. Leap Year. A celestial accounting anomaly this month on Saturday February 29 will have only minor impact on people’s lives and world economies. The extra business day, when … Continue reading →

2020 – a new blank slate

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Matula Thoughts 3 January 2020

A new blank slate

2376 words

One.

 

Tabula Rasa 2020.

Optimists begin New Years with clean slates. Most people negotiate internal tension between optimism and pessimism, but the sense of opportunity that comes with a new year generally tilts the balance toward optimism and the chance to start anew with mistakes and sins of the past perhaps forgotten, if not forgiven. The blank slate, though, is only a metaphor; each year ahead will build on stories of the past – history – and the contingencies of immediate moments. [Above: Blank wax tablet.Wikipedia.]

The new year, next decade, and century ahead for Michigan Urology, may be shaped by the century that unfurled after Hugh Cabot came to Ann Arbor late in 1919, but the critical determinants of the future will be the ingenuity, industry, and success of our educational programs, research, and clinical delivery. The idea that the essential deliverable of academic medicine is patient care, while not historically prominent, is absolutely clear today. That essential deliverable, as we have said in our department of urology for some years, is kind and excellent clinical care, thoroughly integrated with education and innovation. With that, as the “North Star,” navigation becomes simple.

The Latin phrase tabula rasa originates from blank slates or waxed tablets that, after erasure of chalk or melting the wax, are available for fresh notation. Aristotle was one of the early thinkers who likened the mind to a clean writing slate and Avicenna, Thomas Aquinas, and John Locke, among many others, expanded the idea until modern neurobiology brought science to the matter. Metaphors are merely tools for thinking and communication, not absolute “true facts” that Don Coffey sought to recognize amidst the litter of contemporary information. Steven Pinker’s book of 2002,Blank Slate: The Modern Denial of Human Nature, calls out the metaphor and explains that human behavior is not constructed on a blank slate, or tabula rasa, but is heavily programed. [See Pinker’s TED Talks 2008 and 2019.]

Blank Slate is also the clever name for an Ann Arbor Ice cream shop, the actual ice cream serving as a medium for an ingenious palate of flavors. Ice cream, one of the great inventions of humankind, is a delight in any season, although winter demand slackens enough for the Creamery to close up for the coldest months (above at Liberty and S. First Streets). Having borrowed the metaphor for this monthly message, I was duty bound to ask (and receive) permission from Michigan grad Janice Sigler who opened Blank Slate in July, 2014, with her husband.

 

Two.

January 1920 was an optimistic time for Hugh Cabot in Ann Arbor at a high point of his career. Modern Urology, his noteworthy 1918 textbook, capped his 15 year rise to central authority in the field. An early volunteer for the European conflict, well before American entry made it a world war, Cabot commanded a 2,500-bed general hospital on the Western Front by war’s end. His return to Boston at the end of January 1919 was front-page news in the Boston Herald, although not without glitches. Cabot’s team of doctors and nurses was blocked from leaving the train at the Boston station where a reception was waiting for them. A military authority ordered the ensemble to remain on the train and continue on the train to Camp Devon, Massachusetts and then New York City for official discharge of duties. After discussion Cabot declined the order and the entire medical team disembarked from the train to join the waiting reception and then dispersed into the crowd to resume civilian life. [Below: Boston Herald. Front page. “Harvard Surgical Unit held prisoners by error on arrival in Boston.” January 31, 1919.]

As Cabot resumed civilian life the world seemed enroute to a better future in terms of public health, geopolitics, economics, technology, and art. The devastating Great Influenza Epidemic was over, but other pandemics followed. Geopolitical solutions to WWI would pave the way to WWII and later conflicts. The economic world collapsed in less than a decade. Rapid advances of technology that seemed so wonderful in the early 20thcentury proved two-sided by century-end with antibiotic resistant bacteria threatening food safety, robots displacing jobs, computer malware holding businesses and cities hostage, identity theft via internet, and social media manipulation of public elections. The public eagerly embraces Orwellian Big Brother – reassuringly renamed Alexa, Hey Google, and Siri – with ubiquitous cameras on streets and in homes paving the way to authoritarian control of society through artificial intelligence.

 

Three.

The “blank slate” of the new year, brings to mind resolutions and the human itch for personal mastery of something – work, play, family, or hobby. Just as they were once inspired, Bach and Casals are posthumously inspiring future composers and musicians today. The cello suites have had a remarkable 300-year journey since Bach started writing them as exercises for his young wife in 1717. Casals discovered the largely-forgotten music in a shop in 1890 and mastered its performance by 1896 when he became principal cellist in Barcelona at the Gran Teatre del Liceu. [Below: Title page of Anna Magdalena Bach‘s manuscript: Suites á Violoncello Solo Senza Basso. Wikipedia.]

Casals had ups and downs, like everyone, but the worst immobilized him for two weeks in 1939 when he didn’t leave his room in Paris, exhausted from recording the six Bach suites (Casals hated the recording process) and despairing over Franco’s take-over of Spain. Casals was thoroughly burned out, although the favored terminology of the time described him as emotionally exhausted and depressed. Thankfully, he rebounded and his career reached new heights. Nearly 20 years later, at age 80, he married 20-year-old Marta Montañez y Martinez, dismissing concerns over their age discrepancy: “I look at it this way: if she dies, she dies!” [Cesare Civetta. Mar 14, 2018. “Pablo Casals sacrificed his career to protest Franco.” https://CesareCivetta.com/blog] [Below: From Encyclopaedia Britannica, Pablo Casals, 1965. Erich Auerbach, photograph, Hulton Archive/Getty Images.]

The inspiration of the suites lives on: Yo-Yo Ma was inspired by Bach’s cello suites at age 4 and today, at 64, travels six continents to perform all six suites in single sittings at 36 locations.

Combustion control has been a defining feature of our species beginning around campfires for comfort, cooking, and conversation. Heat may erase tabula rasas, but metaphoric self-combustion in modern society seems a new thing. It is not clear when burnout is a “legitimate” dysfunction or an extension of quotidian fatigue? That state of reduced personal efficacy, emotional exhaustion, and depersonalization describes the condition today called burnout, that suddenly, it seems, has become epidemic in many professions, including health care. Conferences, surveys, and editorials proliferate and  medicalize the matter. The Lancet offered a useful perspective in an editorial, Physician burnout: the need to rehumanise health systems. The wording is counterintuitive – the “rehumanization” of human health care. [The Lancet. 394: 1591, 2019.]

 

Four.

So how is it that health care became “dehumanized”– that very suggestion seems to be an oxymoron, a contradiction in terms, as René Magritte cleverly depicted in his surreal paintings such as the 1953 Wonders of Nature (©René Magritte). The dehumanization phenomenon in medicine seems linked to the systematization, corporatization, and commoditization of healthcare. Systems are necessary in modern healthcare, of course, but the displacement of what historically was called the doctor-patient relationship with checklists, guidelines, and clinical pathways distracts from the human element. The EHR-directed patient “encounters” have largely replaced the narratives of the human conditions wrapped-up in taking “the history.”. Corporate medicine is quickly replacing small practices and bringing with it tainted ideas of business management, specifically the failed ideas of Taylorism, managerial accounting, and the North Star of shareholder value.

The idea of the limited liability corporation has largely built the modern world, as human society has given corporations many special rights such as limited liability, free speech, and some special benefits that ordinary people cannot have. (Back around 2003 Julian Wan gave me a book that explains this – The Company – A Short History of a Revolutionary Idea, by John Micklethwait and Adrian Wooldridge.) Undeclared but implicit in that Victorian innovation is a social contract that businesses exist not merely for shareholder value, but more broadly for stakeholder value – jobs, employees, benefits, suppliers, community – and for value to society-at-large, the most important stakeholder of all.

It is natural that some parts of health care are legitimate commodities, functioning optimally in a market-based economy without the necessity of an intermediary professional agent. Examples are many – flu shots, over-the counter medications, food supplements, and countless others. Other healthcare functions are complex, multilayered, and highly professional, such as renal transplantation, mental health treatment, and management of malignancy. In between these extremes are the essential transactions of visits to physicians, dental care, emergency department visits, orthopaedic care, periodic eye care, and treatment of urologic conditions – these are a mix of commodity and profession. The arbitrage of those two elements of society is an endless conversation.

The extension of personal mastery in one’s subject of choice, whether by New Year Resolution or not, is self-vaccination against burnout. The enhanced personal well-being can re-humanize your medical workplace in more ways than this essay can explain. Recently, up in Flint at the Hamilton Community Health Center, Mike Giacalone, Jr., the Chief Medical Officer, was explaining Hamilton to interviewing journalists and said that for the Flint patients, “every visit is not just a medical visit, but equally so a social, economic, and behavioral visit as well.” While particularly relevant in Flint, this should be a universal aspiration in health care. The medical gaze should try to “take it all in” and triage the needs of a patient and family as best possible, in spite of the rigidity of the EHR- constrained medical encounter programmed around a chief complaint.

 

Five.

Media and messages. Whether the medium is ice cream, canvas, blank paper, musical instrument, computer screen, stage, construction site, clinic room, operating room, or learner – artistry can be performed.

Everyone is a lifelong learner, but the health care field demands special attention. Undergraduates and beginning medical students are the most impressionable blank slates and for that reason the responsibility of role models, teachers, and mentors is perhaps the greatest for them among the learners we teach. For many of the younger set their first experiences seeing a physician, nurse, or physician’s assistant at work (sometimes in instances of personal care of a UTI, stone, or surgical correction) imprints and fosters a lifelong pursuit. Whenever possible, these opportunities for shadowing or introductory teaching should be embraced. Residency training, however, is the most critical blank slate of all in medicine, fashioning the knowledge, skills, artistry, and professionalism for a career. [Images above & below from “the internet.”]

Blank slates are opportunities, but risk erasure of the past although that is necessary with wax tablets and chalkboards. Parchment and paper were a big improvement allowing durable manuscripts and books, still at risk from fire (accidental or intentional) or other forms of destruction or deterioration. The new world of digital information carried the conceit that humans could become “paperless”, but that is ultimately not only impractical but also a genuinely bad idea for free societies.

When governments, sectarian authorities, or corporatocracies control printing presses, airwaves, or other social media – society is captive to a few reigning opinions because inconvenient stories, opinions, ideas, or truths are conveniently avoided or erased. Clever memes and tweets easily subvert social groups and human ideals. One great feature of the human condition is the testing and synergism of opinions, ideas, and technologies that can build civilization for the greater good of mankind and sustainability of the planet. The central idea of free speech at the heart of civilization, is being sorely tested by the unexpected opportunities of modern technological social media.

From our parochial perspective in the art and business of health care, erasure of history is an especially unfortunate reality, but we see it with each change of technology in health records. The operative procedure notes and pathology reports from the earlier part of my career seem to have vanished with the paper records we utilized when I started here in Ann Arbor, as I have learned when trying to answer requests from people regarding, say, an exstrophy closure operative report in the 1940’s, a hospital course in the 1960’s, or thyroidectomy pathology findings from the 1970s. Those floppy discs we had in the 1980s and zip-drives of the 1990s are increasingly difficult to access as obsolete technologies disappear. No one today can ensure that the massive data in electronic records will be converted to the media of the future – it seems unlikely that the “data cloud” of 2020 will be maintained in a future data cloud or its equivalent of 2050.

When Ed McGuire brought me to Ann Arbor in 1984 my blank slates were 3×5 index cards and the newly launched Macintosh Computer. Our hospital then had separate inpatient and outpatient paper charts. The Surgery Department administrators cautioned me to not get used to my Apple Computer as UM was preparing to launch the Wang Computer System. I didn’t listen – but still have the cards (one for with every patient I saw at Michigan) and that original Macintosh (now a book end).

 

Postscript

Matula Thoughts analytics, 2019. We have no sense of the total readership of the monthly What’s New delivered by email, but the web version matulathoughts.org has levelled off at 3357 views and 2199 visitors from 78 countries as of 31 December 2019, down from 3458 views, 2226 visitors from 89 countries in 2018, probably due to personal retreat from the chair position of the Urology Department at the University of Michigan. This past year we shortened the essay from 10 to 5 numbered items and dropped the word count to 2000 or so, although still far less convenient than a 140-character microblog tweet.

This leveling-off of Matula Thoughts recalls the Hippocratic Aphorism: Art is long, life is short, opportunity fleeting, experience hazardous, and judgment difficult. Other interpretations of the Ancient Greek vary the nuance and words, but clearly this personal essay, the first Friday of each month, is anachronistic and risky in offering personal judgments and observations. Those facts are more than balanced by the personal delight in hearing back from a handful of readers each month, thus extending these essays to dialogue and conversation, challenging facts, pointing out errors, and teaching me. Comments last month were especially appreciated. For all these, thank you.

 

David A. Bloom

Department of Urology

University of Michigan, Ann Arbor

November one

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DAB Matula Thoughts November 1, 2019

One hundred years of urology
2615 words

One.

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

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

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

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

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

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

 

Two.

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

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

 

Three.

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

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

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

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

 

Four.

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

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

 

Five.

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

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

 

Postscript.

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

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

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

 

PPS

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

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

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

A century and a millennium

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DAB Matula Thoughts October 4, 2019

A century and a millennium

Michigan urology begins its centennial celebration
2087 words

One.

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

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

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

 

Two.

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

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

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

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

 

Three.

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

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

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

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

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

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

 

Four.

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

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

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

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

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

 

Five.

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

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

 

Postscript.

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

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

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

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

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

Thanks for reading Matula Thoughts.

 

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