Urology

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

 

December

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Matula Thoughts

December 4, 2020

Change and hope

2810 words

One.

Hope. Change and uncertainty are inevitable, but hope is the part of the human tool kit that helps people navigate life’s turbulence. Change may bring hope or horror, as imagined in the fictitious scenario (shown above) of audience response to the novelty of moving pictures in 1895 when the magic of film was an expectation beyond reasonable hope. [Above: “Panic in the Audience when Lumiere Shows his first Film.” Figure from Suddenly this Overview. Peter Fischli and Davis Weiss, Exhibit, Guggenheim Museum, April 2016.]

It is rational to hope that things will return to a semblance of normal after this “final wave” of Covid-19 disrupts workplaces and education, prolongs social isolation, and disturbs belief in science and reason. Humans rebound after bad times and new forms of creativity emerge from calamities, as seen with RNA vaccines. Still, we would do better to remember those bad times and plan for their inevitable return. [Below: Michigan Theater – mostly closed in Covid times and its big screen moving pictures sorely missed.]

Last year just around this time, our department hosted its annual Holiday Party, an event inaugurated by Jim Montie after the Urology Department emerged from a Department of Surgery division 20 years ago. As the department expanded, the get-togethers outgrew Ann Arbor venues and moved to Fox Hills Golf & Banquet Center with the help and generosity of Kathy and Mike Aznavorian. Further growth and blurred administrative boundaries over the years stretched even Fox Hills’s capacity for the UM Urology family, their children, and guests to mingle, see Santa, dine, and dance. A few of our staff put their hearts and souls into planning and deploying the event, with food, avionics for Santa, and gifts for children. When the financial uncertainty of 2008 struck, we hesitated but continued the party.  Little did we anticipate an emergent virus from the other side of the planet would break our annual run of holiday parties. Covid not only brings the monetary concern, but also precludes the social interaction and reminds us how much we miss gathering. 

[Above: Santa, Holiday Party 2013. Below: Keller and Osawa families, Holiday Party 2015.]

UM Urology has gotten so large and far-flung that hardly any of us knows everyone else – a far cry from my first days here in Ed McGuire’s Section of Urology.  With clinical and research activities of our department in at least 15 geographic locations, the challenges of communication and cultural identity are great. Families, organizations, and nations tend to grow far from their roots, straining integrity of the whole. Periodic gatherings can be forms of thanksgivings to recall roots and purpose, restore connectivity, and celebrate diversity. We hope and expect to gather again. 

 

Two.

Origins. With December here, a new year just around the corner, and the second century of urology at UM ahead, thoughts turn to the origin stories that ground our views of the world. Personal origin stories as well as organizational ones are idiosyncratic and complex – and all are rich in certainty, invention, and selective memories. The UM urology narrative, is assembling on our website. [Above: Cropsey painting of early UMMS.]

https://medicine.umich.edu/dept/urology/about-us/our-history/origin-story

Origins are never perfectly clear. The past can never be fully ascertained or known as completely as it actually happened. It can, however, be illuminated and investigated not merely out of curiosity but also to understand options for today, reinforce essential values, and prepare for the future. Our origin stories are lean in the details of the original peoples of the Americas who were displaced by explorers and colonists. Examination of origins forces us to see what’s missing, what’s right, and what’s wrong, thus giving opportunity to improve what’s lacking and what’s incorrect with ourselves and our organizations.  

Historians elicit facts, create narratives of the past, and measure it all according to values then and now so as to understand the meanings of those stories. This expansive evaluation is, at first glance, contrary to that of scientists who generally take reductionist approaches that render observations to the simplest explanations. Through methodological analysis   scientists may hope to find grander truths in general rules, laws, and theories. Health care providers, ideally, combine the story of a patient (the larger narrative of their past and present) with the facts of observation and clinical investigation.

 

Three.

Urology is a small detail in history’s medical narrative and its roots at the University of Michigan are uncertain. [Above: medieval uroscopy – man with a matula.] We have no practice logs from UM’s first genitourinary surgeons, Cyrenus Darling and Ira Loree, nor reminiscences to know what they thought of the 1902 “urology” neologism, although they chose not to adopt it. Their recollections of WWI and the Influenza Pandemic can be assumed unpleasant, but how those large events affected their daily lives, families and friends, and political responses can only be vaguely imagined. Who in their time would have thought that the “war-to-end-all-wars” would be followed so quickly by another one and who knew that the 1917 pandemic would end after a third wave in 1920? Who could have doubted that other pandemics wouldn’t follow? Most astonishingly who would dispute, today a century later, that face masks, social distancing, and rudimentary hygiene limit the spread of respiratory infections? 

The thoughts of Darling and Loree concerning their replacement in 1919 by  “Modern Urologist” Hugh Cabot were not positive and those impressions were exacerbated by his brusque manner, causing their swift departure to the welcoming St. Joseph Mercy Hospital a block away. From this disruptive transition, the UM Section of Urology was born.

No less disruptively ten years later Hugh Cabot, Medical School dean by then, was fired by the regents after losing confidence of the faculty. Reed Nesbit, Cabot’s second trainee, built the Section of Urology from 1930 through 1967, when he retired to Sacramento. Then, after an uncertain six months, Nesbit’s trainee Jack Lapides, was named successor and continued the clinical, educational, and research missions of the Section of Urology from 1968 to 1983. Like Nesbit, Lapides trained a great cohort of urologists of all types, including a great string of pediatric urologists: Norm Hodgson (Nesbit 1958), Tomohiko Koyanagi (N’70 – see Postscript), Ed Tank (N’71), Steve Koff (N’75), Evan Kass (N’76), and Barry Kogan (N’81). Still under the administrative management of the Surgery Department, UM Urology gained Ed McGuire (trained at Yale by Bernie Lytton) as Section Head.  This transition, too, caused disruption, with the loss of Ananias Diokno to the Beaumont system. 

The five-person Section of Urology under Ed McGuire (above) welcomed me and my family to Ann Arbor in the summer of 1984. The small section of five is now the large Department of Urology of 50 full-time faculty led by Ganesh Palapattu. Our academic space, initially on the fifth floor bridge between the old Mott and old Main University Hospital, moved to the second floor Taubman Building when it opened in 1986, and then the third floor of Taubman in Jim Montie’s early years as Urology Chief. That space underwent a well-needed facelift this autumn. Although this is the administrative hub of the department, our faculty have offices in the Cancer Center, North Ingalls Building (the old St. Joes Hospital), North Campus Research Complex (our Dow Division of Health Services Research in the old Pfizer Research campus), Muskegon’s West Shore Urology, and clinical and surgical activities at more than a dozen other sites.

 

[Above: Taubman Administrative Urology. Sept. 15, 2020. Below: September 30, 2020.]

The challenges of this Covid year are not over, as we yearn for a return to social proximity and in-person conferences. The postponement of the yearly Nesbit Alumni Meeting, along with other regular medical and scientific sessions was disappointing, but not unprecedented. The AUA, for example, also cancelled this year as well as in 1918, 1919, 1943, and 1945.

Academic routines are changing into new normals, such as our zoom visiting professor lecture in mid-November from Jim Hu at Cornell, shown below in one of his slides. Still, we miss our conference rooms.

 

Four.  

Narratives. The writing process for the UM urology story has strengthened my admiration of others far better at that art. My career, not primarily one of writing, was directed to what Hippocrates narrowly considered “the art of lithotomy,” but grew into its surgical cousins of orchidopexy, hypospadias repair, pyeloplasty, bladder reconstruction, and other needs of modern urology.  Turning facts into authentic narratives is a different occupation and certain writers stand out: John McPhee and E.O. Wilson for nonfiction, or Kazuo Ishiguro and David Mitchell for fictional story-telling. McPhee at age 89 continues to weave artful narratives of fact and people, while Wilson at 91 explains science with clarity and grace. Mitchell at 51 creates tapestries of fact and imagination, crossing fictional genres. Nobelist Ishiguro, at 65, writes novels that explore the uncertainty of memory and its deceptions. The authenticity of great fiction is a mirror to reality; as the Good Lord Bird miniseries proclaims: “All of this is true, most of it happened.” 

Our parochial story, The First Century of Urology at UM, is an accounting of real people and events that built a small specialty in a great public university amidst the contexts of its times, providing and creating state-of-the-art clinical care (such as it was), generating new ideas, educating successors, and leading colleagues.

We were fairly certain of the sequence of Nesbit’s early trainees and associates in our Origin Story of Urology at UM, but new information kept popping up. For example, Susan Dorr Goold, daughter of our recently deceased colleague Dick Dorr (Nesbit 1968), gave me pictures from her dad’s office but the identity of one drew a blank. Skip Campbell and Mac Whitehouse identified the photo as Rigdon “Rod” Ratliff, (Transylvania College A.B. 1924, UMMS 1929) who practiced urology at St. Joe’s. In medical school Ratliff became interested in surgery and urology under Cabot and Coller, and was likely influenced by Huggins and Nesbit – trainees and later junior staff under Cabot. With his MD in hand, Ratliff went across the street for internship at St. Joe’s and fell under the influence of Ira D. Loree, the UM genitourinary surgeon displaced nearly a decade earlier by Cabot. The cataclysmic stock market crash a few months into internship undoubtedly shaped Ratliff’s career plans and he remained at St. Joe’s in practice with Loree, the early years serving as a de facto residency in urology.  

By 1935 Ratliff was considered a legitimate urologist and Nesbit appointed him “Instructor in Urology” without salary. Loree died on August 11, 1936 and Ratliff took over his practice, revising his UM title in 1938 to “Part-time Instructor,” allowing more time for St. Joe’s practice. Ratliff maintained this title until 1946. Curiously, Ratliff didn’t join the AUA until 1946, his application endorsed by Nesbit and Robert Breakey, a Lansing urologist.  Ratliff continued to teach students and interns, and one of them, Tom Newman (Nesbit alumnus 1974 – now retired in Tucson), recalls Ratliff teaching him the “Water sink window test.”

Ratliff (above) collected urine samples in clear specimen bottles (modern matulas) before cystoscopy, holding them up to the window by the sink in the cystoscopy suite and if clear to daylight he poured the urine into the sink and completed the cystoscopy. Only if turbid, would he send the specimen for urinalysis, culture, and sensitivity.  At University Hospital, however, Newman discovered a very different approach; Lapides insisted on routinely spinning the urine and staining it with methylene blue before examination under the microscope and then dipstick urinalysis, with culture and sensitivity, if necessary. One approach was practical and cost effective, the other was richly academic. Newman fondly recalls Rigdon as a quiet gentleman. Clearly, Dick Dorr shared that admiration. Ratliff retired in December, 1973, according to the AUA files (found for us by Tupper Stevens) transitioning his AUA status from active member at $75 per year to senior member at $15. At home on 231 Corrie Road in Barton Hills, Ratliff died of a heart attack January 29, 1977. He was the last link between Hugh Cabot’s era and ours. 

 

Five.

The uncertainty of history. This turbulent political season, a friend referred me to the recent book, American Dialogue, by American historian, Joseph Ellis, who explained a central irony in his field.

“There is an inconvenient truth that most historians acknowledge under their breath, admitting that objectivity, in the sense that mathematicians or physicists, use the term, is not a realistic goal for historians. The best they can strive for is some measure of detachment, which serves the useful purpose of stigmatizing the most flagrant forms of ideological prejudice (i.e. cherry-picking the evidence to claim that Thomas Jefferson was an ideological Christian or Andrew Jackson was a New Deal Democrat). But as you believe that the study of history is an ongoing conversation between past and present, detachment itself is delusional. In his Style in History (1974) Peter Gay put the point succinctly: ‘History is always unfinished in the sense that the future always uses the past in new ways.’ In fact, the past is not history, but a much vaster region of the dead, gone, unknowable or forgotten. History is what we choose to remember, and we have no alternative but to do our choosing now.”  [Ellis, American Dialogue, 1918. p. 7.] 

Certitude, whether moral, intellectual, or political, is a tricky matter as reflected in this column last month when we tried to make a case for an enlightened Certainty 2.0 that allows one to retain some degree of uncertainty to allow for “I’m not so sure” and keep asking questions. Perhaps H.L. Mencken overstated the matter when he claimed that moral certainty should occupy a low rung in the ladder of human intellect, but he had a fair point.  

The moral certitude of John Brown, in song, epic poem, or current Showtime series, The Good Lord Bird, epitomizes the smugness of Certainty 1.0.  Timothy McVeigh’s ideological certainty terrorized Oklahoma City in 1995, striking against the Federal government by bombing a federal building, killing 168 people and injuring more than 680 others. Similarly, Ted Kaczynski (UM Mathematics Ph.D. 1967), certain that industrial-technological society was subjugating mankind and destroying the planet, responded by sending bombs to university faculty and airlines in 1978, to “get back at the system.” He wreaked havoc on the lives of random people who represented modern society or happened to be in the way of the bomb.  This campaign precipitated a long FBI investigation that ended with arrest in 1996 (see Wikipedia). Religious certitude (perhaps a form of ideological certainty) fueled the destruction of the World Trade Center on September 11, 2001. 

Self-serving certitude, another broad form of certainty, is that of psychopaths who justify their actions by personal convenience, often framed by occupation or paycheck, as mentioned here last month, with attribution to H.L. Mencken, Lewis Sinclair, C.E. M. Joad, and others: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Closely related is political certitude, as in recent seasons has tested the flexibility of the American Experiment.

Immaculate Misconceptions, the title of a section of the Law chapter in Ellis’s book  includes two extraordinary quotes relevant to certitude and to stimulate your uncertainty as a reader we defer their sources to the postscript.

Source A. “When a case comes to me, I don’t do whatever I feel like doing, I have a standard. That standard is what would the people at the time the Constitution was enacted have said.”   

Source B. “Some men look at constitutions with sanctimonious reverence, and deem them, like the ark of the covenant, too sacred to be touched. … We might as well require a man to wear still the coat which fitted him when a boy, as civilized society to remain under the regimen of their barbarous ancestors.”  

These ideas relate to the question of the role of originalism or textualism in law. Adjudication of today’s uncertainties according to the exact words of a set of historic bylaws might be considered a cop-out, relieving decision-makers of consideration of contemporary complexities and values. One expects that was not Scalia’s intent in his heart of hearts, but rather his starting point to consideration of legal questions. We surely hope our judges and wise leaders struggle intellectually with uncertainty to arrive at a Certainty 2.0 in their consequential decisions.  

 

Postscript.

Sources. A. Antonin Scalia, speech at the University of Fribourg, March 8, 2008.  B. Thomas Jefferson to Simon Kercheval, July 12, 1816.  [J. Ellis, American Dialogue, The Founders and Us. Vintage Press, NY, 2018. p. 151.]

The Good Lord Bird, is a 2014 book by James McBride on John Brown and its Showtime dramatic series offers an ironic introductory quote, “All of this is true, most of it happened.” This complements Don Coffey’s enduring admonition to his research students to try to understand the difference between facts and true facts, reminding how certainty is tenuous but some things are deeply true to us.

Congratulations. The Japanese Government recently awarded Tomohiko Koyanagi The Order of the Sacred Treasure, Gold Rays with Neck Ribbon in recognition of outstanding contributions to medical education and research. https://en.wikipedia.org/wiki/Order_of_the_Sacred_Treasure

[Above: Tom Koyanagi. Below: Order of Sacred Treasure.]

Thanks for reading Matula Thoughts this December, 2020.

David A. Bloom, University of Michigan Department of Urology

 

Autumn leaves and certitude

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Matula Thoughts 6 November 2020
4129 words



One.

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

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

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

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

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


Two.

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

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

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

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

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

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

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

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

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


Three.

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




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

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

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

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

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


Four.

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

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

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


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

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

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

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

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

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

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

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

Five.

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

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

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

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

Postscript.

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

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

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

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

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

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

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

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

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

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


Additional Postscripts.

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

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

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

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

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

Seasons change

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WN/MT September 4, 2020
Truths & mousetraps.
2450 words



One.

This September feels different. It’s no longer just a matter of seasonal daylight contraction, but also a fact of social shrinkage and much more. Summer 2020 was unlike any before and academics this autumn, from pre-school through medical school, will also be totally different. Innovation is in demand to navigate the crises in business, education, medical practice, public policy, sports, and much of everything else in daily life. The good news is that humans are good at creating new and better mousetraps, although not so good at escaping the mental mousetraps of their own follies. [Above: September ground litter, Scio Township 2018.]



Hunkering down in the first weeks of this 2020 Covid pandemic, I reread Howard Markel’s book, When Germs Travel: Six Major Epidemics That Have Invaded America and the Fears They Have Unleashed. Written in 2004 it holds up very well now, 16 years later, offering pandemic perspective. Howard, shown above, has frequent pieces on Public Broadcasting Service (PBS), maintains the 1918 Influenza Epidemic Encyclopedia in a UM Digital Archive (chm.med.umich.edu), has a recent Medical Dispatch in the on-line New Yorker Newsletter (August 6, 2020), and a new book on genetics, called Helix, in the works.

Lessons learned from past infectious disasters tend to be forgotten. Face-masks, hygienic measures, social distancing, and validated vaccines unquestionably mitigate transmission and acquisition of germs – medical scientists and the informed public know this much is true, but why doesn’t everyone else?

Weaponization of those protections, particularly the ridiculously easy solutions of face masks and social distancing, as political gestures is sadly bizarre. Whether it’s a matter of ludditism, partisan ideology, or mere ignorance will be sorted out by future social critics. As a person who wore face masks in operating rooms for nearly 50 years – alongside uncounted colleagues, nurses, and scrub techs – the claims of “medical reasons” why some people “can’t wear a mask” are incredulous – as unconvincing as claims of pet snakes or birds as “medically-necessary” travel companions on airplanes. The parallel contention that the duty to wear masks violates personal freedom is certainly a far cry from anything reasonably derived from common sense or the American Constitution. It’s not surprising that similar skirmishes sprung up with the Great Influenza epidemic in 1918, when education and science had not quite universally settled the germ theory in minds, but it is astonishing to find such shenanigans a full century later. [Below: mask-wearers at University Hospitals, senior medical student Annie Minns and professors Cosmas Van De Ven and David Spahlinger – social distancing briefly waived for the photo op, Aug. 2020.]


Two.

Basic truths. Mousetraps for infectious diseases have come and gone, but routine hygiene and simple impediments to germ transmission (face masks & distancing) seem to be basic truths.

Historical medical relics were facts once true for their times. The iron lung for the respiratory failure of polio was a “better mousetrap” in the 1930s through the 1950s. The original iron lung used two vacuum cleaners to change pressure in an iron chamber, compressing and inflating chests and lungs of children lying within them. Philip Drinker (1894-1972), teacher of industrial illumination and ventilation at Harvard Medical School (alongside famed UMMS graduate Alice Hamilton), came up with a popular design, the “Drinker Lung.” Haven Emerson (1906-1997), son of NYC Health Commissioner, improved the device by placing the patient in a bellows within the chamber. Emerson’s Iron Lung was quieter, lighter and only $1,000, half the price of others. It remained in production until 1970, when polio largely had disappeared from much of the planet due to vaccination. Coincidentally this is a good opportunity to refer to Markel again. [H. Markel. “The genesis of the iron lung,” Arch Pediatr Adolesc Med, 1994; 148 (11): 1174-1180.]

Polio outbreaks were dreaded in the summer. As a child, I noticed post-polio limps in many people and heard about iron lungs, seemingly ubiquitous in every hospital. The July newsletter, Matula Thoughts, referred to our friend and colleague Skip Campbell who was hospitalized at “old” University Hospital as a youngster to treat his polio. That was just around the time polio began to disappear when field trails of Salk’s vaccine, directed from UM by Thomas Francis, proved it “safe, effective, and potent” in 1955. The Sabin vaccine soon proved better. Oddly, U.S. authorities supported only the Salk clinical trial, and Sabin had to prove his vaccine in field trials in the Soviet Union. This was no small feat in the political theater and Cold War of the 1950s, but Sabin, against the grain, organized the trials and the world ran to his better vaccine. Even now, however, global polio eradication is incomplete. [L. Roberts, Science, 367:14, 2020.]

Situational necessity, inspiration, and competition fuel better medical mousetraps, but innovations happen best in open societies. Iron lungs were useful in their times but gave way to better innovations. Modern respiratory physiology knowledge and more sophisticated ventilatory technology sprang from other responses to polio. [J. West. “The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology,” J. Appl Physiol (2005); 99:424-432.] So once again, let’s celebrate democracy and free speech: innovation -with its validation, dissemination, and improvement – thrive best in the fertile social soil of personal freedom and open expression.


Three.

Mousetraps.  “If you build a better mousetrap the world will beat a path to your door.” Such is the power of “the market” at large, whether the market is commercial or intellectual. Flat Earth maps may lead some mousetrap-seekers astray, but most people find their ways to better ideas and technologies. [Above: Conventional Victor Mousetraps at Barnes Ace Hardware two for $1.69 vs. Intruder’s Better Mousetrap two for $5.99.]

Ralph Waldo Emerson (above), the source of the phrase, actually wrote:

“If a man has good corn or wood, or boards, or pigs, to sell, or can make better chairs or knives, crucibles or church organs, than anybody else, you will find a broad hard-beaten road to his house though it be in the woods.”

Emerson knew something about paths in woods, not only living among them, but also hiring Henry David Thoreau as his property caretaker when the journalist of Walden Pond needed a paying job. A future tenuous connection between Emerson and Ann Arbor materialized after James Elliott Cabot (below), Emerson’s friend, executor, and biographer, fathered Hugh Cabot, who instigated the first century of Michigan Urology in 1919. “Elliott” Cabot (1821-1903, shown below), as he was known, was a brother of Dr. Samuel Cabot III and shares facial physiognomy with at least three of his sons: Michigan’s first urologist Hugh Cabot, twin brother Philip, and internist brother Richard Clark Cabot.



Four.

Medicine has had its share of mousetraps. Enduring diagnostic tools from antiquity  – the medical history, physical examination, rudimentary vital signs, and uroscopy (body fluid observation) – have been tested and refined in medical marketplaces over millennia. For urine inspection, pottery gave way to glass matulas, microscopes extended visual inspection into the microscopic world, chemical analysis opened up molecular composition of urine, and bacteriology led to identification of pathogens. Innovation similarly propelled stethoscopes (1816), x-rays (1896), electrocardiograms (1920s), CAT scans (1970s), and MRIs (in wide use after 2000) into the clinical marketplace. The technology of modern urology is too rich a topic for further mention here, except to take note of Nesbit’s transurethral resection of the prostate, Lapides’s clean intermittent catheterization, and McGuire’s leak point pressure.

Amidst high-tech mousetraps of today, the simple face mask used in ORs around the world is clearly effective against dust and infectious droplets (liquid dust). A recent JAMA article by Brooks, Butler, and Redfield, suggests we implement universal masking for all healthcare workers and patients in clinical situations, affording both personal protection and source control. Aerosol particles range from sub micrometers (0.0001) to a full ten micrometers (microns) in diameter. By the way, 1000 microns equals 1 millimeter. Even simple cloth face coverings substantially limit forward dispersion of exhaled respirations in the 1-10 microgram range. [JAMA 324:635, 2020.]   [Above: ORs & face masks in Mainz, Germany. Below: airborne particles, source – Wikipedia, Particles. Horizontal axis in micrometers, or microns.] 

A higher level of filtration than routine face masks, the N95 mask, was designed to meet the U.S. National Institute for Occupational Safety and Health (NIOSH) specification of filtering at least 95% of airborne particles. To be fully effective, it requires “fit-testing,” an annual ritual at Michigan Medicine along with the TB testing, that few knew would become so useful in these Covid times. [Below: N95 mask.]



Some people, mainly constitutional textualists and originalists, claim that governmental agencies such as NIOSH were not “intended” by the Founding Fathers, who could hardly have known about aerosols, viruses, or the Internet. Yet the Founders surely knew that knowledge, technology, and monetary systems were changing the world and would continue to do so – Franklin, Jefferson, and Hamilton most certainly among them. Enough Founders anticipated that American governmental regulation and American free enterprise would need to work in tandem to support the foundational principles of life, liberty, pursuit of happiness, and First Amendment protections. The NIOSH agency derives from any reasonable interpretation of the Declaration of Independence and the Constitution.

The global nature of human challenges, even for a matter so small as dust particles, is stunning. Airborne dust, solid or liquid, has no national boundaries. A NASA global simulation of aerosol transportation in the troposphere over 12 months beginning 17 August 2006, takes about two minutes to watch and will expunge any notions of national exceptionalism. This video clip shows that the recent African dust storm this year was no anomaly.
[Title: Atmospheric Aerosol Eddies and Flows – NASA GSFC S.ogv
Author: NASA. Date: 1 January 2008, 23:17:03]

On the other hand, the Covid component of respiratory aerosols is fortunately not very durable in time or distance. Infectivity seems to drop off after 6 feet or some number of hours. Otherwise, the above NASA animation would be very alarming in the face of this pandemic. Furthermore, the best evidence indicates that long-range transmission of small-particle aerosols (<5 micrometers) is not the dominant mode of Covid infection. Close-range respiratory droplets (large aerosol particles >5 micrometers) is the far more likely threat, easily thwarted by face masks and a little distance. [M. Klompas et al, JAMA, 324:441, 2020.] 


Five.

Thermometry, a mainstay in the armamentarium of medical mousetraps, is a hot topic these days. Curiously, the fact of “normal human temperature” is not clear and some authorities believe that “normal” has been dropping. One wonders if normal temperature for communities of Inuit people living near the Arctic Circle is the same as “normal” of equatorial people, or could normal in infants be the same as for octogenarians? We don’t treat pulse or blood pressure with the same strict exactitude for all people, so why is 98.6 degrees Fahrenheit held to such precision, even though we know it’s variability in health is narrower than other physiologic parameters? Epigenetic response to modern life (industrialization, central heating, air conditioning, air pollution, global warming, etc.) surely influences the “normal” core human temperatures. Time of day, season, and age must matter as well. The site, method, and precision of measurement also effect any number obtained.

The “normal” of 98.6 degrees Fahrenheit traces back to Carl Wunderlich (1815-1877), a German physician who questioned things (above, per Wikipedia). In 1868 he proposed 37 degrees Celsius as normal after studies using a foot-long thermometer, requiring upwards of 20 minutes to register the temperature. Surgeons may recall the term Wunderlich Syndrome, a nontraumatic surgical emergency of spontaneous retroperitoneal hemorrhage that may be caused by renal neoplasms. Mackowiak, Wasserman, and Levine in 1992, updated Wunderlich’s number. [JAMA 268:1578-80, 1992]. Newer studies suggest that “normal” human temperature has dropped by 0.59 degrees centigrade for men and 0.32 degrees centigrade for women. Urologists and zoologists know that core body temperature is a few degrees too warm for optimal testicular function in man, along with many other species, hence the “social distancing” of their placement. Evolutionary biologists may want to take note that as core body temperatures decrease, there may be no thermal reason for human testes to descend, which may severely limit the market for pediatric urologists. Kangaroos, and other creatures too, may have to adjust their testicular placement to accommodate themselves to a warmer planet (their bifid penile anatomy, caudal to the gonads, is stranger still.) [Below, Wikimedia, photographer and kangaroo unknown.]

Crises test all creatures, from viruses to humankind, forcing epigenetic changes that allow adaptation and evolution not only of individuals, but also their societies. Homo sapiens has taken this force of nature to unprecedented levels, but just as every new era brings out innovation, each challenge uncovers new generations of Flat Earthers who retreat to comforting beliefs, dogmas, and ideologies. In the arc of human progress, truth usually wins out and each crisis finds its own necessary technologies, although the arc of progress is not smooth, but often wobbly and intermittently retrograde.


Postscripts.

Summer reading. Caste, The Origins of Our Discontents by Isabel Wilkerson is a timely book. The title riffs on the first two lines and pun of Shakespeare’s 1593 play, Richard III: “Now is the winter of our discontent/Made glorious summer by this sun of York.” John Steinbeck echoed this in 1961 in the title of his final novel. Coincidentally, my summer reading also included the historical novel, Hamnet by Maggie O’Farrell, that imagined the lost life of Shakespeare’s only son (1585-1596). [Below: Title page First Quatro, Richard III.]



Caste (above) considers social and political power, but Wilkerson begins the book with “The afterlife of pathogens,” an astonishing coincidence with today’s pandemic news and world-wide political discontents. This first chapter describes a heat wave in the summer of 2016 that thawed Siberian permafrost and liberated anthrax spores from long-dead reindeer, thus causing a new epidemic in living reindeer and their indigenous herders, the Nedet people. Wilkerson then links that pathogen awakening to current political awakenings around the world.

“The anthrax, like the reactivation of the human pathogens of hatred and tribalism in this evolving century, had never died. It lay in wait, sleeping, until extreme circumstances brought it to the surface and back to life.”


Coincidences. G.K. Chesterton (1874-1936), English writer and author of the Father Brown priest-detective books, called coincidences spiritual puns. A less spiritual person than Chesterton might call coincidences cosmic puns or stochastic puns, but the idea is the same: unrelated but concurrent events or facts may seem to have been “divinely ordered” or happen “by the luck of the draw.” Chesterton’s actual quote comes from his book, Irish Impressions, in 1919, a year that coincides with the start of the first century of urology at the University of Michigan:

 “All literary style, especially national style, is made up of such coincidences; which are a spiritual sort of puns. That is why style is untranslatable; because it is possible to render the meaning, but not the double meaning.”

Considering this first half of 2020, random chance is due to favor better luck in pathogens.

Thanks for reading Matula Thoughts this Labor Day, 2020.
Best wishes,
David A. Bloom

Folly & truths

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WN/WN/MT Aug 2020

Folly & Truths

2472 words

One.

The Cure of Folly. Overwhelmed by insanity, the world might be a better place if we had a surgical cure for madness, but alas, surgeons can’t fix everything or everyone. Hieronymus Bosch (c. 1450 – 1516) imagined this scene around the time Christopher Columbus made his second voyage to Caribbean Islands and just before John Cabot was the first known European on the North American mainland – journeys that to “Flat Earther believers” seemed examples of pure folly. [Above: detail from The Cure of Folly, Museo del Prado, Madrid.]

Belief that removal of a “stone” in the head could cure “madness” was one of many unscientific ideas of humanity that spawned strong believers and industries. Such “stones” might have been actual subcutaneous nodules or more deeply-situated objects imagined in the brain. Factoids lurked behind fantasy, as so happens with many other follies. Bladder stones, for example, surely were real and caused grief. These unmitigated miseries could be relieved only by lithotomy, for patients lucky enough to survive the horrible experience of surgery without anesthesia, extensive blood loss, and likelihood of postoperative sepsis. No such evidence of relief exists for relief of mental illness by removal of scalp nodules or drilling into the skull by trepanation, beyond a placebo effect. Surgical cure for insanity, was an insanity itself, as Bosch’s painting attests, where he not only visually spoofed the bizarre idea of surgical cure of madness, but also implied a cure to the folly, in the operating theater of public opinion by means of the satirical title.

How does an individual gain confidence or belief in an idea, a skill, or a technology? The discernment of the utility of some thing or the truth of an idea is a critical function learned in childhood and honed throughout life. An open mind that is willing to learn and unconstrained by ideology helps this arbitration. A mind further trained by education and critical analysis improves the odds of giving fair measure to an idea, skill, or device. Humans have had countless ideas and inventions, but for any of these to persist in society they must be tested in commercial and intellectual marketplaces and reconciled to public belief and utility. An idea or technology sticks around when enough of the public – a quorum – becomes confident of its value and truth.

During a recent virtual pediatric urology meeting, in discussions over ideas of validity and truth, Julian Wan reminded us: “there are three types of arguments – the nature of relevant knowledge at hand; pragmatism; and sectarian belief.” As the tagline for The X-Files once promised: “The truth is out there,” although it’s not the same for everyone.

The large contest in play for H. sapiens today, is the ability of people to coalesce around some shared sense of basic truths that enable them to discern and choose between authoritarian societies versus representative democracies. This matter is especially intense now in this interconnected and fragile world where our technologies can distort truth and physically destroy the planet.

 

Two. 

Truth. Isabella Baumfree is a timely person to consider. Born into slavery in a small Dutch-speaking community in the Catskills around 1787, she grew up known as “Belle.” Although New York state began to abolish slavery in 1799, emancipation was not complete until July 4, 1827.  Belle “escaped” just before this, in 1826 with her infant daughter, but she preferred to say that she “walked off,” anticipating the emancipation. She had to leave three other children behind and two years later she went to court to recover her son, then five years-old and enslaved in Alabama. Remarkably, she won. In 1843 she renamed herself Sojourner Truth and became an abolitionist and women’s right’s activist. Her speech in 1851 at the Ohio Women’s Rights Convention in Akron “Ain’t I a woman?” established her celebrity and was reiterated widely throughout the years of the Civil War. Sojourner Truth moved to Battle Creek, Michigan, in 1857 and died at home in 1883.  [Picture above, National Portrait Gallery, c. 1870.]

Sojourn, of course, describes a temporary stay or condition and the extraordinary name Sojourner Truth, writ large, implies a traveler who experiences various postulations of truth in pursuit an ultimate best version of it, through their days and times. The conditionality of facts and truths is not just a matter for philosophers – it is the daily work of historians and scientists who seek to disprove established beliefs (and follies) with better facts and reasoning. Sojourner Truth’s name is a fitting metaphor for the conditionality of truth, whether ascertained by ideology and sectarian fiat or by observation and reasoning, and even once ascertained it is always amenable to further examination.

 

Three.

History and science are good antidotes to folly, provided that their logic trumps the  ideologies and beliefs that so often constrain people. Folly is the antithesis of good history and science. It is, by definition, foolish – lacking defining characteristics of our species: good sense, reason, prudence, and foresight. The rigor of history and science brings verifiable data and rational argument to old beliefs, in pursuit of the idea of truth. This pursuit depends upon free inquiry, free speech, peer review, criticism, and public education – all characteristics of open societies and the institutions sustain those societies. Ultimately, however, the cure of folly requires that people change their minds, based on data, analysis, and argument.

Governments, universities, industries, and all businesses, as they serve themselves, also serve the public interest and their integrity is tied to the public trust. Naturally, our expectation is that self-interest for industry and business is usually greater than their public service, but for governments and universities the public interest should dominate. Good science and good history (in the sense that “good” captures the idea of truth and reflects fundamental values of humanity) do not necessarily find nourishing soil in authoritarian societies, universities, corporations, or “top-down” organizations. In fact, authoritarian government has never worked well for people, history, or science. [Above: The Alchemist, Mattheus van Helmont.]

Society’s instruments, namely its governments, universities, and businesses, too often maintain stubborn illiteracy of history and science. These organizations ignore some truths that are becoming very clear with massively-accruing evidence of basic facts: infectious diseases recur in catastrophic waves, people need basic securities, and human environmental impact is deleterious to a human future. One wonders, then, what are the actual purposes, the main value, of those institutions (governments, universities, businesses, the press, etc.) to “we, the people?” Limiting the question just to government (recognizing that a huge body of scholarly work, beyond capacity of this writer and essay, continues to study this question). The Declaration of Independence, states it simply:

“… in order to form a more perfect union” so as to protect the basic human aspirations for “life, liberty, and the pursuit of happiness.”

Government facilitates these aspirations most fundamentally through basic securities of public safety, public education, assurance of jobs and justice, as well as public and personal health. Security of food and shelter are no less important, as this Covid epidemic is showing. These are the needs of “We, the people.”

 

Four.

New medical students just joined us in Ann Arbor, although the absence of our usual White Coat Ceremony at Hill Auditorium deprived us of the chance to see them on stage, hear their introductions, and give them short white coats, stethoscopes, and MCAS pins. Cliff Craig recently sent Matula Thoughts a note recalling his precise moment of entry in 1969, before the White Coat Ceremony was introduced to our medical school. Cliff and his fellow students assembled to hear the dean, without any family members, children, or friends on hand to offer support and cheers, as would come with the White Coat event years later. [Below: Cliff c. 2019.]

“It was 1965, the first day for the University of Michigan Medical School class of 1969. We saw no white coats, nor short ones either. Dean Hubbard said (paraphrased): ‘You are all worried about failing out, I am not worried about that. I am worried that some of you will be bad doctors, and I wish I knew who you were, I’d kick you out right now.’ That was immediately followed by our first class; – so much for class ‘bonding.’

One year later, in 1966, on the first day of our second year, we were all advised to show up with a short white coat which could be purchased at Ulrich’s (along with the books we needed for the second year). It was a year punctuated by many demonstrations and sit-ins on campus against the Viet Nam war (Tom Hayden etc.). Dean Hubbard then addressed us again (paraphrased): ‘I want you to remember when you wear your white coat, you represent not only yourself but this medical school, the medical profession, but most importantly you represent me! If you want to participate in any of the activities on central campus, take off the white coat.’

I met Dean Hubbard at commencement in the early 2000s, and reiterated what he told us on those occasions. His response: ‘Did I really say that?'”

Time passed and now Cliff is professor at UMMS, specializing in the pediatric orthopedics. He keeps in touch regularly with several classmates including otolaryngologist Mike Johns, who served UM brilliantly as interim EVPMA after being Dean of the Medical School at Johns Hopkins and then Chancellor of Emory University. Rick Rapport, another classmate, is a retired neurosurgeon in Seattle.

 

Five.

William Hubbard was the first “full time” dean at UMMS, in the sense of having no conflicting duties such as departmental chair (like Cabot) or clinical practice (like Furstenberg). Hubbard served from 1959 through 1970, resigning to become a senior vice president at the Upjohn Pharmaceutical Company in Kalamazoo. Just the year before, the regents had given him responsibility as dean to also manage the hospitals of the growing medical center.

One evening in March, 2006, after usual work hours, voices were heard in the otherwise quiet hall outside the office of the Associate Dean for Faculty Affairs, who was curious to see who was wandering about in the administrative area of Dean Allen Lichter. This led to the good fortune of meeting former Dean William Hubbard who had come by to view his portrait. Fortunately, a camera was nearby to capture Dr. Hubbard and his painting from more than 30 years earlier. Fashions change and our deans’ portraits are now in storage. It was fortunate to have been hanging when history was still on display when Dr. Hubbard strolled by and he seemed pleased to reflect back on his time at Michigan. It is too late to ask Hubbard to recall his memories of Nesbit and Lapides, or to get his recollections on the issues of his years as dean, but we can hear Dr. Hubbard through his former students, Drs. Craig, Johns, Rapport, and other classmates who have turned out pretty well. Their origin stories certainly place strong emphasis on the roles of the University of Michigan Medical School, deans like Hubbard, and many of the Medical School teachers who helped form generations of leaders and best.

 

Postscript.

Clair Cox was one of the leaders and best to have come from the University of Michigan Medical School. As a resident in the 1970s at UCLA, reading the urology literature, I became familiar with the name Clair Edward Cox, II, who published interesting and good papers from Bowman Gray School of Medicine (now Wake Forest Medical School) and later the University of Tennessee in Memphis. Little did I know we would become friends during my time in Ann Arbor, where the University of Michigan connected us. I’m sad to report that Clair passed away a few weeks ago.

Clair was born on September 3, 1933 in St. Francisville, IL, and grew up in Mt. Pleasant, MI, excelling in studies and sports. With a Regents Alumni Scholarship, he completed three years of undergraduate studies at the University of Michigan and then entered the Medical School. In his sophomore year, he met junior nursing student Clarice Adele Wicks and they married in 1958 when Clair graduated with an M.D. His Medical School Class of 1958 was a remarkable group in a remarkable time, entering postgraduate medical education in the new era of specialty practice, massive research funding, and a high point of academic medicine. At Michigan, this was at the end of Furstenberg’s long tenure as dean, from 1935 to 1959, when the dean practiced medicine at nearly a fulltime clip whilst tending to the medical school administration. Frederick Coller retired as chief of surgery in Clair’s graduating year and Reed Nesbit, head of urology, was nearing the peak of his career having brought Transurethral Resection of the Prostate (TURP) to the mainstream of international urologic practice. Both men inspired Clair as a medical student and Nesbit, particularly, became a resource as Clair ascended the hierarchy of academic urology.

Clair and Clarice moved to Denver for surgical training at the University of Colorado, anticipating a path to thoracic surgery, but urology gained the upper hand in his interest and the couple continued west to San Francisco for urology training that he completed in 1963 at the University of California. The couple returned east across the country to Winston-Salem, NC for an academic urology position at Bowman Gray where Clair advanced through the ranks to professor. In 1972 Clair was recruited to lead urology in Memphis at the University of Tennessee and held the chair position for 27 years until he stepped down, having trained 90 residents. He continued to work for another 10 years until retiring in 2009.

Dr. and Mrs. Cox raised four boys who would give them 12 grandchildren. In retirement Clair enjoyed his family, their home, and the family ranch in Hernando, Mississippi. His last academic paper, a historical investigation, entwined the stories of a fellow Memphis urologist (Thomas Moore), Graceland, Elvis Presley, and the American Urological Association. Michigan Football frequently brought Clair, Clarice, and occasionally a son and grandson back to Ann Arbor. Of Clair’s multiple university affiliations, the Michigan connection was the strongest, as evident to visitors to the lovely Cox home on Sweetbriar Cove in Memphis where maize and blue colors and UM symbols flourished. The Nesbit Alumni Society includes UM Medical School graduates along with the UM trainees who became urologists and Clair was pleased to be a member, after all Nesbit was his first teacher of urology. Clair once said that while he enjoyed working in five excellent medical centers, it was the University of Michigan that was always closest to his heart and running through his veins. Just as he felt the University of Michigan distinguished him as a citizen and a urologist, he distinguished the University of Michigan as an exceptional alumnus, educator, clinician, and scholar.

Clair Edward Cox, II, died peacefully at home on July 9, 2020. [Above, Dr. Cox on his ranch in Hernando, 2017.]

 

Thanks for reading Matula Thoughts, this first Friday of August 2020.

David A. Bloom

University of Michigan Department of Urology

 

Origin stories

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WN/MT July 3, 2020
Origin stories
2518 words



One.

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

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

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

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


Two.

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

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

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

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



Three.

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

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

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

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


Four.

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

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

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

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



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

Polio testing children, May, 1954.


Five.

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

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

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

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

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


Postscripts.

Another Shimomura. 

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

 

Ed Tank reminiscences.

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

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


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

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

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