Be Worthy to Serve the Suffering” ��

“Be Worthy to Serve the Suffering”

Ofﬁcers and Directors at Large Editorial Board Medical Organization Director Councilor Directors Coordinator, Residency Initiatives Student Directors

Editorial Standing on the shoulders of giants

Richard L. Byyny, MD, editor

am proud and honored to be serving as the Executive The Pharos continues as an excellent exponent of the aims and Director of Alpha Omega Alpha Honor Medical Society and purposes of our society and showcases AΩA and the values of EditorI of The Pharos. the profession of medicine. Our society, AΩA, is the national honor medical society for AΩA’s motto is: “Be worthy to serve the suffering.” Our mis- medical students, physicians in postgraduate training, medi- sion statement says: “Alpha Omega Alpha—dedicated to the cal faculty, practicing clinicians, and scientists. Alpha Omega belief that in the profession of medicine we will improve care Alpha is to medicine what Phi Beta Kappa is to letters and the for all patients by: recognizing high educational achievement; humanities and Sigma Xi is to science and engineering. Our honoring gifted teaching; encouraging the development of aims are the promotion of scholarship and research in medical leaders in academia and the community; supporting the ideals schools, the encouragement of a high standard of character of humanism; and promoting service to others.” and conduct among medical students and graduates, and the Up to one-sixth of a medical school class may be nominated recognition of significant contributions in medical science, for membership. Scholarly achievement is the primary but not practice, and related fields. AΩA membership is the best- the sole basis for nomination of a student. Leadership capa- recognized medical school award for achievement in medicine. bilities, ethical standards, fairness in dealing with colleagues, Since most members are elected in medical school and before demonstrated professionalism, potential for achievement in medical specialization, the membership is interdisciplinary and medicine, and a record of service to the school and community represents all fields of medicine. AΩA recognizes and advo- are additional important criteria. cates for excellence in scholarship and the highest ideals in the There are now  AΩA chapters in medical schools and profession of medicine. there have been more than , members since the found- Our society represents more than a hundred years of hard ing of AΩA. As one example of AΩA members continuing to work, perseverance, and high ideals. My predecessors in AΩA demonstrate leadership in our profession, nearly seventy-five were an outstanding group of dedicated physicians who suc- percent of deans of medical schools are members of AΩA. cessfully led and continuously improved AΩA and our lasting Fifty-one Nobel Prize winners in Physiology or Medicine, and mission. William Root and a small group of medical students in Chemistry are members of AΩA. Thirty were elected before started AΩA in  at the College of Physicians and Surgeons they received the Nobel prize. Eleven U.S. Surgeons General of Chicago. At that time, the practice of medicine relied on have been AΩA members. unproven traditions and mostly empirical practices. Medical Chapters are led by councilors and supported by the deans, education was poorly structured and medical students were AΩA faculty, and student members. Councilors manage the poorly prepared academically. Most faculty were unqualified nomination and election process of new members. In addi- to teach a scientifically oriented medical curriculum. Many tion to the nomination of students, chapters also nominate physicians, faculty, and students questioned the value of re- faculty, residents, and alumni who fulfill AΩA qualifications. search in contributing positively to the practice of medicine. Honorary members, from among distinguished physicians and Root started AΩA because of students’ lack of interest in scientists ineligible for nomination by any other means, may scholarly attainment and their lack of high professional values. be nominated by any member. The Councilors also submit Membership in the society was based on scholarly achieve- programs and candidates for AΩA awards and honors. AΩA ment and appropriate professional demeanor and values. After provides more than half a million dollars per year to sup- AΩA’s charter was granted by the state of Illinois in , the port AΩA programs and awards. These include the Robert J. group then provided leadership regionally and nationally to es- Glaser Distinguished Teacher Awards; the Edward D. Harris tablish other new AΩA chapters. Root continued to lead AΩA Professionalism awards; the Carolyn L. Kuckein Student for thirty years. Subsequent leaders, referred to as Secretary- Research Fellowships; AΩA Visiting Professorships; the AΩA Treasurer, included Dr. Winfield Scott Hall, Dr. Russell Burton- Medical Student Service Awards; the Helen H. Glaser Student Opitz, Dr. John Heffron, Dr. Walter Bierring, and Dr. James Essay Awards; the Pharos Poetry Competition awards; and the Campbell. The title was later changed to Executive Secretary AΩA Volunteer Clinical Faculty Awards. and Dr. Robert J. Glaser, one of my mentors, served for thirty- I thank the Board of Directors and members of AΩA for the four years, followed by Dr. Edward (Ted) Harris, who served opportunity to serve as the new Executive Director of Alpha for fourteen years until his death last May. Many other Omega Alpha. I am committed to providing leadership, sup- distinguished AΩA members have provided important port, service, and advocacy for AΩA and I will work diligently leadership and service to AΩA over the last  years. and thoughtfully in my service to you. I will strive to maintain The Pharos, AΩA’s journal, was founded by the excellence of The Pharos and hope excellent thinkers and Dr. Bierring in  and is named for one of writers will submit their work for consideration. the seven wonders of the ancient world, the To use a metaphor, I am fortunate to be standing on the Pharos lighthouse of Alexandria, whose shoulders of giants. beacon symbolizes the search for truth. To reiterate: “Be worthy to serve the suffering.”

The Pharos/Spring 2011 1

DEPARTMENTS ARTICLES

Editorial In anticipation of the germ theory 1 Standing on the shoulders of giants of disease Richard L. Byyny, MD, editor Middleton Goldsmith and the history of bromine Health policy David E. McMahon, MD, and Gregory W. Rutecki, MD 40 Will the new generation of physicians promote health care reform? Arnold Relman, MD Oswald Avery and the pneumococcus The physician at the Irving Kushner, MD, and David Samols, PhD 42 movies Peter E. Dans, MD The Social Network Secretariat Community-acquired pneumonia The tyrany of a term Reviews and reflections Bennett Lorber, MD, and Thomas Fekete, MD 49 Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform Reviewed by Jack Coulehan, MD La Clinica: A Doctor’s Journey Defeat, poised in stone Across Borders Anatomical dissection and the indignity of Reviewed by Robert H. Moser, MD Smugglerius Stabbed in the Back: Confronting Back Pain in an Overtreated Trahern Jones Society Reviewed by Paul Levin, MD 53 Letters

On the cover Former AΩA leaders Drs. Root, “Be Worthy to Serve the Suffering” Hall, Burton-Opitz, Heffron, Bierring, Campbell, Glaser, and Harris.

Cover illustration by Marvin Plummer

AΩA NEWS

The poison in the cup Alpha Omega Alpha elects Horton A. Johnson, MD 38 honorary members National and chapter news 55 Minutes of the 2010 meeting of A modern epidemic in a historic city the board of directors of Alpha Tackling diabetes in Old Dehli Omega Alpha Syed Saad Mahmood, MD, MPH POETRY That which we carry with us Dyspnea Ibiayi Dagogo-Jack 13 Jordan Grumet, MD Cheated 25 Aysha Malik

Agha 37 Akas Siddiqui

Pericarditis 48 Chris Marett, MD

Umbilicus 54 Jennifer Stella

I Became a Doctor

56 Michael R. Milano, MD

INSIDE Nomenclature BACK 40COVER Jana Lichtenfeld

BACK COVERXX Medical Excellence Without Question Ralph Crawshaw, MD

Hemlock plant, Conium maculatum. Sheila Terry/Photo Researchers, Inc. In anticipation of the germ theory of disease

4 The Pharos/Spring 2011 In anticipation of the germ theory of disease Middleton Goldsmith and the history of bromine

David E. McMahon, MD, and Gregory W. Rutecki, MD Dr. McMahon is clinical associate professor of Medicine While the clinical description—including rapid evolution, at the Boonschoft School of Medicine at Wright State fetid odor, and the dissolution of surrounding tissues—has University in Dayton, Ohio, and practices general internal remained consistent, the condition has been known under a medicine in Grove City, Ohio, for Pickaway Health Services. broad array of titles.3 One of them, “hospital gangrene,” was Dr. Rutecki (AΩA, University of Illinois, 1973) is professor coined by Joseph Jones and contemporary military physicians of Medicine in the Division of Nephrology and Hypertension at the time of the American Civil War.4 Even today, in spite of at the University of South Alabama in Mobile. He was AΩA the likelihood of early diagnosis, and with surgical interven- councilor at the Northeastern Ohio Universities chapter from tion and antibiotic therapy, necrotizing fasciitis can still be 1993 through 1996. a lethal disease. What is surprising is that at the time of the Civil War, substantial reduction in the mortality of hospital ince , a distinct group of soft tissue infections has gangrene was attributed to its treatment with liquid bromine, been categorized under the term “necrotizing fasciitis,” 1 a practice instituted by Dr. Middleton Goldsmith of Vermont.5 although Hippocrates called it “erysipelas”: This therapeutic invention preceded the germ theory of dis- S ease, and Dr. Goldsmith’s empirical observations about its In many cases erysipelas, from some obvious cause, such as efficacy were bolstered by the statistics he collected. an accident, and sometimes from even a very small wound, broke out all over the body . . . if such an accident was ne- Bromine, the wounded, and hospital gangrene at the glected in the slightest degree; . . . great inflammation took time of the Civil War place, and the erysipelas would quickly spread all over. In the Accounts by individuals who had experience with both most of them abscesses ended in suppurations, and there hospital gangrene and bromine testified of bromine’s thera- were great fallings off (sloughing) of the flesh, tendons, and peutic impact.6,7 An infectious complication of projectile bones.2p400 injuries, hospital gangrene exacted a horrible toll on wounded soldiers and spread rapidly through military hospitals.

Previous page, top photo: Streptococcal Gangrene or Necrotizing Fasciitis of the foot and ankle. ©Corbis. Below, Chlorine, Bromine, and Iodine elements, from Theodore Gray’s The Periodic Table of The Elements. ©2011

The Pharos/Spring 2011 5 In anticipation of the germ theory of disease

A slight flesh-wound began to show a gray edge of slough, . The wound must be thoroughly cleansed of all gangre- and within two hours we saw this widening at the rate of half nous slough . . . and the parts dried as perfectly as possible an inch an hour, and deepening, until in some horrible cases with tow. To do this effectually, the patient is first placed un- arteries and nerves were left bare across a devastated region. der the influence of anaesthetic. . . . Without first thoroughly . . . Instant removal to the open air of tents, etherization, clearing away the diffluent slough, bromine, powerful as it savage cautery with pure nitric acid or bromine, and dress- is, is unable to penetrate to the healthy tissues. To want of ings of powdered charcoal enabled us to deal with these this very necessary precaution I believe all the failures at- cases more or less well, but the mortality was hideous—at tributed to it are to be ascribed. least  per cent.8p7 . Having thus prepared the wound, pure bromine is applied by means of swabs of lint attached to the ends of small In this account by a physician in the Confederate Army, sticks . . . great care must be taken to touch every portion of note the similarities to Hippocrates’ description, which was gangrenous surface. The bromine, being extremely volatile, available in translation at the time of the Civil War: penetrates every sinus &c., which could not be reached by any of the other liquid or solid escharotics in use. The bed In some cases the progress of the disease is rapid and or operating table upon which this application is performed terrible. The edges of the wound become hardened and must be placed in such a position that the fumes, which are everted, the surface of the wound rises up into a pulpy, extremely irritating and annoying, will be carried off by a ragged, gray and greenish mass. When the sloughs are de- draught of air in a contrary direction.7 tached, the disease attacks other adjacent structures from day to day, extending its ravages both in length and breadth, Goldsmith prescribed bromine’s preparation and application: and involving aponeuroses, muscles, blood-vessels, nerves, tendons, the periosteum, and bones and joints.4p268 Bromine, one Troy ounce; bromide of potassium, one hundred and sixty grains; distilled water, enough to make four Since the infectious pathology underlying hospital gan- fluid ounces of the entire mixture.9p834 grene was then unknown, surgery, invariably amputations, and antiseptics remained mainstays of treatment. Goldsmith felt The results of the use of bromine on hospital gangrene that nitric acid used as an antiseptic did not adequately curb were spectacular. This table of Goldsmith’s own data is the ravages of hospital gangrene. His use of liquid bromine adapted from reference . ushered in a therapeutic para- digm shift. John William Bligh, a Goldsmith disciple, described Consolidated tabular statement of cases of hospital gangrene both technique and results: Total Avg. Days, Hours of No. Recovered Died Amputations Treatment ! of Deaths The deaths from this cause alone Treated with bromine in !"# !$% $ & " d, !$ h #.'" were, in some sections of the any way U.S. army, truly appalling, until Treated with pure bromine #( #" # & # d, #)." h #.'" the use of bromine as a treat- exclusively ment was introduced by Surgeon Treated with bromine solu- %' %$ # & ' d, !!.3 h #.'" Middleton Goldsmith, U.S. vol- tion exclusively unteers, in charge of the Jefferson Treated with pure bromine % % & & !# d, !% h #.'" Hospital, Jeffersonville, Indiana. after solution failed After this time no deaths attrib- Treated with bromine after #) ## & ! ) d, !'.) h #.'" utable solely to this cause oc- nitric acid failed curred, when properly treated Treated with bromine after % % & & ) d, $ h #.'" other remedies failed by it. During the months of June, July, and August, , when in Treated with nitric acid exclu- !) " % & ) d, !$.$ h '!."$ sively charge of wards in the above- Treated with other remedies !) ( " ! ( d !).( h )%.$( named hospital, upwards of  exclusively cases came under my care, all of Treated with other remedies $ $ & & which terminated favourably. . . . after bromine failed The mode of applying the bro- Reference ", page *'. mine is substantially as follows:—

6 The Pharos/Spring 2011 Gangrenous ulcer on external side of left foot resulting from gunshot wound. Private John D. Parmenter, Company G, 67th Pennsylvania Volunteers, was wounded at Amelia Springs, Virginia, on April 6, 1865. He was treated at Harewood Hospital in Washington, DC, by Dr. R. B. Bontecou. HIs leg was amputated. Courtesy of the Otis Historical Archives, National Museum of Health and Medicine.

The halogens: discovery and uses during effect of “impotence.” 12 Since Locock understood the condi- Goldsmith’s time tion to be a result of sexual excitement, he embarked upon a Bromine was discovered in , following the discovery of truly Victorian therapeutic endeavor. If bromine dampened chlorine in  and iodine in . Its name is derived from sexual passions, he reasoned, could a presumed therapeutic the Greek “bromos,” meaning “stench,” alluding to liquid bro- commonality among halogen salts mitigate hysteria—an al- mine’s irritating vapors. The history of the halogens—particu- ready accepted stimulus for epilepsy? larly selected portions engaging medicine—may be informed through a review of iodine’s medical applications beginning Sir Charles Locock, then President of the Society, first in Europe. recommended its use, on the occasion of a paper on epi- In France, eight years after the discovery of iodine, Jean lepsy communicated by Dr. E. H. Sieveking. “About fourteen François Coindet administered tincture of iodine to patients months ago,” said Sir Charles, “I was applied to by the par- with goiter, successfully decreasing the size of their enlarged thy- ents of a lady who had hysterical epilepsy for nine years, and roid glands.10 Shortly thereafter, European and then American had tried all the remedies that could be thought of by vari- practitioners embraced iodine and the other halogens as pana- ous medical men (myself among the number) without effect. ceas, using them for a veritable potpourri of pathologies.11 This patient began to take bromide of potassium last March In , Queen Victoria’s physician Sir Charles Locock ap- twelvemonth, having just passed one of her menstrual plied bromine to the treatment of “hysterical epilepsy.” Locock periods, in which she had two attacks. She took ten grains had read a German report claiming that  grains of potas- three times a day for three months; then the same dose for sium iodide administered three times a day led to the side a fortnight previous to each menstrual period; and for the

The Pharos/Spring 2011 7 In anticipation of the germ theory of disease

Wounded at hospital in Fredericksburg, Virginia, 1864. Courtesy of the National Library of Medicine.

last three or four months she has taken them for only a week that, with these in his hands, the medical man need wish for before menstruation. The result has been that she has not nothing more.” 13 had an attack during the whole of the period. I have tried the remedy in fourteen or fifteen cases, and it has only failed in Evidence that bromine was a valuable disinfectant awaited one; and in that one the patient had fits, not only at the time Goldsmith’s input during the Civil War. of menstruation, but also in the intervals.12 Bromine was critical to the nascent industry of photography, being used on the production of the daguerrotype. In Before the Civil War and the development of the germ fact, a patent for the production of bromine was granted in theory of disease, it was universally understood that disinfec-  to Dr. David Alter, a physician and expert during the early tants could decrease the prevalence of certain illnesses that history of photography. He wrote about the use of bromine in only later were discovered to be infectious in nature. In , medical therapy: Dr. Thomas Herbert Barker wrote: A number of physicians in this vicinity, and myself, by We may say, however, that we have chlorine, ozone, iodine, my recommendation, use Bromine and its preparations, in nitrous acid, and sulphurous acid. I believe that these are the practice of medicine. Not as a substitute for Iodine, but the five representative deodorants and disinfectants, and as far superior to it in a great many cases.

8 The Pharos/Spring 2011 A solution of Bromide of Iron, containing an excess of when the external air was warmer than that of the cellar,) Bromine, is one of the most efficacious remedies I have yet and when, from the extinction of fires, no air was drawn in been able to use, in cases of Neuralgia, Tubercular Disease of at the windows, the disease ceased.9p8 the Lungs, and as an external application in Erysipelas.14p345 Goldsmith concluded that hospital gangrene was a result of a chemical reaction: Why bromine? To the medical profession of that time, “miasms” were It is probable, for the results thus far reached point in this responsible for what later were known as infectious dis- direction, that peculiar alkaloids are produced in putrefac- eases. Miasms were perceived to be poisons that were spread tive decomposition, and that one or more of these are the throughout the atmosphere. Miasms would “adhere with great active agents. Whatever the agents are, they exist to some endurance and tenacity to fomites,” areas that were pathologi- extent in all kinds of putrescent animal matter.5pp16–17 cally at risk.5p7 According to Goldsmith, He thus sought assistance from a chemist, Acting Assistant these three affections, hospital gangrene, pyaemia, and Surgeon Thomas E. Jenkins, who summarized the current erysipelas, are in some way connected with miasms, or knowledge of the causes of the condition and the treatments with poisonous substances, by some process developed in used to arrest it. animal matter in the course of a series of chemical actions expressed in the generic term, putrefaction.5pp20–21 about all we know is this: the effluvia from foul and putrescent ulcers are composed chiefly of sulphuretted and As by-products of these reactions, poisonous substances were phosphuretted hydrogen, ammoniacal and sulphuretted produced, resulting in putrefaction, what we call necrosis.5p21 ammoniacal gases, with a little carburetted hydrogen. All of Projectile wounds and primitive surgery could permit the these bodies have been proved to be incompetent to induce entry of miasms, which contained a poison toxic to tissues. diseases similar to those which gave rise to them. Goldsmith correctly surmised that overcrowded wards, in Among the many substances which have been employed heightening tissue exposure to contaminated air, were the with a view to the arrest of the disease, or the checking or vehicle for epidemics of hospital gangrene: prevention of putrefaction, or the destruction of the noxious vapors and gases, may be enumerated both physical and Hospital gangrene arises spontaneously in wards where the chemical agents . . . 5pp21–22 wounded are crowded together—where the wards are filled with the stench of traumatic profluvia, and receive the air of Goldsmith considered the various agents Jenkins had listed sewers and cellars.5p6 and concluded,

Joseph Jones, in the  report The Medical and Surgical My attention was at once turned to the halogens, and History of the War of the Rebellion, suggested absorption of to substances acting like the halogens. The halogens, as is miasmic substances by tissue: well known, are fluorine, chlorine, iodine, and bromine. The action of these substances is alike in kind, but different In the early part of the season one patient was brought in degree. They differ in their physical properties. Fluorine into the ward with hospital gangrene. In a few hours six cannot be isolated on account of its ravenous activity. other cases were developed in wounded men lying adjacent Chlorine cannot be had pure except as a gas, or as a fluid, to him. . . . unless under pressure, and all the solutions of chlorine are It will appear, from the facts related, that the miasms feeble in their action. Iodine cannot be had at ordinary tem- evolved by putrefying animal matters in the cellar of the peratures in a gaseous state, and cannot be employed except hospital, and perhaps in the area of the barracks, were given in a solid state, or, if in a fluid state, too largely diluted to off at all seasons; that just during the season when, from possess the necessary degree of activity. the relations of the temperature, the atmosphere of the Bromine was found to be a fluid vaporable at ordinary cellar and this upward current would enter the ward most temperatures, and, unlike chlorine, respirable without injury constantly (i.e., when it was necessary to heat the ward with or inconvenience. stoves,) the cases of gangrene occurred; that they occurred Dr. Brainerd, of Chicago, had, as I am informed, already in just that locality in which the miasm of the cellar, in least found in his researches upon the bite of the rattlesnake, that dilution, would impinge upon the patients; and that as soon iodine mixed with the virus destroyed its activity, and had as those relative conditions of the temperature obtained in shown that like effects were produced upon other animal which the miasm of the cellar would flow downwards (i.e., poisons. From these facts, bromine seemed to hold out the

The Pharos/Spring 2011 9 In anticipation of the germ theory of disease

most promise for the purposes in view. 5pp22–23 the words of one Union surgeon:

A paper published in  by Dr. Charles Hughes also claimed Surgeon Cleveland states, among other things: “Nearly success for neutralizing snakebite by the use of Bibron’s every day I have had either cuts, pricks, scratches or other Bromine Mixture.15 abrasion on my hands, which are freely exposed in dressing Brainerd, Goldsmith, and their contemporaries believed the wounds and in the dead house, with no unpleasant con- snake venom to be a virus, resembling the miasms that caused sequences. I have always applied bromine to the denuded hospital gangrene. To Goldsmith, subcutaneous necrosis from surfaces before exposure, and am convinced that the virus snake venom or from hospital gangrene were absolutely equiv- of the dead house, as well as other animal poisons, is entirely alent. Since halogens had neutralized poisons in tissues, and destroyed by the action of bromine.18p234 since chlorine and iodine could not be used because of their irrespirable properties, why not try another halogen, bromine? Brigadier General and Surgeon General M. O. Terr y wrote Bromine, the only halogen liquid at room temperature, could that printed directions for the use of bromine were issued as be the ideal halogen to arrest putrefaction. follows: Bromine was produced in the United States, mainly in States belonging to the Union. Bromine was relatively inex- . For Fumigation: Place vessels containing one ounce of pensive; by the time of the Civil War, it cost approximately solution at different points of the ward and in number suf- . to . per pound. Hospital formularies composed for ficient to secure in the latter the constant presence of the the Union explicitly included bromine.16 odor of bromine.18p233 Finally, it is interesting to see bromine therapy from the perspective of a wounded soldier rather than the treating Is it possible that hospital gangrene as experienced in physician. This excerpt is from the Civil War journal of David Goldsmith’s era was not the lethal disease identified today Milburn Haworth: as necrotizing fasciitis? Loudon would vigorously dispute this premise and argue that a diverse nomenclature—from The next day two Doctors came in and told me they Hippocrates’ erysipelas, to the Civil War’s hospital gangrene, were going to burn the gangrene out. They wanted to give to the contemporary appellation of necrotizing fasciitis— me choloroform, but I told them I could stand it. They gave should in no way suggest that this specific disease was any me all the brandy that I could drink then they poured the different from its inception onward: wound full of bromine and it smoked and hurt pretty bad. . . . It was pretty painful while it lasted. I spent the rest of The identification of past diseases is often difficult because the month on my cot. of changing disease nomenclature and vague clinical de- July scriptions that lack diagnostic detail. Necrotising fasciitis is My wound is worse now that it was at the start. They ate an exception. There are historical descriptions of a disease out so much rotten flesh that the hole was bigger than it was that are so consistent, so unlike any other disease, and so at the start.17pp58–59 close to modern descriptions of necrotising fasciitis that one can say with confidence that necrotising fasciitis, or a disease closely similar to it, was first clearly described in the Discussion late th century by Claude Pouteau, chief surgeon to the Although bromine was discovered in Europe in , and Hôtel Dieu in Lyon, in . . . . was used medically in disparate ways, no one had used it for What can be said with confidence is that a disease hospital gangrene (necrotizing fasciitis) before Goldsmith. known as malignant ulcer, hospital gangrene, or phageden, While European medicine of Goldsmith’s generation used which resembled necrotising fasciitis so closely that it was halogens for multiple medical indications, they were directed probably the same disease, was well known as a common primarily towards neurological disorders. Although Dr. David and horribly virulent condition in the armed forces during Alter experimented with bromine, he used it topically instead the Napoleonic Wars, the Crimean War, and also in the of Goldsmith’s infiltrative application. Contemporary docu- Confederate Army in the American Civil War.3 ments consistently credit Goldsmith with the successful initia- tion of bromine therapy for hospital gangrene, according to his Dr. Middleton Goldsmith, with Ignaz Semmelweis and own specific prescription. Sir Joseph Lister, helped to usher in an era of antisepsis. Like If indeed bromine was as successful as claimed in the his- them, he improved the treatment of serious infections through torical texts of that time, it must have acted as a disinfectant. simple practices like handwashing. His career after the Civil Is it possible that bromine’s broader presence—as an all- War included recognition such as The Middleton Goldsmith pervasive vapor—impacted survival in hospital gangrene? In Lectures for the New York Pathological Society, where his

10 The Pharos/Spring 2011 Courtesy of the National Library of Medicine.

library of , books now resides. He died at the age of sev- Douglas Hospital, Washington, D.C. Am J Med Sci ; : –. enty, and his obituary in the New York Times described him . Bligh JM. On the use of bromine in the treatment of hospital simply as, “physician, surgeon, and author . . . President and gangrene. Lancet  Aug ; . professor of several medical colleges.” . Mitchell SW. The Medical Department in the Civil War. Chicago: American Medical Association; . References . The Medical and Surgical History of the War of the Rebel- . Wilson B. Necrotizing fasciitis. Am Surg ; : –. lion (–). Prepared, in accordance with Acts of Congress, . Hippocrates. Of the Epidemics. In: Adams F, translator. The under the direction of Surgeon General Joseph K. Barnes, United Genuine Works of Hippocrates. London: Sydenham Society; . States Army. Part III. Volume I. Medical History. Being the Third . Loudon I. Necrotising fasciitis, hospital gangrene, and Medical Volume. Washington (DC): Government Printing Office; phagedena. Lancet ; : –. . . Jones J. Surgical Memoirs of the War of the Rebellion. Vol- . Kelly FC. Iodine in medicine and pharmacy since its discov- ume II. Investigations Upon the Nature, Causes, and Treatment ery—–. Proc R Soc Med ; : –. of Hospital Gangrene, as It Prevailed in the Confederate Armies, . Brunton TL. A Text-Book of Pharmacology, Therapeutics, –. Cambridge (MA): United States Sanitary Commission; and Materia Medica. Adapted to the United States Pharmacopoeia : –. by Francis H. Williams, M.D., Boston, Mass. London: Macmillan; . Goldsmith M. A Report on Hospital Gangrene, Erysipelas : . and Pyaemia, as observed in the Departments of the Ohio and the . Pearce JMS. Bromide, the first effective antiepileptic agent. J Cumberland, with Cases Appended. Louisville: Bradley & Gilbert, Neurol Neurosurg Psychiatry : : . published by permission of the Surgeon General U.S.A.; . . Barker TH. On deodorisation and disinfection. BMJ  . Thomson W. Report of cases of hospital gangrene treated in Jan : –.

The Pharos/Spring 2011 11 In anticipation of the germ theory of disease

. Alter D. Bromine. Daguerreian J ; : . Address correspondence to: . Hughes CH. Bibron’s Bromine Mixture an antidote to the Gregory W. Rutecki, MD poison of the Boa crotaloides. Am J Med Sci ; : –. Department of Medicine . Hasegawa GR. Pharmacy in the American Civil War. Am J Division of Nephrology and Hypertension Health-Syst Pharm ; : –. The University of South Alabama . Haworth DM. Haworth Brothers Civil War Diary. haworthas- 2451 Fillingim Street sociation.org/Family-Notes/David-Milburn/Civil_War_Diary.htm. Mastin Building, Room 503 . Terr y MO. The value of bromine in military surgery. Int J Mobile, Alabama 36617-2293 Surg ; : –. E-mail: [email protected]

A contemporary case of necrotizing fasciitis

ecrotizing fasciitis, commonly referred to as “flesh- disease. She called me at my office to tell me that Eric had eating disease,” continues to be a serious, difficult-to- necrotizing fasciitis and was critically ill. I called his physi- Ndiagnose, devastating, and often fatal disease. cians and then arranged emergency transfer by helicopter My personal experience with necrotizing fasciitis in- to the University of Colorado Hospital. On arrival Eric was volved friend and colleague Eric Allin Cornell, PhD, who acutely ill, febrile, and the doctors diagnosed septic shock with Carl Wieman, PhD, won the Nobel Prize in Physics in as well as necrotizing fasciitis. We weren’t sure he was  for synthesizing the first Bose-Einstein condensate, going to survive. A team of surgeons, infectious disease a new form of matter. As Chancellor of the University of specialists, and nurses evaluated and admitted him to the Colorado Boulder, where they worked at the Joint Institute Burn ICU, where they worked to treat the septic shock and for Laboratory Astrophysics (JILA), I attended the Nobel necrotizing fasciitis, and administered antibiotics. They Prize Award ceremony in Stockholm, Sweden. performed additional and more aggressive surgery, ampu- After receiving the prize, Eric and Carl continued their tating his left shoulder and upper left arm. outstanding research and teaching and lectured around the At last Eric began to improve, and four days later they world. performed surgery and found no additional tissue affected In October , Eric developed chills, generalized by necrotizing fasciitis. After a skin allograft, the wound body aches, malaise, and fever. He thought he probably had was treated like a third degree burn. A week later Eric re- the flu. The next day he was still symptomatic and called gained consciousness, and although confused began com- in sick to work. Later that night he developed persistent municating with his family. He had additional skin grafts, pain in his left arm. He couldn’t sleep and the pain was still and was then transferred to the rehabilitation unit. I saw there in the morning. He was examined and evaluated by him and his family many times during that hospitalization. a physician’s assistant and another health professional in With the exceptional medical, surgical, and nursing care he the clinic that morning. They ordered laboratory tests and received, he had survived and was recovering. He returned X-rays, then prescribed pain medication and a sling and to his family and then to work in  and continues to sent him home. That evening he felt temporarily better. research, lecture, and teach. Last year I saw him riding his The next morning he noted shoulder and arm pain with bike with his wife and children. walking and then vomited. The pain increased markedly This story had a good outcome with survival, but with and became unbearable even with NSAIDs. That afternoon permanent scars and what Eric describes as “very modest he returned to the clinic, where the physician noted that disability.” He notes however that if he were in a profes- his left shoulder was very swollen, but couldn’t understand sion requiring two arms—a clarinetist, brick layer, or prize the severity of the pain. She referred him to the emergency fighter, for example—he would probably have a different room in the community hospital. The MRIs taken there attitude. He hopes that physicians will learn and remember were abnormal, but the doctors didn’t know how to inter- that patients with necrotizing fasciitis often present ini- pret them. An orthopedist consulted and unsuccessfully tially with intense pain without surface lesions or wounds tried to aspirate the shoulder. They started him on antibi- and without even surface discoloration, especially with otics, which had no effect. virulent Streptococcus A infection. That night they began to suspect necrotizing fasciitis I doubt whether topical bromine would have made any and Eric had his first debridement surgery. The next morn- difference in Eric’s case. However, I recently learned that ing he was worse and they decided to amputate his left arm wound surgeons are using dilute sodium hypochlorite, and do more debridement. A physician friend, who had closely related to bromine, to treat infected wounds. been one of my residents, told him and his wife that they Richard L. Byyny, MD, editor needed to go to a hospital with more experience with this

12 The Pharos/Spring 2011 Buoyed by urgency Diving into the human D!sabyss"nea The body’s traitorous conspirator A return to primordium Yearning for Atlantis Alveoli float helplessly In the deep pneumatic ocean Jordan Grumet, MD

Dr. Grumet (AΩA, Northwestern University, !""") is an internal The Pharos/Spring 2011 medical physician. His address is: #$#! Bryant Avenue, Evanston,13 Illinois %&#&!. E-mail: [email protected]. Illustration by Jim M’Guinness Oswald Avery and the

Irving Kushner, MD, and David Samols, PhD Dr. Kushner (AΩA, Washington University in St. Louis, time, infectious diseases were the major public health concern 1954) is professor emeritus of Medicine, and Dr. Samols and bacteriology was the most glamorous and promising field is professor of Biochemistry at Case Western Reserve in the nascent biomedical science of the day. Opportunities University School of Medicine. for research at that time were very few, but Avery did find a position at the Hoagland laboratory, a privately-endowed s the years have passed, the tremendous contributions bacteriology laboratory in Brooklyn, where he worked for six of Oswald T. Avery (–) to biomedical science years, performing largely unimaginative work. are fading from our collective memory. A modest and self-effacingA man, Avery was one of the outstanding biologi- The Rockefeller Institute for Medical Research cal scientists of the first half of the twentieth century,1 felt by At the end of the nineteenth century, John D. Rockefeller some to be the most deserving scientist not to have received was seeking guidance about how to deploy his philanthro- the Nobel Prize. His laboratory was responsible for three land- pies most effectively. He was the richest man in the world, mark contributions: perhaps the richest man in history. Rockefeller’s principal . The demonstration that polysaccharides are antigenic philanthropic adviser was a Baptist minister, Frederick Taylor . The discovery of C-reactive protein (CRP), which Gates, himself a physician’s son, who had noticed during his opened the door to study of the acute phase response2 ministry that physicians were rarely able to deal with serious . The demonstration that DNA conveys genetic medical problems. information. Gates read Sir William Osler’s magisterial textbook, The Avery was born in Nova Scotia in , the son of a Baptist Principles and Practice of Medicine,3 in which Osler, some- minister. The family moved to New York City when Oswald thing of a therapeutic nihilist, expressed his skepticism about was still a child. He graduated from Columbia University’s prevalent forms of therapy. Gates was impressed. He later College of Physicians and Surgeons in , when medicine wrote: was just beginning to abandon its reliance on tradition, although medical practice was still largely empirical. Good I had been a sceptic before . . . This book not only confirmed outcomes largely depended on the healing power of nature my scepticism, but its revelation absolutely astounded and and the power of faith. American physicians generally felt that appalled me. . . . I found . . . that the best medical practice laboratory science could never contribute anything of practi- did not, and did not pretend to cure more than four or five cal value to medical practice. diseases. . . . about all that medicine up to  could do was Avery practiced medicine for three years, but apparently to nurse the patients and alleviate in some degree the suffer- didn’t find it intellectually or emotionally satisfying. At that ing. Beyond this, medicine as a science had not progressed.

14 The Pharos/Spring 2011 The Rockefeller Institute for Medical Research. Left, Oswald Avery in his lab at the Rockefeller Institute, circa 1940s. Courtesy of the National Library of Medicine. In headline, Streptococcus pneumoniae (Diplococcus pneumoniae). Capsule stain light micrograph at 1000x. © Visuals Unlimited/Corbis.

The Pharos/Spring 2011 15 Oswald Avery and the pneumococcus

. . . It became clear to me that medicine could hardly hope anxiously for “the crisis,” the characteristic feature of lobar to become a science until medicine should be endowed and pneumonia, which would not occur until a week to ten days qualified men could give themselves to uninterrupted study after the onset of illness, if the patient survived that long. At and investigation, on ample salary, entirely independent of that point the temperature, heart rate, and respiratory rate practice. To this end, it seemed to me an Institute of medical rapidly fell, and the patient recovered. research ought to be established in the United States. Here was an opportunity, to me the greatest, which the world Polysaccharides and type-specific serum therapy could afford, for Mr. Rockefeller to become a pioneer.1p21–22 Avery started his career at the Rockefeller working on serological classification of the various pneumococcal types. This Rockefeller was receptive to this suggestion and the led to the finding that a soluble substance, specific for each Rockefeller Institute for Medical Research was dedicated in pneumococcal type, was present in the serum and urine of . Its small hospital followed in . The Institute, now a patients. Avery and his collaborators identified these as poly- university, still occupies its original site in New York City on saccharides and showed that they were antigenic, which had the East River and th Street. When John D. Rockefeller, Jr., not been suspected previously. Most importantly, the polysac- retired as president of its board of trustees in , he stated charide made up the pneumococcal capsule, which was differ- that he had always regarded the institute as “the most signifi- ent for each pneumococcal type. It is the capsule that renders cant and the most permanent (philanthropy) of any that my the organism resistant to phagocytosis. For the pneumococ- father established.” 4 cus to be virulent, it must form a substantial capsule, while unencapsulated organisms are not virulent. The “crisis” is the Pneumonia result of the appearance, after about a week, of antibodies to In , three years after its opening, Oswald Avery took that capsular polysaccharide, which opsonized the bacteria, the job of bacteriologist at the Hospital of the Rockefeller leading to phagocytosis and clinical recovery. Institute, where a considerable effort was directed to the Type-specific serum therapy, made possible largely through treatment of pneumonia and its most common cause, the the fundamental discoveries in Avery’s lab, at that time con- pneumococcus. Avery became part of this effort. His entire sisted of administering horse serum prepared against the subsequent career was driven by a search for an understanding specific type of pneumococcus with which the patient was in- of pneumococcal pneumonia—and for its cure. fected.5 Some of the mechanics of its administration are illus- At that time, pneumonia was the leading cause of death in trated in this tribute to Max Finland, who ran the pneumonia the United States. Here is how Osler described it: service at the Boston City Hospital for many years:

Definition.—An infectious disease characterized by in- you went to the hospital laboratory to get the [pneumo- flammation of the lungs, toxaemia of varying intensity, and coccal] isolate; if the house officer was not at the City a fever that terminates abruptly by crisis. . . . Hospital, he got on the trolley and traveled to the Thorndike Incidence.—The most widespread and fatal of all acute Memorial Laboratory, where Dr. Finland was always avail- illnesses, pneumonia is now the “Captain of the Men of able; he would type the organism and hand you a bottle of Death.” 3p108 type-specific serum; then, it was back on the trolley to your hospital; finally, you administered the serum to the patient. Lobar pneumonia was not limited to the infirm or elderly; Whereas the mortality rate for untreated pneumococcal people in the prime of life were affected. Entire lobes were bacteremia was almost , type-specific serum therapy consolidated, often more than one, resulting in little gas resulted in survival of more than one-half of the patients.6 exchange. Most medical care was provided in the home. X-rays and blood counts were rare. The mortality rate ran This was the only way to treat pneumonia until the introduc- between twenty and forty percent. Osler’s section on treat- tion of antimicrobial drugs in the late s. ment begins “Pneumonia is a self-limited disease, which can neither be aborted or cut short by any known means at our C-reactive protein and the acute phase response command.” 3p134 Throughout his career, Avery’s approach to biological By the fourth day or so after the onset of symptoms, a hos- elucidation of the pneumococcus involved understanding its pitalized patient would typically be highly febrile, tachypneic, immunochemistry. Pursuing this line of study, William Tillett, dyspneic, tachycardic, cyanotic. He was frequently delirious. working in Avery’s laboratory, prepared a polysaccharide Bacteremia occurred in about one-third of the patients. If fraction derived not from the capsule but from the cell wall. infection of the meninges or of a heart valve ensued, it was He called it the “C” fraction because it appeared to be analo- invariably fatal. gous to the C polysaccharide of the hemolytic streptococcus Patients, family members, and physicians would wait studied by Rebecca Lancefield a few years previously. This

16 The Pharos/Spring 2011 Chart 3 adapted from Tillett and Francis, reference 7. This chart com- pares the temperature course of pneumonia in a patient (top row) with anti-capsular antibodies (second row) and C-fraction precipitation (third row).

pneumococcal C-polysaccharide, it was later learned, was antibody response. shared by all pneumococci, regardless of their type. This phenomenon was not limited to pneumococcal pneu- To explore the serologic response to the C-polysaccharide, monia, nor to acute infections. For example, in a patient with Tillett and his colleague Thomas Francis set up precipitin bacterial endocarditis, who died on hospital day twenty-one, tests against sera from serial bleedings of pneumonia patients. the C-precipitin never went away. They also observed pre- The results were surprising—completely the opposite of what cipitin reactions with sera from patients with acute rheumatic they had expected. At the top of the figure is the temperature fever, lung abscess, and osteomyelitis, all believed to be caused curve, starting at °F, with the patient undergoing a crisis by Gram-positive organisms. No reaction was observed with on day six or seven. The second row shows the antibodies sera from normal individuals. These results were published to the capsule, here called “type specific agglutinins,” which in .7 appear about the same time as the crisis and are responsible Avery was fascinated by these findings. He saw this for it. When Tillett and Francis looked at the reaction with C-reaction as an entrée to study of the host response to infec- the C-polysaccharide, however, they got a surprise. A pre- tion. Avery was a captivating raconteur, known for his inimita- cipitate formed when the C substance was mixed with sera ble monologues describing the various paths of research in his obtained at the time of admission and throughout the febrile laboratory. In his biography of Avery, René Dubos recounts: period (the acute phase). This reaction diminished after the crisis and ultimately disappeared. This time course was the Avery never discussed the C-reactive protein without reciprocal of that seen with antibodies directed against the turning the conversation to what he was wont to call “the capsular polysaccharide, and was not how antibodies behaved. chemistry of the host.” Although he never spelled out what It took the investigators a while to digest this finding and he meant by that expression, he clearly had in mind all the for its implications to sink in. Ultimately they realized that unidentified body substances and mechanisms of a nonim- the C-precipitation phenomenon differed from an immune munological nature, both protective and destructive, that reaction, and that it was something new, different from an come into play in the course of infectious processes.1p99

The Pharos/Spring 2011 17 Oswald Avery and the pneumococcus

The discovery of C-reactive protein and the acute phase of the pneumococcus could be better understood. The three response in the Avery lab opened the door to contemporary major discoveries of the Avery laboratory have all led to major scientific pursuit of this phenomenon—the metabolic, physi- advances in diagnosis, disease prevention, and treatment, and ologic, nutritional and plasma protein changes that occur dur- the circumstances should remind us that accretion of sound ing inflammatory states8—as well as to the clinical use of acute basic biologic knowledge can be expected to ultimately lead phase protein determination for diagnosis and management of to practical results. Without such knowledge, practical results patients. New insights into the biological and clinical signifi- will never ensue. cance of the acute phase response continue to emerge.9 References The “transforming principle” . Dubos RJ. The Professor, the Institute, and DNA. New York: In , Fred Griffith in London observed that heat-killed Rockefeller University Press; . encapsulated Type I pneumococci (the donor) could transform . McCarty M. Historical perspective on C-reactive protein. living unencapsulated (hence non-virulent) Type II pneumo- Ann NY Acad Sci ; : –. cocci (the recipient) into encapsulated virulent type I organ- . Osler W. The Principles and Practice of Medicine: Designed isms.10 The capsule of the organism that grew out consisted for the Use of Practitioners and Students of Medicine. New York: D. of the carbohydrate that had been expressed by the killed, Appleton; . donor organism. This characteristic persisted in all succeeding . The Rockefeller Archive Center—JDR Jr. Biographical Sketch. generations of daughter cells—that is, it was heritable. At that rockarch.org/bio/jdrjr.php. time, the chemical basis for heredity was still unknown, and . Podolsky SH. Pneumonia Before Antibiotics: Therapeutic the vast majority of informed opinion considered it virtually Evolution and Evaluation in Twentieth-Century America. Baltimore certain that genes were composed of protein of some kind. (MD): Johns Hopkins University Press; . Over the years Avery’s interests increasingly shifted toward . Klein JO. Maxwell Finland: A Remembrance. Clin Infect Dis understanding basic biological questions relating to the pneu- ; : – . mococcus, since they might bear on treatment. Over the next . Tillett WS, Francis T Jr. Serological reactions in pneumonia fifteen years, the Avery lab focused its attention on the nature with a non-protein somatic fraction of pneumococcus. J Exp Med of the “transforming principle.” 11 Since only encapsulated ; : –. organisms could cause disease, Avery felt that an understand- . Kushner I. The phenomenon of the acute phase response. ing of how capsule production is controlled might lead to Ann NY Acad Sci ; : –. treatment. . Kushner I, Samols D, Magrey M. A unifying biologic explana- This avenue of investigation ultimately led to one of the tion for “high-sensitivity” C-reactive protein and “low-grade” inflam- most important biomedical papers ever published. Avery, Colin mation. Arthritis Care Res ; : –. MacLeod, and Maclyn McCarty reported in  that heredi- . Griffith F. The significance of pneumococcal types. J Hyg tary information could be transmitted from one bacterium to (Lond.) ; : –. another by purified DNA.12 The report was greeted with con- . McCarty M. The Transforming Principle: Discovering that siderable skepticism, and it took a few years before its validity Genes Are Made of DNA. New York: W. W. Norton; . was accepted. A feverish race to solve the structure of DNA . Avery OT, MacLeod CM, McCarty M. Studies on the chemi- then ensued, a race won by James Watson and Francis Crick cal nature of the substance inducing transformation of pneumococ- nine years later, and described by Watson in his famous mem- cal types: Induction of transformation by a desoxyribonucleic acid oir The Double Helix. As we all know, the finding that genes are fraction isolated from pneumococcus type III. J Exp Med ; : made of DNA revolutionized biology. Of note, in their paper in –. Nature describing the structure of DNA, Watson and Crick did . Carmichael M, Begley S. Desperately seeking cures. News- not credit the Avery lab for their contribution. week  May  & : –. . Wade N. A decade later, genetic map yields few new cures. A long and winding road NY Times  Jun : A. Several publications have recently indicated the public’s . Krauss LM. The Gulf spill and the limits of science. Wall impatience with the failure of recent basic science discoveries Street J  Jun . to lead to practical results—something that helps patients.13,14 However, as has recently been pointed out, “The road from Address correspondence to: basic knowledge to successful technology is a long and wind- Irving Kushner, MD ing one, usually taking decades, not weeks or months.” 15 It is MetroHealth Medical Center worthwhile to point out that the extremely consequential work 2500 MetroHealth Drive of Avery’s lab was not carried out under the aegis of transla- Cleveland, Ohio 44109 tional research. Rather, it was carried out so that the biology E-mail: [email protected]

18 The Pharos/Spring 2011 What is your diagnosis? Courtesy of the author. Community-acquired pneumonia The tyranny of a term Bennett Lorber, MD, and Thomas Fekete, MD Dr. Lorber (AΩA, elected as faculty, Temple University, to complete her antibiotic course. 1980) is the Thomas M. Durant Professor of Medicine, and Two weeks later her fever and cough have not subsided so Dr. Fekete (AΩA, elected as faculty, Temple University, she returns to the emergency room. The infectious diseases 1997) is professor of Medicine at Temple University School consultation service is called to see her. They take a history! of Medicine. Among the information that is quickly obtained with just a few questions is the following: Her cough and fever had been What signifies knowing the name, if you know not the na- present for almost two months before she made her first trip to ture of things? the emergency room; she had lost nine pounds since the illness —Benjamin Franklin began; she had night sweats almost daily; and she resided in a recovery home for former drug users where another resident icture this. It’s a true story. has had a bad cough for a few months. What is the diagnosis? A twenty-nine-year-old woman enters a hospital emer- Tuberculosis seems very likely. She is hospitalized, isolated, Pgency room with complaints of fever and cough. In the and a sputum sample has acid-fast bacilli and later grows emergency room her fever is confirmed, she has a cursory Mycobacterium tuberculosis. exam and is sent for a chest X-ray that shows a left mid-lung What should we make of this story? If one were to present infiltrate (see the X-ray above). A diagnosis of community-ac- the case of a patient with two months of cough, fever, night quired pneumonia (CAP) is made, and the patient is discharged sweats, weight loss and a pulmonary infiltrate, any third-year on azithromycin. medical student would consider the diagnosis of tuberculosis. She faithfully takes the antibiotic, but after a week is no Yet fully trained physicians missed the diagnostic boat on three better and returns to the emergency room. This time the chest occasions. Why? We believe it is the tyranny of the term “com- X-ray shows expansion of the left mid-lung infiltrate and a munity-acquired pneumonia.” All one needs is a cough, fever, new right upper lobe infiltrate. She is admitted to the hospital. and an abnormal chest X-ray and no further information is What is the admission diagnosis? It’s community-acquired required. We have a diagnosis and a course of treatment. What pneumonia. After all, she has evidence of pneumonia, and could be simpler? Yet the hazards of this approach are obvious. it occurred outside of a health care setting, so it is, in fact, a Language matters. The way we frame an issue, and the community-acquired pneumonia. This time she is treated with words we use to indicate it or describe it can dictate the way in moxifloxacin, and, after four days, she is stable and discharged which it is handled. The term CAP has eliminated thoughtful

The Pharos/Spring 2011 19 Community-acquired pneumonia

investigation of a clinical syndrome and turned the response replace thoughtful clinical investigation; in practice, however, into a spinal reflex arc. Clearly those who developed the term that seems to be what has happened. The fact that it can’t be CAP, and those who developed guidelines for management of this simple is well illustrated by the fact that, not including this syndrome, never intended that the term should or would references, the consensus guidelines for the management of community-acquired pneumonia jointly developed by the Infectious Diseases Society of American and the American Thoracic Society are more than thirty-five pages long.1 Most patients with fever, cough, and a pulmonary infiltrate on X-ray do have an acute infectious pneumonia that will be treated well with one of the regimens outlined in CAP guidelines. Cases of tuberculosis, endemic mycoses, and other infections that will require specific diagnostic and therapeutic approaches are uncommon, but we shouldn’t miss these diagnoses when a few simple questions about duration of illness and exposures might point us in the right direction. Think of the potential health harm and the very real follow-up costs in both time and money because the tyranny of a term resulted in our patient with tuberculosis being hospitalized for four days without appropriate isolation. The term “community-acquired pneumonia” first appeared as a published entity in the late s. A Medline search showed limited references to community-acquired pneumonia in abstracts in  and in titles in , but the term must have been in common use since it was not formally defined. The concept of community-acquired pneumonia was used to distinguish infection in independent-living children and adults from that in nursing home patients (rather than hospitalized patients). Contrast this with  when the term was used Second x-ray in the series. Courtesy of the author. in  references and  titles that lump together patients with varying degrees of immune depression and residential situations and contrasts them to patients who acquired their pneumonia in the hospital. Operationally, the transition from “bacterial pneumonia” and “atypical pneumonia” to “community-acquired pneumonia” appears to have been driven by two factors. First, there was an increased appreciation of the difficulty of making clear clinical distinctions among pneumonias of different etiologies. Limitations of culture and non-culture tests were more apparent when there was an imperative to begin treatment with information generated entirely by clinical evaluation and chest radiography. Second, there was a major shift from using narrow spectrum agents such as ampicillin, amoxicillin, and oral cepha- losporins to macrolides and tetracyclines for the treatment of pneumonia. This trend increased further when respiratory fluo- roquinolones and newer-generation macrolides were marketed in the early s. The concatenation of these events made it possible to treat broadly with convenient and relatively nontoxic therapy without need to wait for diagnostic test results. For a long time, one of the staples of house-staff training was the Gram stain. Residents were expected to be able to Gram stain sputum specimens from their patients with suspected pneumonia and, in many cases, they were tasked with recognizing common bacteria and starting pathogen-specific Third x-ray in the series. Courtesy of the author. treatment. In the wake of the Clinical Laboratory Improvement

20 The Pharos/Spring 2011 Amendments (CLIA) and changes in residency training, not would advocate turning back the clock to the halcyon days only have the house staff labs disappeared, but also, in many of the s when these other terms were in wide circulation hospitals, the entire microbiology venture has been out- and still found wanting? So what alternatives do we have? We sourced. Doctors are so far removed from sputum Gram stain now have tools that may enable us to make a more specific results that it is nearly impossible to picture treatment for microbiologic diagnosis within the first twenty-four hours of pneumonia being guided by microscopy results. Cultures are hospital admission. But, as one example, the use of antigen slow and insensitive, so it is commonly believed that no infor- tests for pneumococcus and legionella is not universal, may mation from stains and/or cultures would trump the combina- not be as reliable as once thought and is probably not cost- tion of clinical presenting features and response to treatment. effective. Future technological improvements, e.g., RT-PCR, Consequently few sputum cultures are sent (even from patients may be better, but they are unlikely to be embraced unless with a strong suspicion of bacterial pneumonia). the costs are reduced. Indirect tests such as procalcitonin The problem with this state of affairs is that we are much might not be able to distinguish among the various bacterial more assertive and certain about our diagnosis of pneumonia etiologies of pneumonia, but might be useful to distinguish than is merited by the real world correlation between initial among the causes of acute respiratory symptoms (pneumonia impression and final diagnosis. Our confidence lives in the versus congestive heart failure, for instance). Point-of-care or distorted reality sometimes called post hoc ergo propter hoc. stat testing as is done for myocardial infarctions (troponin) Once we conclude that a patient had pneumonia, we can go and heart failure (BNP) could reduce the burden of unneces- back through the record and study the choices made when the sary antibiotics. It might also allow us to unravel the skein of patient first presented for care. This approach has dominated diseases currently managed with a combination of diuretics, the published studies of CAP. In the  combined consensus antibiotics, and beta-agonists. Even if we don’t have an elegant guidelines for management of CAP,1 there were sixteen Level name, we should be able to avoid many of the blunders that I (randomized-controlled trial based) recommendations: six our current system imposes. were related to validating the utility of specific antibiotics, In the meantime, we can be a little more thoughtful and, five to influenza prevention and treatment, two to ventilator/ when faced with a patient having a cough and an X-ray infil- oxygen management, and one each for development of local trate, ask a few more questions and perform a focused exam guidelines, obtaining blood cultures and the safety of a five-day before reflexively applying the community-acquired pneumo- course of treatment. None of them related to diagnostic uncer- nia label and pulling the antibiotic trigger. This not only would tainty in the ER, diagnostic testing, or timing of antibiotics. On have spared our patient with tuberculosis a series of unhelpful the other hand, retrospective studies have shown an outcome interventions and hospitalizations, but also would have re- benefit for very early administration (e.g., within four hours of duced the chance of her spreading tuberculosis to those around ER admission) of empiric antibiotics. The apparent benefit of her, including vulnerable hospitalized patients. this approach2 led to guidelines and incentives for early treatment. In an urban U.S. hospital, comparison of pneumonia References admissions in  versus those in  showed some telling . Mandell LA, Wunderink RG, Anzueto A, et al. Infectious changes: in , more antibiotics were administered and were Diseases Society of America/American Thoracic Society consensus given earlier, but fewer patients given antibiotics actually had guidelines on the management of community-acquired pneumonia pneumonia (fifty-nine percent versus seventy-six percent).3 in adults. Clin Infect Dis ; : S–. Thus, very early treatment becomes, de facto, excessive treat- . Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, ment. We showed a similar result in our analysis of patients process, and outcomes in elderly patients with pneumonia. JAMA receiving very early ceftriaxone/azithromycin—a combination ; : –. that seems tailored for community-acquired pneumonia.4 . Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of Only thirty-nine percent of the patients who received this community-acquired pneumonia and inappropriate utilization of combination had a discharge diagnosis of pneumonia, although antibiotics. Side effects of the -h antibiotic administration rule. virtually all of the patients without pneumonia had respiratory Chest : : –. symptoms resulting from congestive heart failure or chronic . Mayro G, Axelrod P, Fekete T. Early ceftriaxone combined obstructive pulmonary disease. with azithromycin: Indicator for community-acquired pneumonia? Would it be better to describe pneumonias by their etiol- Infect Dis Clin Pract ; : –. ogy, their clinical appearance, their pathophysiology, rather than by the current “site of acquisition?” Each of these models Address correspondence to: has potential downsides. The etiology can be hard to deter- Bennett Lorber, MD, MACP mine, the clinical appearance can be misleading, and we can Temple University Hospital rarely ascertain whether a pneumonia is acquired via aspi- Broad and Ontario Streets ration of oral or GI tract contents versus inhalation versus Philadelphia, Pennsylvania 19140 arrival via bloodstream (the latter two are quite rare). Who E-mail: [email protected]

The Pharos/Spring 2011 21 Anatomical dissection and the indignity of Smugglerius

Trahern Jones The author is a member of the Class of 2013 at Mayo of medical and art students. Recently, the skilled work of an- Medical School College of Medicine. thropologist Dr. Jeanne Cannizzo and artist Joan Smith has led us, for the first time, to a potential identity of the “donor”: a curious specimen resides in the Royal Academy of footpad named James Langar.2 the Arts in London: a grotesque cast made from the Langar was probably executed sometime around  for flayed figure of a man. In a surreal neoclassical twist, highway robbery rather than smuggling, making the epithet Ait is posed in the attitude of the famous Hellenistic sculpture, Smugglerius a bit of a misnomer.2 Occupying a shameful place Dying Gaul. A recast of an original conceived by Dr. William in the history of medicine and anatomy, he is but one man in Hunter, the premier eighteenth-century anatomist and obste- a long line of victims of body-snatching and nonconsenting trician,1 it is named Smugglerius in a pseudo-Latinized epithet body donors. To be sure, the treatment of his body after his referencing the “donor’s” supposed previous occupation. It has execution, like that of many others, is both an indignity and long served in the Academy as a remarkable display of human an injustice—but we can learn something from the peculiar, form and anatomy, and has inspired and tutored generations significant choice of pose given to his body by William Hunter.

22 The Pharos/Spring 2011 As the Dying Gaul generates a profound, instructive pathos and sense of respect in the viewer, so does Langar’s tragedy as an unwilling body donor; we are inducted by the cast’s naked vulnerability into the strange narrative of his victimhood. The Dying Gaul was created about the time that the kingdom of Pergamon defeated the hostile Celtic tribes of Northern Europe around  BCE.3 In it, we see a pathos rarely exhibited in Greek art up to that point: the barbarian enemy warrior, a Gaul, whose tribe traditionally entered battle nude, has fallen to the ground. He is mortally wounded—fresh blood pours from a spear wound between his ribs—brought to his hands and knees by the discipline of Attic civilization. At the same time, he evokes a sense of admiration and pity: his expression is profound, his face conveys a noble acceptance of the indignity of defeat, and his nakedness is no longer a mark of

The Hanged Man. Victor Hugo, circa 1855–1860. Brush and ink wash on wove paper, sheet: 12 x 7-11/16 inches. Gift of Kristina and Guy Wildenstein, 2003. Metropolitan Museum of Art. © The Metropolitan Museum of Art/ Art Resource, NY.

Opposite page, Dying Gaul. Roman copy after a Greek original, circa 230–220 BCE. Lifesize marble. Musei Capitolini, Rome, Italy. Photo credit: Scala/Art Resource, NY. A cast of a man, named “Smugglerius,” at Edinburgh College of Art. © DAVID MOIR/Reuters/Corbis.)

The Pharos/Spring 2011 23 Defeat, poised in stone

savagery, but becomes beautiful form. Lord Byron, like others, remained at the Academy among other unfortunate donors was moved to such pity upon seeing the Dying Gaul that he as a model for anatomically-correct figure drawing. included it in Childe Harold’s Pilgrimage: We cannot surmise William Hunter’s reasons for choosing the pose of the Dying Gaul as the model of Smugglerius, but I see before me the Gladiator lie: in doing so, he matched the undignified fate of James Langar’s He leans upon his hand—his manly brow body quite well to a timeless narrative of defeat and the sen- Consents to death, but conquers agony4 sitivity of the defeated, specifically in the darker history of anatomical dissection. There is no justice in the fate accorded Through the nude humanity of the Celt, this villain of civiliza- to Langar: his body was taken without consent, treated with tion, one sees a world in which barbarian pathos counts more no more respect than a scientific curiosity, and converted than the triumph of the Greek armies. This very human death, from living being to an objet d’art, a plaster cast gawked at delicately poised in stone, is a sensitive consideration for the by Academy students and insulted daily by the epithet of its profundity of loss and defeat. popular name. Yet in the subtle pathos of his posing, in the ul- Nearly two millennia later, defeat loomed over another timate nakedness of his flaying, a deeper sensibility is revealed. tragic figure. As the noose was slipped over James Langar’s The man behind the cadaver is illuminated in this art imitating neck, a prayer may have graced his lips but he certainly life. He is a hanged criminal, it is true, an enemy of the law and knew that no Christian burial awaited him. Freshly executed all it stands for. Yet his nudity, like the Gaul’s, brings us closer criminals often provided eighteenth-century anatomists to his humanity; his brow consents to death, and conquers the with their only legally obtainable human material; the dis- agony of this untoward spectacle. We admire and pity his fate, secting table was bound to be Langar’s destination rather as Hunter certainly did not. than the churchyard grave.5 Hapless bodies such as his were Thus it is that we appreciate the injustice of similarly the stuff that medical education was built upon. With or wronged men and women in the early history of anatomy, without his consent, his cadaver would serve as yet another human beings whose bodies were unrightfully acquired with- learning ground. out their consent, whose anatomy formed the groundwork The noose tightened, the soul fled. A brief process, but of Western medical science. It is hardly a small comfort, but galling; an inhuman tragedy repeated daily on the gallows it serves as a remarkable lesson to generations in the future, crossbar. The man’s remains were promptly delivered to observing the attitude of Langar’s defeat, the shock of his the anatomist, in this case, to one of Scotland’s finest and exposed intimacy, the beauty of his humanity, and the im- most brilliant obstetricians, Dr. William Hunter.6 On seeing portance of his tragedy. Langar’s example reminds us that the Langar’s muscular corpse, the result of his having served in scientific advancement of humanity rests on the humanity of the army for nearly a decade, it is said that William Hunter the dead. decided that it deserved no ordinary treatment.1 Rather than destroy the body by dissection, Hunter chose to preserve References Langar’s lithe frame and musculature for generations: he . Engelstein S. Anxious Anatomy: The Conception of the Hu- would produce a cast of it. man Form in Literary and Naturalist Discourse. Albany (NY): State In fact, this would not be the first time Hunter had done University of New York Press; . so. The flesh of other executed felons had met similar fates . Wade M. Story of th-century footpad is laid bare. The in his practiced hands; they had been donated to the Royal Times (London)  Jan . www.timesonline.co.uk/tol/news/uk/ Academy for the ironic purposes of instruction in life draw- scotland/article.ece. ing.1 For Langar’s cast, Hunter called upon the talent of his . Stokstad M. Art History: A View of the West. Third edition. friend, the sculptor and painter Agostino Carlini. Hunter Upper Saddle River (NJ): Pearson Education; . stripped the skin and fat from the corpse to produce an . Byron GG. Childe Harold’s Pilgrimage. Chicago: W. B. Con- écorché (“flayed”) figure of the original, then arranged key Company; . Langar’s cadaver into a surreal imitation of the Dying Gaul.2 . Richardson R. Death, Dissection and the Destitute. Second Carlini poured the plaster, sealing the hanged man’s body edition. Chicago: The University of Chicago Press; . into a strange parody of the ancient sculpture—a masterpiece . Fox RH. William Hunter, Anatomist, Physician, Obstetrician, of which Langar had likely never even heard, much less pre- (–), with Notices of His Friends Cullen, Smellie, Fothergill, ferred to imitate in death. At Hunter’s behest, the cast was and Baillie. London: H. K. Lewis; . taken to the Royal Academy, where he delivered multiple anatomical lectures throughout the year to the art students The author’s address is: there. The students dubbed the cast Smugglerius, a pseudo- P.O. Box 551 Latin derivative mocking of the hanged man’s supposed Rochester, Minnesota 55903 occupation. For nearly two centuries, this écorché figure E-mail: [email protected]

24 The Pharos/Spring 2011 Winged doors slid open and she came rolling through, Leaving behind a trail drib, drib, drib !eatedSo that death could follow her in. Sterile curtains slapped aside rattling hands grasping for her soul. All right, docs, we will save a life tonight! A faint pulse electrified with new life lub, dub. lub, dub Her breath exploded with new strength lub, dub. lub, dub. Hah! Vessels and nerves severed now resewn Her heritage replaced by a stranger’s blood. And thus she was assembled—the Bride of Frankenstein. The surgeons and therapists so proud of their creation, On how they cheated death trapped behind the iron gates. To the world she was released in her suffocating existence, Drowning in air, yet wanting none. Gretel set her last trail to sight, Along with a note and “I love you’s.” As the water engulfed her mangled body, she saw death’s face for a second time: An indifferent emptiness for the game it had won. Ms. Malik is a member of the Class of "#$% at the University of Missouri—Kansas City School of Medicine. This poem won Aysha Malik honorable mention in the "#$# Pharos Poetry Competition. Ms. Malik’s e-mail address is: amd&'@mail.umkc.edu.

Illustration by Jim M’Guinness The poison in the cup

Hemlock plant, Conium maculatum. Illustration by Jim M’Guinness.

26 The Pharos/Spring 2011 Horton A. Johnson, MD The author (AΩA, Tulane University 1979), was formerly active ingredient could be isolated, how it functioned physi- director of Pathology, St. Luke’s/Roosevelt Hospital and ologically, and whether it might be another plant alkaloid like Professor of Pathology, Columbia University College of morphine, strychnine, and quinine, which had just recently Physicians and Surgeons. A previous contributor to The been isolated. The winner of the prize, August Ludwig Gieseke Pharos, he is a docent at The Metropolitan Museum of Art. (Giseke), had received from a colleague an ample quantity of seeds of the spotted hemlock and decided to use that as the robably the best-known image of the death of Socrates subject of his investigations. is the painting by Jacques-Louis David now in the His report of his work3 recalls the fact that it took place Metropolitan Museum of Art. David followed, more just thirty-six years after Lavoisier’s Traité had given birth to Por less, the eyewitness account of Phaedo as recorded by modern inorganic chemistry. Organic chemistry was still in its Plato.1 Socrates, in prison, shackles removed, discoursing on infancy, just emerging from the shadowy worlds of alchemy the after-life, is about to accept the poison. Having followed and herbalism. The litmus test was available from the alche- Zeus’s command in a dream to “make music and work at mists, but otherwise organic substances were characterized it,” his lyre is at his side. Crito clutches his master’s leg and chiefly by odor and taste. Gieseke had no thought of atoms Apollodoros weeps. In the background Socrates’s wife is being or molecules. led away at his request. At the foot of the couch, facing away Gieseke planned to separate various fractions of the hem- from Socrates and the grief-stricken disciples, sits the ghost lock juice on the basis of volatility, solubility, and crystalliza- of Plato, a gray figure, head bowed in thought, scroll, pen, tion. The various components would then be tested in rabbits and ink at his side. Plato was, by his own admission, absent to determine which contained the active principle, the poison. because of illness, but David has placed him there in spirit. He would follow closely on the work of the Swiss apothecary The centerpiece of the painting is the cup of poison, offered chemist Jacques Peschier, who in  had separated the juice by the distraught jailer and calmly accepted by Socrates as he of the hemlock into several components. One of these, ob- continues his discourse. It has been assumed that the poison tained after treatment with magnesium hydroxide and ether was the juice of the spotted hemlock, Conium maculatum L, extraction, yielded a mere one-half gram of an alkaline mate- a member of the parsley family and unrelated to the hemlock rial, not enough for further investigation. Peschier had named tree. The Greeks had a specific word for the poisonous hem- the substance coniine after the Latin for hemlock.3 lock, κώνειον (hence the Latin conium), but Plato never called Gieseke’s first attempt failed rather badly. He began by it that. Instead he used the general term, φάρμακον, simply mashing hemlock seeds in wine spirits (ethyl alcohol) and fil- meaning a drug or poison. Since the juice of hemlock leaves or tering out the solid material. He then evaporated the alcohol seeds was, at that time, commonly used to execute criminals, and dissolved the residue in water. Following Peschier’s lead, and since it was repeatedly referenced by ancient authors in the aqueous solution was heated and mixed with magnesium connection with the death of Socrates, and given Phaedo’s de- hydroxide. As he did this, an intolerable odor spread not only scription of the mode of death, it seems reasonable to assume through his laboratory but throughout the entire building. that Socrates did, in fact, drink juice of hemlock.2 One won- Fearing for his health and that of others, he quickly brought ders, then, just what was the poisonous substance in that cup? the procedure to an end. Starting over, he heated the aqueous hemlock extract In  the medical faculty of the University of Halle, with magnesium hydroxide again, but this time in a retort, Germany, offered a prize for the investigation of any of the capturing the noxious fumes by condensing them along with local poisonous plants. The study was to determine how the the steam in the neck of the retort. The residual material

The Pharos/Spring 2011 27 The poison in the cup

Phaedo recalled that Socrates’s jailer, who must have witnessed many deaths by hemlock poisoning, said that a “cold- ness [lifelessness?] and congealing” would travel from the legs up the body until it reached the heart, causing death. The experienced executioner tested the progress by pinching hard first the feet, then calves, and so on. Although he appeared to be testing for sensory loss, it may have been for motor loss, loss of pain-withdrawal reflex. If the cup really contained the juice of Conium maculatum, a flaccid paralysis moved up Socrates’s body until it affected the muscles of respiration, causing asphyxia. In theory, he could have been saved by arti- ficial respiration until the effects of the poison wore off. Gieseke made several speculations that would be proven correct. He suggested that any basic substance, not just magnesium hydroxide, might somehow drive the poison out of The coniine molecule. the hot water solution and that addition of any acid might draw it back into solution. Actually, coniine, the most impor- remaining in the retort was saved and further separated to tant of several alkaloids in the hemlock plant, was present in make two fractions that would eventually prove to be innocu- the form of stable, water-soluble, acid salts. As he heated the ous to the rabbits. The distillate, a slightly yellow, turbid, crude aqueous extract and made it basic by adding magne- aqueous solution, had oily droplets floating on its surface. sium hydroxide, Gieseke was liberating the free, basic, poorly It had a very bitter, ammonia-like taste, an odor much like soluble, and volatile coniine from its acid salts and into the the spirits of hartshorn, and a strongly alkaline reaction with atmosphere. A century and a half before the scourge of “crack litmus. It was neutralized with sulfuric acid and then evapo- cocaine,” Gieseke was “free-basing” another plant alkaloid, rated to obtain needle-like crystals. These were dissolved coniine. Adding acid reversed the process, recapturing the in alcohol to produce a fraction that was lethal to rabbits. coniine into acid salts. Gieseke had, with this simple procedure, isolated from the As he worked with the poison, there was always a smell of crude hemlock extract the active principle of hemlock in pure ammonia about. He speculated that traces of ammonia were crystalline form, probably as coniine sulfate. Interestingly, he being released from the poison itself, that ammonia might be never used Peschier’s term, coniine, but simply referred to it a part of the poison. Coniine can, in fact, be reduced to release as Schierlinggift, hemlock poison. ammonia, leaving a straight carbon chain, ordinary octane. The dried material was dissolved in water and given (route Gieseke suggested, as had others before him, that it might be not specified, probably by mouth) to two young rabbits, one an ammonia component that gave the plant alkaloids their grain ( mg) to one and  grains to the other. The rabbit given basic or alkaloid character. It is indeed the nitrogen atom with the larger dose died within two minutes. The other, however, its lone pair of electrons that makes coniine “alkaloid.” died slowly, allowing Gieseke to describe what would become Alkaloid chemistry moved ahead swiftly in the following known as the typical syndrome of hemlock poisoning: as- years. In , the great A. W. Hofmann determined the em- cending flaccid paralysis, not unlike the death of Socrates as pirical formula of coniine, CHN, and deduced its structural described by Phaedo. Within fifteen minutes the animal began formula, a piperidine ring with a propyl group at the  posi- to hop around anxiously. Soon the hind legs became paralyzed tion.4 By century’s end, dozens of plant alkaloids had been and stretched out on the table. The animal struggled to sup- isolated and characterized, including morphine, codeine, port itself upright with its forelegs. After twenty minutes the nicotine, atropine, cocaine, quinine, strychnine, and caffeine.5 forelegs collapsed, and the animal tried to support itself off the Coniine, the simplest of all the plant alkaloids, was the first table with its head. After thirty minutes it lay down on its side. to be synthesized in  by Ladenberg6 who, in his compre- Clonic spasms began. Eyes became fixed. After fifty-five min- hensive History of the Development of Chemistry,7 made no utes the animal was dead. Autopsies of these animals showed mention of Gieseke and his primitive experiments. no significant pathological changes. It has since been shown that coniine blocks the neuro- The Metropolitan Museum of Art bought David’s painting muscular junctions of skeletal muscles, but Gieseke, knowing in . Within a few years millions of visitors to the museum nothing of neuromuscular junctions or lower motor neurons, had witnessed Socrates accepting the cup of hemlock with attributed the deaths to poisoning of the spinal cord and its coniine. Those who knew the story could foresee Socrates brain. His rabbits actually died of paralysis of the muscles of drinking the poison cheerfully and arising to walk about until respiration. he felt a heaviness in his legs. They would remember how he

28 The Pharos/Spring 2011 Jacques-Louis David (French, 1748-1825), The Death of Socrates, 1887, oil on canvas, 51 x 77¼ in. The Metropolitan Museum of Art, Catharine Lorillard Wolfe Collection, Wolfe Fund, 1932(31.45). Image © The Metropolitan Museum of Art.

lay on his back as the chill of death traveled upward toward Did Plato Tell the Truth? In: The Trial and Execution of Socrates: his abdomen, and how he spoke his last words, “Crito, we Sources and Controversies. Brickhouse TC, Smith ND, editors. New owe a cock to Asclepius. Pay it, and do not neglect it.” After a York: Oxford Press; : –. while he moved a bit. Then his eyes became fixed. Crito closed . Gieseke AL. Über die wirksame Princip des Schierlings, Co- his eyes and mouth. “Such was the end,” said Phaedo, “of our nium maculatum. Arch Pharm ; : –. friend, who was, as we may say, of all those of his time whom . Hofmann, AW. Einwirken der Wärme auf die Ammonium- we have known, the best and wisest and most righteous man.” basen. Ber dtsch chem Ges ; : –. In , long after the painting had become an icon of the . Pictet A. The Vegetable Alkaloids. With Particular Reference Phaedo, the brilliant Belgian sleuth, Hercule Poirot, became to Their Chemical Constitution. Biddle HC, translator. New York: acquainted with a landed English gentleman who distilled John Wiley and Sons; . coniine in his home laboratory, evidently following, more or . Ladenburg A. Über die imine. Ber dtsch chem Ges ; : less, the method of Gieseke. The amateur chemist enjoyed –. demonstrating the procedure to friends and neighbors, after . Ladenburg A. Lectures on the History of the Development of which he led them into the library for a reading of the death Chemistry since the Time of Lavoisier. Dobbin L, translator. Edin- of Socrates in Plato’s Phaedo.8 One cannot help but wonder to burgh: The Alembic Club; . what extent Dame Agatha may have been inspired by David’s . Christie A. Five Little Pigs. New York: Dodd, Mead and Com- The Death of Socrates. pany; : –, .

References The author’s address is: . Plato. Phaedo. Fowler HN, translator. London: William 160 West 66th Street #47C Heinemann; . New York , New York 10023 . Bloch E. Hemlock poisoning and the death of Socrates: E-mail: [email protected]

The Pharos/Spring 2011 29 Tackling diabetes in Old Delhi

Syed Saad Mahmood, MD, MPH

The author (AΩA, Case Western each crumbling sandstone facade or Reserve University, 2010) is a resident ornate wooden doorway. Shams, the in Internal Medicine at Massachusetts home-visit nurse, after waiting for me to General Hospital. This essay won third finally catch my breath, knocked on our prize in the 2010 Helen H. Glaser patient’s front door. Fifty-eight-year-old Student Essay Competition. Mrs. Nida greeted us with a smile that brought into relief the high cheekbones ut of breath from trying to and almond shaped eyes pointing to the keep up with the home-visit Central-Asian ancestry of Old Delhi nurse, I was relieved to reach residents.1p50 Mrs. Nida lived with her ourO diabetes patient’s quarters deep three daughters in two cramped rooms within historic Old Delhi. The cool carved out of a dilapidated mansion. March breeze made its way through the Focused on saving for her children’s city’s labyrinth of gullies, or alleyways, wedding dowries, she had ignored years helping the sweat on my face evapo- of blurring vision, constant thirst, and rate. Seeing the row of now ramshackle a tingling sensation in her feet. Only houses, I imagined the story behind when her eldest daughter noticed an

30 The Pharos/Spring 2011 ulcer on her foot was she brought to a hand-woven dupatta, or head stole. Adams Care Charitable Hospital, where Shams and I joined her on a thin cotton- I first met her, and where she was diag- filled mattress laid on the floor. To show nosed with the “sugar disease,” as type  gratitude to Shams, Mrs. Nida offered diabetes mellitus is locally known. us Rooh Afza sherbet, a syrup of rose Mrs. Nida’s type  diabetes is not water and honey that I accepted while unusual. India has . million diabet- making a mental note to list the drink ics, more than any other country in the “off-limits” for diabetics. world.2 Diabetics make up a relatively higher percentage of India’s population, Observing Mrs. Nida’s mannerisms, . percent, compared to . percent of I began to think about the narrative the U.S. population.3 Yet India has an of her historic city. Old Delhi truly obesity rate of . percent of the total came to life in  when the Mughal population, compared with approxi- Emperor Shahjehan laid the founda- mately  percent in the United States. tion stone to establish his new capital, India’s modern diabetes epidemic is fu- Shahjehanabad. The Mughal emperor eled by a combination of environmental had been grieving after the death, dur- factors, such as higher smoking rates, ing childbirth, of his queen, Mumtaz and a genetic predisposition that may Mahal, and had decided to relocate his account for why the urban poor, like court. After nine years of construction, Mrs. Nida, are so likely to develop the the royal household moved to the new pathology. Some researchers contend city, leaving behind the previous capital, that in-utero exposure to undernutri- Agra, but not before bequeathing it with tion—the case for  percent of Indian a place in the history books through the infants—can lead to higher susceptibil- construction of Taj Mahal, a tribute to ity to type  diabetes later in life. The Mumtaz Mahal. urban poor are also less likely to receive Shahjehanabad’s centerpiece was adequate treatment since diabetes and Chandni Chowk, Moonlit Square. Built other diet-related noncommunicable by the Emperor’s favorite daughter, diseases account for . percent of Jahanara Begum, the Chowk’s focus was India’s total health care cost.4 water—it featured a square reflecting As part of my public health cap- pool fed by a tree-shaded canal running stone project at Case Western Reserve along the avenue that supplied water University, I was in India to assist in pro- to residents.11p198 Under royal patron- viding charitable hospital care for Old age, the capital evolved into boulevards Delhi’s underprivileged. The hospital of Mughal Gardens and ornate hawe- wanted to produce an educational bro- lis—courtyard mansions—with arched chure on type  diabetes that targeted doorways and elaborately painted ve- the unique diet of their patient popula- randahs. As a center for Urdu literature tion. To learn about the dietary habits and Islamic calligraphy, many of India’s and barriers to care in this community, finest poets—Mir, Zauq, and even the I accompanied Shams during his home great Mirza Ghalib—composed their visits to change ulcer dressings twice a poems in these hawelis. In , poet week. And that is how I found myself at Chandar Bhan Brahman proudly wrote Mrs. Nida’s home. Though living a chal- that the city’s “towers are the resting lenging life of limited resources, Mrs. place of the sun. Its avenues are so full Nida had a subtle regality and a sense of pleasure that its lanes are like the of culture, as if her comportment had roads of paradise.” 1p53 been passed down through successive For over two centuries the capital generations in a once-prosperous pre- prospered as a center of trade, hosting colonial metropolis. During each visit, coronations and, later on, even the early Mrs. Nida sat with her back straight and marriage of a young boy who would her henna-dyed hair neatly bundled in grow up to become India’s first prime

The Pharos/Spring 2011 31 A modern epidemic in a historic city

About the author I grew up in cities across India, spent a few years on the Red Sea coast, and consider New Delhi as my home. It was a pleasure exploring the tranquil U.S. Midwest as a college student and then medical student at Case Western. Now longing for the organized chaos of New Delhi, I recently moved to Boston, where I can once again relive the hustle and bustle of a global metropolis. As I begin my Internal Medicine residency at Massachusetts General Hospital, I hope to still be able to carry on my love for reading. Perhaps inspired by conversations with my grandfather, a recurrent subject choice is the biographies of the leaders of South Asia’s freedom struggle. I am grateful to the Thomas M. and Janet S. Daniel Fellowship for funding my work in Old Delhi. Shah Jehan on Horseback. Attributed to Bhag. © Francis G. Mayer/CORBIS. minister.5 But with its fortunes inter- residents began to abandon what they As I continued to visit Mrs. Nida, twined with that of the empire, the me- now dubbed Old Delhi. In , the city she began to share her family’s story. tropolis began to decline with the fall was the scene of some of the worst tur- Her forefathers had been the official of the dynasty to Great Britain. After moil of India’s partition into the newly cooks to the fourth Mughal emperor. the failed First War of Independence established state of Pakistan as this erst- The family had thrived while serving in , the last Mughal emperor was while unified nation achieved indepen- the royal household, but like the city exiled to Burma and the city finally lost dence from Great Britain, fueling the fell onto difficult times when the royal its royal patron. Like Shahjehan, the final mass exodus of affluent residents.6 family was exiled. Mrs. Nida’s ancestors British Raj also wanted a new capital Left behind were those too poor to went from preparing stately cuisine to of its own. In , Sir Edwin Lutyens migrate, who today constitute some of toiling in the warehouses and facto- was tasked with creating a “New” Delhi modern India’s most underprivileged ries that encroached on the abandoned southwest of the defeated city. Lutyens citizens. The city’s current residents, buildings. Her people had endured the created Imperial India’s capital by much like our patient Mrs. Nida, are purges following the failed First War of blending Indian and Victorian archi- mostly day-laborers, unable to obtain Independence, as well as the communal tectural styles.1p84 With the shrinking medical care and living in congested turmoil of India’s partition. She was a metropolis already in decline, and faced slums or rusted tin huts in the shadows survivor who seemed to not mind the with the draw of Lutyens’s “New Delhi,” of mansions from yesteryear. hardships, but proudly carried with her

32 The Pharos/Spring 2011 Aerial view of Chandnee Chauk, Delhi, circa 1857. Bettmann.

the knowledge of her roots. in time for the wedding. Once again sit- References Befitting her family history, it was ting regally on the cotton mattress, she . Dalrymple W. City of Djinns: A Year Mrs. Nida who introduced me to the gave her final approval of the brochure. in Delhi. New Delhi: Penguin; . local diet to help me create a diabetes- I congratulated her on the upcoming . Chan JCN, Malik V, Jia W, et al. Dia- related educational brochure for Old wedding and waved a final goodbye. As I betes in Asia: Epidemiology, risk factors, Delhi’s residents. I learned about vari- left, I was acutely aware that many other and pathophysiology. JAMA ; : ous high-sugar dishes, such as papay, a residents of Old Delhi would not be as –. popular daily tea-time snack. Mrs. Nida fortunate as she: the Indian Council of . Yoon K-H, Lee J-H, Cho JH, et al. Epi- also helped me to understand that the Medical Research estimates that diabe- demic obesity and type  diabetes in Asia. residents of Old Delhi were unfamiliar tes causes , deaths per year.7 As Lancet ; : –. with the symptoms of type  diabe- a city past its zenith, Shahjehanabad’s . Popkin BM, Horton S, Kim S, et al. tes and believed that it needed only a current inhabitants are overwhelmingly Trends in diet, nutritional status, and diet- one-time treatment. With her input we likely to succumb to diseases fueled by related noncommunicable diseases in China compiled a brochure to fill these knowl- poverty and lack of awareness. But I and India: The economic costs of the nutrition edge gaps. Our brochure listed the local also felt a sense of hope, inspired by the transition. Public Health Nutr ; : –. diet and divided food habits into three resilience of Mrs. Nida and the chari- . Frank K. Indira: The life of Indira categories: food that could be eaten table hospital that had invested in the Nehru Gandhi. Great Britain: Harper Col- freely, food that required moderation, educational brochure. On my last walk lins, : . and food to be avoided. Also listed were through the gullies, I paused at what . Wolpert S. Jinnah of Pakistan. New inexpensive and traditional therapies for remained of Chandni Chowk. Suddenly Delhi: Oxford University Press; : . reducing hyperglycemia, such as eating able to see remnants of the royal avenue, . Mohan V, Pradeepa R. Mortality in soaked methi (fenugreek) seeds. I began to appreciate even more the diabetes mellitus: revisiting the data from As Mrs. Nida’s treatment slowly pro- poet Ghulam Khan’s optimistic words a developing region of the world. Postgrad gressed between each visit, so too did on his home city: Med J ; : –. our educational brochure. During my final days in the one-time royal metrop- It is like a Garden of Eden that is The author’s address is: olis, I dropped off the completed Hindi populated. It is the foundation of the Bulfinch Medical Group (WAC-5) language brochure for her approval. eighth heaven.1p53 Massachusetts General Hospital Mrs. Nida was busy preparing for her 15 Parkman Street elder daughter’s marriage, and very Now sharing Mrs. Nida’s pride in Old Boston, Massachusetts 02114-3117 pleased that her foot ulcer was healing Delhi, I could not agree more. E-mail: [email protected]

The Pharos/Spring 2011 33

Ibiayi Dagogo-Jack The author is a member of the Class the plank, and beheaded for carrying a knows that a running stitch will never of 2011 at the University of Chicago kaleidoscope in a monocular time. be fast enough to carry me away. Today Pritzker School of Medicine. This es- The world we live in, as medi- I twine my fingers together, exploring say won an honorable mention award cal students, is an optical illusion. It my strength, as I pound tirelessly at a in the 2010 Helen H. Glaser Student is composed of an endless sequence stubborn heart. Essay Competition. of Rorschach blots. We are a race of A month ago I sat beside a patient I Picassos relegated to defining ourselves liked so much that I wished that some- cannot distinguish red from dark in concrete terms. Two years ago, a one else would take her place. And a few pink, among other things. When I woman asked me what would become days after she left, when another woman look at the human hand, I do not see of me. I will be an oncologist, I told her, looked up at me from her bed, I found theI three-dimensional melding of all of with finality. And two years ago I would myself wishing that yet another person the rows of bones into a final product. have been an oncologist. Then I was would take her place. Exasperated, I I see individual bones that happen to not so intimately familiar with dying recounted my feelings to my resident. be neighbors. And for the first time or so bitten by the frost of mourning She regarded me with the same pity in my life, I am beginning to wonder that I could appreciate the stinging per- that I had extended to my patients. We whether an orange tastes different if it manence of death. A year ago, another have two new patients waiting to be ad- is dark red, bright orange, spherical, or woman, curious to pin me down in time, mitted in the ER, she said. And in that flat. I am aware that this is not the first repeated the question. A head and neck moment I realized my error. Still, I am time that there has been dispute about surgeon, I answered decisively. Perhaps not angry that I confided in her. These dimensions. Still I am bothered by the if I see this woman now, she will ad- are the mistakes all explorers make in question: Would you have walked off dress me as one addresses a head and mapping the new world. I am, however, the edge of the world because I sub- neck surgeon. My hands will stammer, furious that I was discovered in my cor- scribed to a theory of flat expanse? At my lips will clasp, and I will shake my ner of the jungle, clad in wilting leaves, this moment, I believe that you would head. I am something else today, I might shooting lifeless darts from a blowgun not have . . . in the same way that I am tell her, and she will scoff at my evanes- at a mighty man in a helicopter. The last certain that no hat fits any two people cence. But I do not lament the mercurial isolated tribe has been discovered in the the same way. But we live in a one-size- as much as I condemn consistency. My Amazon, the headlines will boast. And fits-all universe and I am learning to hands are not the same today as they I, of course, will wonder how isolated navigate it. I am learning that simplicity were a year ago. Before, I held a pen- one can be in a crowd in the same way suits. Every day, I am advised to use cil with precision as I blackened sheet that I wonder about the only man who Occam’s razor: Entia non sunt multi- after sheet of paper. Before, I believed smiles at a funeral. Most often he is the plicanda praeter necessitatem, roughly that I could stitch the human body one closest to the deceased. But he does translated as “Entities must not be mul- with the nonchalance of passing thread not sit with the family. We worship too tiplied beyond necessity.” And every through a sweater. But part of me, the strongly the ties of blood. day, I am burned at the stake, cast off part that shivers in the operating room, The other day, I saw an elderly woman

34 The Pharos/Spring 2011 Illustration by Erica Aitken The Pharos/Autumn 2010 35 That which we carry with us

struggling to push her grocery cart along home. And as a wearer of so many flags, the contrary sidewalk. I walked past her. it bothers me that people wish to pin- About the author Then I turned around because she re- point my identity. For the first time, I I was born in Port minded me of what my mother’s mother am seeing the world through my eyes Harcourt, Nigeria, would have looked like. Would you like alone. My father does not always pick up and raised in St. me to help you, I offered. She shook the phone on the first ring. My mother Louis, Missouri. her head and smiled as she dragged tells me that she is tired. I forget to call I graduated from away. I promise that for a moment she home. And the world looks much differ- Vanderbilt University looked younger and her back arched ent from two eyes than it did from six, with a BA in biologi- less. Yet I felt deflated—as if someone a little more cohesive yet a little more cal sciences. I am currently a student had punched me in the stomach—be- disorganized. Every day I look out of the at the University of Chicago Pritzker cause I was realizing just how invisible window of my apartment at the sailboats School of Medicine. I have always we become in a crowd. I do not want to on the lake. I am drawn to water in the been interested in writing and have be overlooked. I refuse to be life’s punc- same way that a rabbit is drawn to a trap written several essays related to my tuation mark. But sometimes I am afraid and a fish is drawn to a worm. It terri- medical school experience, in ad- that such is the fate of all. fies me and tantalizes me. It reminds dition to two unpublished fiction People laugh when I tell them that I me of two years ago when we celebrated books. In the past three years of am exceptional. And sometimes, after our final day of the first year of medical medical school, I have become in- being lanced by their criticism, I con- school. As I sat down on the rocks over- creasingly interested in the patient sider the cost of greatness, whether it is looking Lake Michigan, I expounded voice and background and its con- something worth chasing or something about life. I’ve never seen you this happy, tribution to the experience of being that I should run from, whether it ex- my friend commented, is it because it ill. I plan on pursuing a residency in ists at all or is merely a term born of is the last day of school? No, I said, it is Internal Medicine. comparison. Yet somehow I know that because I am by the water. The danger greatness exists in the same way that I of hanging off of the edge thrills me. My know that I hear at eight channels. My friend continued to look at me, sensing teacher, trying to explain the concept that I had stopped mid sentence. I sup- not photogenic. Change is most forgiv- behind ear implants, had us all close our pose it is in my blood, I concluded, my ing to those who do not pose.” I was eyes as he played a message using in- Nigerian ancestors are people of the riv- so proud of the line that I made it my creasing numbers of hair cell channels. ers. For some reason, I feel most at home away message for the day. My younger No one heard anything at four channels; by the water. My friend nodded his head brother instant-messaged me and asked no one is supposed to. I squeezed my and moved on. Perhaps my words had the origin of the quote. I wrote it, I eyelids and tuned out the world. I heard transported him back to his own womb, replied. It took him minutes to believe the message, “my appointment is for six the cradle of his ancestry. me. After a year of resisting, he asked o’clock in the afternoon.” Eight chan- It worries me that something as tu- to read my book. I reminded him that I nels! No one else heard it. Still, my voice multuous, inconstant, and abusive as had offered it to him many times before. wobbled as I relayed the message to the the water reminds me most of myself. He could not remember ever refusing it. whole class. Even now, I am not certain But without water life would be in- I am beginning to believe that life will that I could repeat the achievement. feasible. In the same way, I guess, I do always unfold like this, in convincing But then again, the first man who ran not have to be sustained to provide the contradictions. I am not disgruntled a marathon dropped dead after deliver- world sustenance. I am not the per- by this realization. We will not all take ing his message. It only takes one time son at this moment that I was when I the same path to reach the corner of to succeed. Interestingly, my physical started writing this. I am not the person the world. We will not all walk over the diagnosis class informs me that the big- today that I was when I first moved to edge. But those of us that do will find, gest battle in old age plays out between Chicago. Please do not expect me to be. upon reaching the other side, that we obscurity and immortality. I wonder if I Last week, I stumbled across a book will still be standing beside our friends am aging too quickly because my knees that I wrote many years ago, that I had that did not cross. For life is not that whine from walking up the stairs. I won- forgotten during this time of change. It which carries us, pushing us forward der if I am aging too quickly because was not until I reread the entire book like a gust of wind. Rather, life is that at age twenty-four I am obsessed with that I found my favorite line in the which we carry with us. immortality. acknowledgment section. I did not re- I live nine hours away from home. member writing it. “Life is too short The author’s e-mail address is: ibiayi.da- Actually, I live many worlds away from for sitting down for pictures. Time is [email protected]

36 The Pharos/Spring 2011 My father eats grapes with roti late one March night, chasing each verdant orb around the plate with a torn roti piece, pinching each grape with the same delicate insistence that he uses with forceps during surgery. He recalls his mother telling him to eat such scraps when there was no meat for saalan, which upset him then, the same way dada abu did when he beat dadi ami for the lack of meat, but satisfies him now, like when he recollects his agha sitting in the Pakistani monsoon, eating iced mangoes from a bucket. I imagine agha— who loves by helping to heal, reinflating lungs, unclogging arteries— on his final visit to his father, starting cigarettes for my bed-bound dada abu, whose joviality was enough strength to recite ghazals. Through the rickshaw blare of life, I spy the serenity of simplicity in my father: the bread, fruit, rain. Though he does not light any more cigarettes, the ghazals he can sing. Akas Siddiqui

Glossary of Urdu words: agha = father; roti = soft, round flat bread; saalan = curry; dada abu = paternal grandfather; dadi ami = paternal grandmother; ghazals = genre of Urdu poetry. Mr. Siddiqui is in the Sports Medicine Research program at the University of Texas Southwestern. This poem won honorable mention in the "#$# Pharos Poetry Competition. Mr. Siddiqui’s e-mail address is: [email protected]

Illustration by Erica Aitken Alpha Omega Alpha elects honorary members

ndividuals who have contributed substantially to medicine and fields related to medicine, I and the National Academy of Social but who are not eligible Insurance. He earned AB, AM, and PhD degrees from Harvard for membership in AΩA University. Fox has been publishing regularly as graduates of a medical for half a century. In addition to peer-reviewed articles, commen- school with an AΩA chap- taries, and reviews in journals of health care, health services research, ter or as a faculty member Daniel M. Fox, PhD health policy, law, and history, he is Daniel M. Fox, President Emeritus the author of The Convergence of of a medical school main- of the Milbank Memorial Fund, is Science and Governance: Research, an author of books and articles on Health Policy and American States taining an active AΩA health policy and politics and an (); Power and Illness: The adviser to public officials, leaders of Failure and Future of American chapter, may be nominated provider systems in health and long- Health Policy ( and ); term care, research organizations, Engines of Culture ( and ); for honorary membership publishers, and foundations. Before The Discovery of Abundance ( serving as president of the Fund and ); Economists and Health by any active member of ( through ) he worked in Care (); Health Politics, Health state government (Massachusetts and Policies: The Experience of Britain the society. In  Alpha New York) as an adviser to and staff and America – (); and member of three federal agencies (the Photographing Medicine: Images and Omega Alpha’s board of Office of Economic Opportunity, and Power in Britain and America since Departments of Housing and Urban  (). Books he co-edited in- directors extended invita- Development, and Health and Human clude AIDS: The Burdens of History Services) and as a faculty mem- (); AIDS: The Making of a tions to the following dis- ber and administrator at Harvard Chronic Disease (); Five States University and at the Health Sciences That Could Not Wait: Lessons for tinguished physicians and Center of the State University of New Health Reform from Florida, Hawaii, York at Stony Brook. He is a mem- Minnesota, Oregon and Vermont scientists. ber of the Institute of Medicine of (); Home-Based Care for a New the National Academies of Sciences, Century (); and Treating Drug the Council on Foreign Relations, Abusers Effectively ().

38 The Pharos/Spring 2011 co-authored forty-eight articles in peer- reviewed journals. He has also authored eighteen chapters of rheumatology Robert M. Klein, PhD textbooks in Argentina, Spain, and the Robert M. Klein received his BA de- United Kingdom. Dr. Hubscher is a gree cum laude with Honors in Biology founding member of ASSA (Asociación from Queens College of the City Sindrome de Sjogren Argentina) and of University of New York and his Master’s ALUA (Asociación Lupus Argentina), and PhD degrees in Biomedical one of the international chapters of the Sciences from New York University, Osvaldo Hubscher, MD, MACR Lupus Foundation of America. School of Medicine, Graduate School Osvaldo Hubscher of Buenos Aires, He served as President of the of Arts and Sciences. He completed Argentina, is Associate Professor of Argentine Society of Rheumatology a postdoctoral fellowship at Medical Medicine at CEMIC Medical School. from  to  and was designated College of Wisconsin/Marquette He graduated cum laude in Medicine Master of Rheumatology in  by the University. from the University of Buenos Aires Society. A member of the Argentine Professor Klein has been a faculty in  and completed specialist Society of Clinical Investigation, Dr. member in the Department of Anatomy certification in Internal Medicine Hubscher is an honorary member of and Cell Biology at the University of and rheumatology at CEMIC where the Brazilian, Chilean, and Colombian Kansas, School of Medicine (KUSOM) he has remained as a faculty mem- societies of rheumatology. He also for thirty-two years and has risen ber. At present he is Consultant served as Vice President of PANLAR through the ranks from assistant pro- Rheumatologist of the Section of from  to . fessor, being promoted to the rank of Rheumatology and Immunology, In  Dr. Hubscher became a professor on July , . He has taught Department of Medicine. Fellow of the American College of microscopic anatomy, cell biology, de- Dr. Hubscher served or is still Rheumatology (ACR) and has been a velopmental biology, and embryology serving on the editorial boards of member of the International Advisory to medical students during his tenure several journals including Arthritis Committee from  to  and in the School of Medicine. Over the & Rheumatism, Current Opinion in of the Annual Meeting Planning past decade, Dr. Klein has been active Rheumatology, LUPUS, Osteoarthritis Committee for the period  through in curriculum development for the un- & Cartilage, and Clinical . In  he became Master of the dergraduate medical program. Dr. Klein Rheumatology and has authored or ACR. has earned most of the major teaching honors awarded to faculty in the School of Medicine. He also was a charter recipient of a Kemper Fellowship for excellence in teaching and mentoring at Wahid Ali Said AlKharusi, MD the University of Kansas and followed Dr. Wahid AlKharusi is the first Dr. AlKhauri was instrumental in or- that by becoming the only faculty mem- foreign educated orthopaedic surgeon ganizing emergency care in Oman, with ber to receive two Kemper Fellowships. in the Sultanate of Oman, and built up a special interest in road traffic safety. Professor Klein was appointed modern orthopaedic treatment in the With other members of the Bone and as Associate Dean for Professional country. He received his surgical train- Joint Decade, he advocated for the United Development and Faculty Affairs ing at Cambridge University and his Nations to pass five resolutions on road (PDFA) in the School of Medicine, July orthopaedic consultant accreditation safety. He became a member of the UN , . The PDFA office organizes from the University of Edinburgh and Raod Safety Collaboration, chared by and runs major programs and activi- Glasgow in . He served for many WHO, and is the official representative ties including an array of professional years as the head of Khuola Hospital in from Oman and recently appointed am- development workshops to facilitate the Muscat. bassador in the foreign ministry. research, teaching, and clinical activi- ties of the KUSOM faculty.

The Pharos/Spring 2011 39 Health policy Will the new generation of physicians promote health care reform?

Arnold Relman, MD The author is professor emeritus of Medicine and Social Care? An Open Letter to Medical Students” in the November Medicine at Harvard Medical School, and is the former  issue of the AAMC Reporter, in which they urged stu- Editor-in-Chief of the New England Journal of Medicine. dents to oppose the new law. They argue that ACA will change the doctor-patient relationship, “gives Washington more hysicians in the United States have in the past generally power to determine care . . . encourages ‘cookbook medicine’ taken a conservative view of major changes in the medical with new comparative effectiveness authorities that will make careP system, fearing heavy-handed government interference coverage determinations based on cost—rather than what may with professional autonomy and with the relationship between be best for individual patients,” and “relies on unproven pilot doctors and patients. But the need for reform has become programs to deliver needed savings.” They add, “Costs will increasingly clear in recent years and doctors’ traditional sus- continue to rise. Bureaucrats and politicians will have more picion of legislative efforts to improve the health system has control, while patients and doctors will have less.” Barrasso begun to moderate. and Coburn offer no specific alternatives to ACA, but claim The leadership of the American Medical Association re- that in the past they have suggested reforms that would lower versed its longstanding opposition to health reform legislation costs, improve quality and “give all Americans more control of by endorsing the Patient Protection and Accountable Care their health care dollars.” 3 Act (ACA) that the Obama administration managed to enact On November , , a response to this Open Letter in March , despite the fact that it did not provide for tort was posted on the Huffington Post by four MDs-in-training, reform or resolve the problem of the scheduled reduction in all of whom are current or former national leaders of the Medicare payments to physicians. American Medical Student Association (Lyah Romm, John Recent polls of practicing physicians have found consider- Brockman, Elizabeth Wiley, JD, MPH, and Sylvia Thompson, able support for some type of health care reform. One such MD, MPH). These authors defended ACA as a valuable step poll published in the New England Journal of Medicine in toward rescuing a health system “on the brink of collapse.” , with responses from  physicians in all specialties, They wrote, “The imperfection of the ACA is not that it went found that almost three-quarters favored public, or public and too far, but that it did not go far enough to address profit- private, options for expanding health insurance, and a little driven intrusions into the patient-physician relationship. . . . more than half supported expansion of Medicare to include Your assertion of having supported reforms that would pro- adults between  and  years of age.1 vide affordable, high-quality coverage within reach for every An even more remarkable result was obtained in a poll American is not borne out through fact or experience. . . . The of practicing physicians in Massachusetts conducted by the overwhelming majority of physicians agree that key provisions Massachusetts Medical Society just before passage of ACA. of the Affordable Care Act will improve access to health care Fully a third of respondents thought the reform legislation services for millions of Americans. . . . Please stop obstructing should include a single-payer system offering health care to health care reform implementation.” 4 all citizens, while an almost equal number thought that public If this rousing statement by leaders of AMSA does indeed and private health insurance should include an option to buy reflect the views of a majority of their colleagues, then we in to a public Medicare-like option.2 should be proud of the idealism and good sense of the new The passage of ACA nevertheless has generated consider- generation of physicians. They apparently support ACA but able opposition among conservatives (mainly Republican) in understand that “it did not go far enough.” Congress, and also among the public at large. Current polls As I have written elsewhere,5 ACA clearly falls short of the show public opinion just about equally divided on the health reforms we need. Much more remains to be done if we want to reforms included in ACA. An explanation for this public control costs and improve the quality of U.S. health care. ACA skepticism is probably to be found in the aggressive campaigns is at least a start. It can and must be extended by reforms that waged by Republican and Tea Party organizations, which have change the way medical care is organized and paid for. Many spread much misinformation about the legislation and raised health economists now believe that cost control will require a unfounded populist fears about a “government takeover” of transition away from fee-for-service payment to some type of the medical care system. payment that rewards quality and efficiency, rather than the Two Republican senators who are also physicians (John number of services provided. “Global” payment, i.e., a single Barrasso of Wyoming and Tom Coburn of Oklahoma) pub- payment for comprehensive care of a given medical problem, lished “Will the Health Overhaul Improve American Health or capitated payment for total care over a period of time,

40 The Pharos/Spring 2011 would meet that need. However, to receive and distribute holds them accountable for costs and quality would undoubt- global payment would require organizations of physicians edly follow. working together with affiliated hospitals. Without this kind of reorganization of medical care, effec- ACA provides for demonstration projects and limited trials tive payment reform and cost control are unlikely. But such of new forms of provider organizations and payments (e.g., the changes cannot be accomplished without initiatives and future so-called “accountable care organizations” that would receive support from the medical profession. I am betting that the and distribute “global payments” rather than fees-for-service). new generation of physicians will meet that challenge. But there is no legislative mandate in ACA for nationwide implementation of such sweeping change, and little likelihood References that a deadlocked Congress will be able to enact any major . Keyhani S. Federman A. Doctors on coverage—Physicians’ reforms in the near future. views on a new public insurance option and Medicare expansion. N Nevertheless, I believe there is now an opportunity for Engl J Med ; : e. the medical profession to take the next steps toward reform . Massachusetts Medical Society.  Physician Work- even without any immediate legislative action.6 Multispecialty force Survey: –. www.massmed.org/AM/Template. group practice, with physicians paid at least in part by a salary, cfm?Section=Research_Reports_and_Studies&CONTENTID= is the best kind of physician organization that could accept &TEMPLATE=/CM/ContentDisplay.cfm. Accessed  Feb . and distribute a global payment, and could also be account- . Barrasso J, Coburn T. Viewpoint: Will the Health Overhaul able for quality and efficiency. There is evidence that perhaps Improve American Health Care? An Open Letter to Medical as many as a quarter of all practicing physicians now belong to Students. AAMC Reporter  Nov. www.aamc.org/newsroom/ these group practices, and their number is rapidly increasing.6 reporter/nov//viewpoint_barrasso_coburn.html. Accessed If this trend were to accelerate, and if most or all of the groups  Feb . were to be not-for-profit physician-managed organizations . Romm L, Wiley E, Thompson S, Brockman J. Medical stu- that paid their professional staff mainly by salary (even while dents to Senate Republicans: Repeal is not the solution to our health allowing for bonuses based on effort and contributions to the care crisis. Huffington Post  Nov . www.huffingtonpost.com/ group), a major step toward reform would have been taken. iyah-romm/medical-students-to-senat_b_.html. Accessed  Without coercion by government or pressure from private in- Feb . surers, the medical profession would have started on the road . Relman A. Health care: The disquieting truth. NY Rev to the type of reform we need. Books  Sep : –. http://www.nybooks.com/articles/ Well-managed multispecialty group practices have been archives//sep//health-care-disquieting-truth/. Accessed  demonstrated to provide excellent care more efficiently than Feb . the expensive and fragmented system that now dominates . Relman A. Could physicians take the lead in health reform? the U.S. health care scene. Almost half of new physicians are JAMA ; : –. women, and a growing number of the new generation seems to be choosing this style of practice because it also offers them The author’s address is: many personal and professional benefits. If multispecialty 13 Ellery Square groups become the predominant form of practice, public and Cambridge, Massachusetts 02138 government support for legislation that supports groups and E-mail: [email protected]

The editors invite original org or to our regular mail- articles and letters to the ing address:  Middlefield editor for the Health Policy Road, Suite , Menlo Park, section, length  words or CA . E-mail submis- fewer for articles,  words or sions preferred. All essays are fewer for letters. subject to review and editing Please send your essays to by the editorial board of The info@alphaomegaalpha. Pharos.

The Pharos/Spring 2011 41 The physician at the movies

Peter E. Dans, MD

obnoxious. Not only is he rude and arrogant but he manages to alienate everyone he comes in contact with and to betray his only friend. To call him “hyper” is an understatement. He is portrayed as a fast-talking self-referential obsessive-compul- sive manic-depressive. Like many of his Harvard classmates portrayed in the film, he shares the sense of their being “special people.” And to some extent they are, having stood out at their high schools and, as one guidance counselor used to say, having built a cyclotron in their backyard or its equivalent. They are placed in a pool of “number ones,” making it harder to stand out. As his date, Erica Albright (Rooney Mara), tells him, it may sound trite but “you should try to become the best you” rather than obsess about and envy his privileged classmates. Some students manage to do just that, as witnessed by the Harvard student who graduated at the top of her class last year and then entered a convent. Zuckerberg, on the other hand, craves recognition and, despite his whining, many do recognize the sophomore’s genius, or as one student says, he is the “Big Man on a campus” with nineteen Nobel Prize winners, fifteen Pulitzer Prize winners, two future Olympians and one movie actor” (presumably Natalie Portman). Despite screenwriter Aaron Sorkin’s claim that the story is true, he did use a fictional narrative thread,2 crediting Zuckerberg’s energy to create Facebook and the associated spitefulness as stemming from his being rejected by Albright, something she had every reason to do. For example, at the Jesse Eisenberg as Mark Zuckerberg, in beginning of the film, he says to her: “You don’t have to The Social Network. © Columbia Pictures/Photofest study; you go to BU (Boston University),” as he tries to im- press her with how dating a Harvard student would benefit The Social Network her. In another exchange, she says, “Dating you is like dating a Stairmaster. You believe that every thought that tumbles Starring Jesse Eisenberg, Andrew Garfield, Justin Timberlake, through your head is so clever it should be a crime for it and Armie Hammer. not to be shared.” Zuckerberg is particularly upset that he Directed by David Fincher. Rated PG-13. Running time 120 is not a candidate for one of the big clubs, which he feels minutes. would get him the attention he deserves. When asked why, he says they’re exclusive and fun and can lead to a better ’ve always believed that in order to enjoy a movie, the life, pointing out that Theodore Roosevelt was a Porcellian characters, especially the protagonist, have to be likable. and that led him to become president. Erica tells him that Consequently,I I found much of The Social Network difficult he is an a—hole and dumps him. He runs to his dorm, blogs to watch. Based on Ben Mezrich’s book The Accidental that she is a “bitch” and, while drunk, hacks into the home Billionaires,1 it tells the story of the founding of Facebook pages of women in the various Harvard residence halls and by Mark Zuckerberg (Jesse Eisenberg) while an un- creates The Facemash site. Using an algorithm developed by dergraduate at Harvard. Mezrich’s consultant was his friend Eduardo to rank chess players, he invites Harvard Zuckerberg’s jilted cofounder Eduardo Saverin men to rank the women. The site is a sensation, earning him (Andrew Garfield), so the book’s “nonfiction” the enmity of the women students and a six-month academic label is subject to debate. Zuckerberg, as probation for the resulting crashing of the Harvard network. portrayed in the film, is thoroughly During the hearing, he claims that Harvard should thank him

42 The Pharos/Spring 2011 for showing them the flaws in their network security. no satisfaction, they schedule an appointment with Harvard Zuckerberg’s accomplishment wins him the admiration President Larry Summers, asking his help with enforcing of identical twin students Cameron and Tyler Winklevoss Harvard’s student Code of Conduct about not cheating on (Armie Hammer), who hire him to help them and Divya your classmates. The portrayal of Summers as a jerk stretches Narenda (Max Minghella) build their Harvard Connections credulity. He disavows their contention that the invention is site. He stonewalls them for weeks, during which time he de- worth millions, asserting that it is just their imagination and velops Facebook with Saverin and Dustin Moskovitz (Joseph that, after all, he should know because he used to be Secretary Mazzello). His vision is to take the whole college experi- of the Treasury. He dismisses them and advises them to in- ence and put it online on the premise that there is nothing vent something else, “which is what Harvard students do.” that people like to do more than talk about themselves. The Interestingly, in , Summers would cite Bill Gates and Mark Winklevoss twins are stunned when he announces the launch Zuckerberg as arguably the two Harvard freshmen who have of Facebook and, on being confronted, he denies that he used been the most transformative of the world in the past twenty- any of their code or ideas, which he pronounces to be lame. five years, adding that neither graduated.3 Facebook fever develops as he expands to Yale, Columbia, Zuckerberg borrows from his friend Eduardo to finance Stanford, and Cambridge. Facebook but refuses his urging to get advertisers, saying that The Winklevoss twins embody all that Zuckerberg en- Facebook is cool and he is not interested in ruining it for the vies and despises. They are handsome future Olympians on sake of money. He changes his mind when he is introduced the crew team, products of WASP wealth, and shoo-ins for to Sean Parker (Justin Timberlake), the ousted founder of the best club. They are in reality trusting fellows, especially Napster, who makes the prophetic statement, “We lived on Cameron, who refuses for a long time to agree with his part- farms, then we lived in cities, and now we are going to live on ners to sue Zuckerberg. Instead he believes that they should the Internet.” Parker gets him capital for what he sees as a bil- act like “Gentlemen of Harvard.” When Zuckerberg gives them lion dollar company. Meanwhile Zuckerberg keeps Eduardo in

Andrew Garfield (as Eduardo Saverin), Joseph Mazzello, Jesse Eisenberg (as Mark Zuckerberg), Patrick Maple in The Social Network. © Columbia Pictures

The Pharos/Spring 2011 43 The physician at the movies

the dark about his joining forces with Parker. When Eduardo isolated occurrence? I don’t know, but in the end, the question is finally eased out of the company, he joins the Winklevoss’s is moot, since the genie is out of the bottle suit. Much of the story is told through the deposition process. Full disclosure: I am a confessed troglodyte and techno- Parker adds high living, marijuana, bongs, cocaine, strip clubs, phobe. I don’t own a Blackberry, don’t text, and have never and sex parties with underage girls to the venture. Add this to accepted invitations to join Facebook even when I recognize the portrayal of hard partying, hard drinking, and the hookup the people as friends with whom I wouldn’t mind conversing culture so prevalent on today’s college campuses and it’s hard with by phone, e-mail, or in handwritten letters. So take what to fathom how this film got a PG- rating when The King’s I say with a pound of salt. My concerns are that we are creat- Speech was rated R. ing a generation of people who attach too much importance to Given the characterization of Zuckerberg, the youngest talking to strangers rather than doing something worthwhile billionaire ever, I found it strange that the film appeared while with their time and communicating with those around them. he is very much alive. Zuckerberg calls it fiction, but Sorkin They have their heads focused on the machines, texting and stands by his screenplay, saying that he relied on depositions tweeting, rather than on their surroundings, loved ones, and taken during the lawsuits filed against Zuckerberg and blogs natural community. Then again, maybe it’s better than hours that he wrote during the period in question. Sorkin does al- spent on video games. For views of a couple who use Facebook low Zuckerberg’s defense lawyer to possibly negate the value and whose judgments I respect, see Addendum  below. of the depositions by saying that eighty-five percent of them are exaggerations and the rest outright lies. I’m not sure law- Addendum 1 yers would agree. Furthermore, when questioned about the In the end credits, we learn that Cameron and Tyler re- film’s veracity, Sorkin said, “I don’t want my fidelity to be to ceived a settlement of  million and signed a nondisclosure the truth; I want it to be to the storytelling. What is the big agreement. They both rowed for the United States in the deal about accuracy purely for accuracy’s sake, and can we not Olympics in Beijing and placed sixth. Eduardo Saverin re- have the true be the enemy of the good?” 4 I’m still trying to ceived an unknown settlement and his name was restored to figure that out. In sum, I guess when you’re running a  bil- the Facebook masthead as cofounder. lion company, it doesn’t matter what they say about you, even when the film’s closing line is “You’re not an a—hole, you’re Addendum 2 just trying really hard to be one.” I use Facebook strictly for family and close friends. I ask Another thing that struck me about the film is how tech- my business acquaintances and colleagues to connect with me nology that purports to connect one with “friends” was on LinkedIn, a business social networking site. I’m the most fashioned by a self-referential loner. There’s no question that engaged on Twitter. I don’t believe in online privacy. Some Facebook can be used for good purposes, e.g., keeping ser- young people are making bad choices about what they are vicemen in touch with their loved ones, reconnecting with posting online, in their words and photos. Youngsters need old friends, posting worthwhile messages, or connecting with to think about the digital footprint they are leaving. Frankly, the people in repressive regimes as we are seeing in today’s I have a bit of a love/hate relationship with social media in headlines. This is alluded to when Marylin Delpy (Rashida general. I approach it cautiously. It can consume a lot of time Jones), one of Zuckerberg’s lawyers, asks what he is doing on (if you let it). her borrowed laptop at the end of the deposition. He says “I’m My first encounter with Facebook was as a sort of commu- checking in to see how it’s going in Bosnia.” She responds: nity bulletin board for public protest. I stayed with it to reach “Bosnia, they don’t even have roads but they have Facebook!” some classmates. My sense is that Facebook satisfies many We are told in the end credits that there are  million people disparate social elements and personalities. It is a combina- in  countries using Facebook. tion soapbox, e-mail, rants, photo albums, standing distribu- Still, too often it’s seems to me to be merely self-promotion lists, as well as a way to cyberstalk people. I use it to post tional and used by people who obsess and need to tell others my thoughts and links to articles I think are worthwhile and I about their daily actions, rather than live in the moment and read the thoughts of only a select few. let their lives speak for themselves. I wonder if they wouldn’t be better off to communicate with those around them than References with unknown people, some of whom could be predators us- . Mezrich B. The Accidental Billionaires: The Founding of ing aliases or making false statements. As I was writing this, Facebook: A Tale of Sex, Money, Genius and Betrayal. New York: there were also privacy concerns raised about ownership and Doubleday; . use of Facebook content. In addition, I came across a story . Internet Movie Database (IMDB): The Social Network. www. about a woman accused of running over her cousin twice with imdb.com/title/tt/. her minivan and leaving her bleeding in the middle of the . Baker G. Larry Summers vs. the Tiger Mom. Wall Street J street after “a Facebook-fueled catfight over a man.” 5 Is this an  Jan -: c.

44 The Pharos/Spring 2011 . Harris M. Inventing Facebook. New York Magazine  Sep the fact that it was a Disney film and that the screenwriters, . nymag.com/print/?/movies/features//. producer, and director had been involved with such films as . Woman accused of mowing down cousin after Facebook The Blind Side, Braveheart, We Were Soldiers, The Nativity feud. New York Post  Jan . www.foxnews.com/us//// Story, Finding Forrester, and The Rookie. These were seen woman-accused-mowing-cousin-facebook-feud/. as “uplifting,” not “edgy,” as many critics would prefer. Add to that, Disney had marketed it to Christian groups, just as Secretariat Warners had done with The Blind Side. What clinched it Starring Diane Lane, John Malkovich, James Cromwell, and was Diane Lane’s voiceover of a passage from the Book of Fred Dalton Thompson. Job in which Yahweh challenges Job about the creation of Directed by Randall Wallace. Rated PG. Running time 123 various animals, including horses. As Lane recites the passage, minutes. Secretariat is shown entering the starting gate and seeming to act out in a remarkable verisimilitude to the biblical words.

Do you give the horse his strength or clothe his neck with a flowing mane? Do you make him leap like a locust, striking terror with his proud snorting? He paws fiercely, rejoicing in his strength, and charges into the fray. He laughs at fear, afraid of nothing; he does not shy away from the sword. The quiver rattles against his side, along with the flashing spear and lance. In frenzied excitement he eats up the ground; he cannot stand still when the trumpet sounds. —Job :-, New International Version

One the many examples of such critical reviews is illustra- tive.3 The chief critic for Movie Line, Stephanie Zacharek, began her review by saying: “If, like most sane people, you’re inclined to flee movies that open with biblical quotes, you Secretariat winning the Triple Crown. © Bettmann/CORBIS. might want to concentrate on the image that accompanies those words.” 4 She goes on to talk about how the viewer should forget the “biblical stuff” and concentrate on the image Based on the book Secretariat by William Nack,1 this en- of the horse’s supernatural alertness, his twitching ears, and tertaining film chronicles the career of the horse that some enormous eyes and nostrils. She missed or chose to miss the consider to be the greatest thoroughbred that ever raced. It filmmakers’ desire to pair words and pictures. In so doing, the was one of the few films in  to tell a coherent story and filmmakers were riffing off the title of one of the many books not rely on special effects. I agree with Joe Queenan’s com- about Secretariat, The Horse that God Built.5 Later, after mentary in the Wall Street Journal that  might be the stating her fears of the possibility of an “aggressively religious worst year in film history, although it has had many recent message” she added, “I will tell you—if you haven’t guessed competitors.2 The greatest of the film’s many assets is Diane already—that I’m a left-leaning agnostic, and the closest I can Lane, who plays Penny Chenery Tweedy, Secretariat’s owner. ever get to believing in the existence of God is in the presence Ms. Lane has shown the ability to light up the screen and carry of animals. (I find human beings to be highly flawed inven- a film as narrator and participant as she does here. She plays tions, but maybe that’s just me.)” 4 This all goes to prove the the epitome of a ’s/’s woman full of class and determina- old adage that what you get out of a movie depends on what tion, a “housewife” who refuses to be intimidated in a so-called you bring to it. man’s world. Her prim behavior and stylish appearance con- Frankly I missed all this in enjoying the film. Indeed, I trast sharply with that of trainer Lucien Laurin, played by an found it particularly amusing because the parts of the film that over-the-top John Malkovich. He provides comic relief with were off-putting to me were the scenes involving Tweedy’s his outrageous outfits and equally outrageous comments. His rebellious daughter, Kate (A. J. Michalka). Caught up in the character is quite different from the real Laurin, but this is a antiestablishment tenor of the times, she rebels against her Hollywood entertainment, not a documentary, and it enlivens parents’ middle-class values and petitions her high school the film. principal to turn the annual Nativity pageant into a Vietnam After seeing Secretariat, I found that many critics took a War protest. After first being rebuffed, she volunteers in a negative view of it, seemingly put off by what they saw as the commune in Chile and then gets the green light the next film’s religious overtones. They may have been sensitized by year to go ahead with her vision. Though I found it to be

The Pharos/Spring 2011 45 The physician at the movies

Dylan Baker, Diane Lane, Nelsan Ellis, Otto Thorwarth, and John Malkovich in Secretariat.

extraneous and distracting, I guess it was the screenwriter’s organization run by the Secretary-General, suggesting “leader- way of bringing a little bit of the flavor of the times into the ship and power without referring to royalty.” 7 How the percep- film and also keeping it from being focused only on the horses, tion of that body has changed! the stables, and the racetracks. It also served to show how Hancock helps her hire respected trainer Lucien Laurin to Tweedy was much more tolerant of her daughter’s beliefs than work with her horses. As noted, Laurin is portrayed as a flam- her lawyer husband Jack (Dylan Walsh) who considered her to boyant Southerner (he was a more reserved French-Canadian) be a “Commie.” who played golf (which he never did).8 He dishes out colorful The film begins in  with the burial of Tweedy’s mother lines like, the young Big Red being so slow that “he couldn’t and her decision to stay back in Virginia to help her sick father beat a fat man encased in cement being dragged backwards by Chris Chenery (Scott Glenn) who has withdrawn into him- a freight train.” Laurin is instrumental in hiring famed jockey self. She recognizes how important the horse farm is to him and fellow French-Canadian Ron Turcotte (played by real and she is anxious that it remain under the family’s control, jockey Otto Thorwarth). against the wishes of her brother Hollis ( Dylan Baker) and her While the story about Secretariat saving the farm is nice, lawyer/husband, who thinks she is over her head and should it was actually saved by the horse Riva Ridge, who had been be back in Denver, not in Virginia. She is supported by her sickly and suffering from diarrhea and a high fever shortly father’s long-time secretary Miss Ham (Margo Martindale), after birth and looking poor and thin.7 However, after the groom Eddie Sweat (Nelsan Ellis), and the family lawyer Bull administration of antibiotics, he became strong and grew Hancock, played with just the right earthiness and human- to be a classic thoroughbred, going on to win the Kentucky ity by ex-Senator Fred Dalton Thompson. After her father Derby and the Belmont stakes. His name came from a battle dies, it becomes more difficult to hold on to the farm and the that the Army th Mountain Division fought to secure an horses because of the estate tax, which requires that assets be Italian Apennine range in World War II, and in fact Tweedy’s sold off. She manages to hold on to it by selling shares in the husband and his friends from that division founded the Vail, horses. Her main assets are two recently-born foals and she Colorado, ski resort and named their favorite trail Riva Ridge.7 arranges with her principal stockholder Ogden Phipps (James Nor did Turcotte, as portrayed, just come on the scene with Cromwell) to have a coin toss to select first. She “loses,“ but Secretariat. He actually rode Riva Ridge many times. actually gets the horse she wanted, a chestnut red horse with There are many excellently filmed races, one of which is three white stockings and a star on a thin blaze, who was able the actual footage of the Preakness Stakes shown on a grainy to stand up immediately after he was born. Familiarly called small television screen to capture the way most people saw “Big Red,” he is named Secretariat after the United Nations the race. The scenes that didn’t seem realistic involved the

bluster and braggadocio of Pancho Martin (Nestor Serrano), References: the trainer of Sham, Secretariat’s chief rival at the Derby and . Nack W. Secretariat. New York: Hyperion; . the Belmont. He was apparently nothing like his portrayal,5 . Queenan J. The worst movie year ever? Coming soon to a the- but it helped strengthen the story line that Tweedy, being a ater near you, absolutely nothing you want to see. Why Hollywood woman, got little respect. The highlight of the film is the run- keeps trying to sell us on pointless sequels, lame remakes and the ning of the Belmont Stakes, at a mile and a half the longest of stardom of Shia LaBeouf. Wall Street J  Jul . the Triple Crown races. Because of Secretariat’s pedigree, it . Donohue W. “Secretariat” Spooks Reviewers. Catalyst  was assumed it would be his undoing. However, coming from Nov: . behind, he won by an incredible thirty-one lengths. Fittingly, . Zacharek S. Secretariat spreads the gospel of one auda- the film ends with the same quote from Job and pictures of the cious horse. www.movieline.com///review-secretariat. horse (or one of his five stand-ins) with Tweedy doing some php?page=all. horse whispering that film critic Ann Hornaday aptly calls “a . Greydanus SD. The Horse That God Built. Secretariat: The moment of transcendent recognition.” 9 Legendary Racehorse Runs Again. National Catholic Reg  Oct The filmmakers use various techniques to convey the : B. strength and power with the sounds of the horse’s breathing . Tweedy KC and Ladin LM. Secretariat’s Meadow: The Land, and the pounding of his hooves as he moves into gear, usually The Family, The Legend. Manakin-Sabot (VA): Dementi Milestone coming from behind such that the biblical quote seems quite Publishing; . prophetic. As film critic Steven Greydanus notes, Secretariat . Internet Movie Database (IMDB.com). Secretariat. www. was truly big-hearted in that his heart was found to be more imdb.com/title/tt/. than twice the average size for a thoroughbred, which is about . Hornaday A. Get a great story and run with it. Washington nine pounds.5 His was nearly twenty-two pounds, and it was Post  Oct . not because of a malformation. As Greydanus notes, it has been discovered since, that some thoroughbreds have a “large Dr. Dans (AΩA, Columbia University College of Physicians and heart gene” that is passed from their dam, which was the Surgeons, 1960) is a member of The Pharos’s editorial board and secret of his stamina. His great sire Bold Ruler was long on has been its film critic since 1990. His address is: speed but short on stamina, the principal reason that Phipps 11 Hickory Hill Road selected the other foal under the assumption that a horse’s Cockeysville, Maryland 21030 traits came largely from the sire’s pedigree, another good ex- E-mail: [email protected] ample of why one should never underestimate Mom!

The Pharos/Spring 2011 47 Pericarditis

Rising with the moon, I rinse the night from eyes and mouth and clavicles and ribs that vibrate with my heart’s familiar call: Diastole—a parable of hunger, and systole—that sleepless score of loss. The pulse of work has now become my peace. White mugs of tea, a stack of notes, my patient’s breath a metronome of wince and heave, her heart’s caul swollen, rubbing with each beat. She lifts her gown, permits my stethoscope to catch the rasping sound her sternum shields. She names the pain a struggle in my chest. I am acquainted with this kind of ache: The heart’s embracer torments all it holds. Chris Marett, MD

Dr. Marett is resident in Psychiatry at the University Hospital at the University of Cinncinnati. This poem won third prize in the !"#" Pharos Poetry Competition. Dr. Marett’s e-mail address is: [email protected].

48Illustration by Jim M’Guinness The Pharos/Spring 2011 Reviews and reflections

David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors

clearly articulated the need to achieve health insurance industry to buy into three major goals in health care reform: his reform initiative. Obama believed decreased costs, improved quality, and that by bringing these players into the universal coverage. And the voters had fold and giving them good publicity evidently agreed. I realized that the for their public spiritedness, he could country was divided between those who induce them to partially set aside self- viewed a single-payer system as the only interest in the interest of the public. way to achieve reform and their op- Wrong! The insurance industry was ponents who violently disagreed and happy to support universal coverage, argued that modifications of the ex- given the prospect of millions of new isting health insurance system would enrollees, but it lobbied against effective suffice, and I anticipated serious and cost controls. At the same time, “the top energetic debate. As it turned out, nei- five insurers in the country rung up  ther Democrats nor Republicans dem- billon in profits in  while dropping Hijacked: The Road to Single onstrated the political courage to seize . million enrollees.” p14 Likewise, the Payer in the Aftermath of the day. The debate degenerated into a pharmaceutical industry loudly pledged Stolen Health Care Reform quagmire of complexity, misinforma-  billion toward health care reform, John Geyman, MD tion, and fear. It was remarkable, un- while at the same time raising its prices Monroe, Maine, Common Courage der these circumstances, that Congress by nine percent over the previous year, Press, 2010, 290 pages did, in fact, manage to pass the Patient a price increase supposedly justified by Protection and Affordable Care Act of costs of research and development, even Reviewed by Jack Coulehan, MD, . But, according to Geyman, the though the industry “spends two to three MPH (AΩA, University of Pittsburgh, limitations and complexity of that legis- times more on marketing than it does on 1969) lation raise two burning questions: Why research and development.” p21 In other and how did we squander our best shot words, the price of these stakeholders’ at genuine reform? And is the reform endorsements was to weaken compre- ijacked, the most recent of John they enacted better than nothing? hensiveness and introduce additional Geyman’s critical explorations Geyman contends that both politi- barriers to reform, like agreeing to avoid ofH the American health care system, cal parties bear some responsibility for negotiating drug prices. combines extensive documentation, stealing reform. The Obama admin- The Republican response was es- reasonable argument, and rhetorical istration shot itself in the foot at the sentially to stonewall, a mixture of no passion. Geyman, an eminent academic outset by framing the discussion to ex- compromise and no ideas. It became family physician and former president clude a single-payer system. It failed to quite clear, Geyman claims, that the of Physicians for a National Health play its strongest card, a system simple chief Republican goal was not to offer Program, initiated his analyses in  to understand and with an established a principled conservative approach to with Health Care in America: Can Our track record throughout the world. health care reform, but rather to pre- Ailing System Be Healed? and has subse- Perhaps not politically acceptable in its vent the president’s success at all costs. quently published books on health care entirety, but a strong opening position. First, they squelched the “public op- inequities, corporate medicine, health However, in his desire to appear “mod- tion.” Then they exploited both the real insurance, and the decline of moral and erate” and obtain Republican support, and imagined weaknesses of Democratic professional values in medicine. The Obama ruled out single-payer, which plans by a high-pitched campaign of present book, Geyman’s response to the almost guaranteed that universal cover- disinformation. Finally, they employed Patient Protection and Affordable Care age would be prohibitively expensive. the undemocratic Senate cloture rule to Act of , summarizes its theme in the Rather, the administration squandered block legislation there. subtitle, The Road to Single Payer in the its momentum on the relatively weak In a chapter subtitled “Better Than Aftermath of Stolen Health Care Reform. idea of a “public option” to compete with Nothing?” the author presents his analy- The word “stolen” will reso- private insurers as a method of achieving sis of the net worth of the new system. nate with many Americans who, cost savings. On the positive side, the act will extend like me, believed that Barack The second mistake the author at- health care to  million more people Obama’s election in  had tributes to the president was his highly by , phase out the “doughnut hole” opened a window for gen- touted attempt to co-opt health care coverage gap for Medicare prescription uine change. Obama stakeholders by getting hospitals, or- drug benefit, and initiate certain signifi- the candidate had ganized medicine, big pharma, and the cant reforms of the insurance industry,

The Pharos/Spring 2011 49 Reviews and reflections

like prohibiting exclusions for preexist- The Pharos and a member of the journal’s Sklar was contacted by Carl Wilson, ing conditions and banning annual and editorial board. His address is: who operated a primitive medical clinic lifetime coverage limits. However, most Center for Medical Humanities, Com- in the Sierra Madre region of Mexico. of the increased cost of these “posi- passionate Care, and Bioethics Wilson emerges as an enigmatic, charis- tives” has no clear-cut linkage to cost- HSC L3-080 matic central figure. For many years he reduction strategies. The bottom line, State University of New York at Stony has been the sole “physician” caring for according to Geyman, is that the cost of Brook the poor farmers of the village and sur- health care will continue to skyrocket, Stony Brook, New York 11794-8335 rounding area. Subsequently it is discov- while the goal of universal coverage will E-mail: [email protected] ered that he is not a licensed physician, also not fully be attained. but a bright, highly-motivated autodi- Geyman presents the reader with dact who devours medical books. His eleven major lessons from Obama’s nationality is not disclosed, but he is flu- health reform effort. Several of these ent in Spanish and embraces his role as seem self-evident, e.g., the quest for bi- a healer. (The villagers never challenge partisanship was futile; real reform was his credentials and eagerly accept him— considered politically infeasible; health attributing god-like qualities to him.) care is not just another commodity; and Also, to compound the complexity of Senate rules blocked the democratic this character, he can best be described process. (This refers to the Senate’s clo- as a “benign” pederast (my oxymoronic ture rule that requires a super-majority term). He exploits adolescents, but also of sixty percent to bring any bill to a helps with their education and aids in vote. It means that forty-one senators their pursuit of a better life outside the can—and did—block legislation sup- stifling village environment. ported by a majority of both houses of The Mexican adventure begins when Congress and the president.) A few of Sklar responds to a call for professional Geyman’s lessons are more controver- La Clinica: A Doctor’s Journey help from Wilson and goes to work in sial, i.e., “the private health insurance Across Borders the clinic for about six months. His only industry is in a death spiral and does preparation is a crash course in suturing not provide enough value to justify a David P. Sklar and some exposure to a physician’s as- bailout.” p183 This is a position that is University of New Mexico Press, sistant program. Suddenly he finds him- supported by the evidence in my opin- Albuquerque, New Mexico, 2010, self thrust into caring for some very ill ion, but obviously many would argue 248 pages patients with little or no guidance from otherwise. Similarly, the final lesson that Reviewed by Robert H. Moser, MD Wilson, few tools, and a very primitive “health care reform must be fundamen- (dirt floors) physical facility. (AΩA, Georgetown University, 1969) tal and comprehensive with a simplified The story evolves in a rather convo- financing system” is not one that the luted fashion. Apparently, it was writ- majority of our senators and represen- found this book to be subtly disquiet- ten while Sklar was chief of emergency tatives—especially as of November , ing, to the extent that I read it again. medicine in a university hospital. As the —agree with. ItI is a quasi-autobiographical story in author describes his rather quotidian The great value of Hijacked: The which the author, David Sklar, frequently present life in Albuquerque (mostly con- Road to Single Payer in the Aftermath uses quotations from individuals he en- cerning events in the emergency room), of Stolen Health Care Reform derives countered up to twenty years ago. This he interjects frequent recollections of his from Geyman’s ability to marshal over- device makes for dramatic rhetoric (and time in Mexico—over twenty years back. whelming evidence and then present some “literary license” is acceptable), his arguments with clarity and passion. but the extent to which this device is Even though I was only twenty-two The book is “trenchant and highly read- deployed challenges credibility. years old and was not yet a doctor, able,” as Marcia Angell comments in It would seem quite rare in medicine and even though I barely understood her blurb. It is also sobering and some- that an encounter that occurred before their language, they would come to what depressing. Nonetheless, it is a entering medical school would have a my window in the night. must-read for anyone who seeks a better profound and prolonged influence on And I’d dress and stumble over understanding of the problems facing one’s professional and personal philoso- the uneven rocks of the unlit street American health care reform in . phy of life. Yet this is the central thesis to an adobe house with a single lan- of La Clinica. tern illuminating a feverish patient Dr. Coulehan is a Book Review Editor for Upon completion of his college years, lying on a burlap cot in the darkest

50 The Pharos/Spring 2011 corner of the room. I’d smell the wisdom of the aphorism, “In the land of Rick, a cynical racist whose deep-seated strange pungent herbs and oils cov- the blind the one-eyed man is king.” prejudices encompass ethnic and social ering a place where the pain resided, One cannot help being dismayed by “classes.” One must wonder if his biases usually in the middle of the belly or Sklar’s abiding insecurity and depres- could jeopardize his judgment in car- under a breast. sion in his professional and personal ing for patients he considers less “wor- After a while they’d whisper my life. It permeates the entire text. Too thy,” and how the author could maintain name again. “David, David is there frequently (for me) he indulges in pain- friendship with such a person. It is a no medicine for this?” ful introspection—almost confessional rather anomalous interjection for this And I’d have to walk back across in intimacy. His wife has left him taking altruistic writer. the village to the clinic to find some- their two children, which has a devastat- In contemplating this rather strange thing that might help.p2 ing impact. We never learn why. book, I wondered what long-range im- He describes his two return visits pact the time in the village had upon This statement would epitomize his time to the village—once with his new bride his ultimate philosophy of life in medi- in Mexico. and then twenty-odd years later. In the cine. He is now an associate dean at a In essence, Carl (who was totally dis- interim, Carl has significantly improved Western medical school—far removed enchanted with the world of organized life in the village (running fresh water, from the poor of rural Mexico. One can medicine, where he saw avarice, lack of electricity, waste disposal). He has be- only wonder if his sensitivity to patient caring, and corruption of ethical values), come an international lecturer on how welfare, his concern about the prevail- preached his gospel that care of sick to set up and operate a rural clinic. But ing health care mechanism where indi- patients could be done by anyone mo- after twenty-five years, the original La viduals are getting rich from the illness tivated to provide succor and comfort Clinica is gone, and the government has of others while many millions remain with even minimal medical skills. This set up a new facility with a full-time phy- outside the system, plus his knowledge philosophy was largely enabled by the sician. In general the medical situation of Third World medical problems, has local population who were culturally has improved. been translated into any continuing pos- adapted to low expectations for relief or Sklar discovers how the narcotic traf- itive action. There is no indication in cure and believed that ultimate survival ficante gangs have come to dominate the the book. of an individual was in God’s hands. lives of all the people in this region of ru- In the final pages Sklar contemplates They utilized the services of witch-like ral Mexico in the years since he left (and the legacy of Carl Wilson: curanderos, who relied on incantations, this dreadful situation with murder and charms, and spells. Sklar devotes too kidnapping on an outrageous scale per- I wondered what his legacy would little text to a discussion of his interface sists today, especially along the border): be, how we would remember him. with local healers. Would it be the images of the clinic, His ability to help the villagers is The village and the clinic had been the many people from the village facilitated by the low expectations of his my engine all these years, powering whose lives had been changed, the patients and their belief that the gringo me forward with a vision of why my Americans like me who returned doctor can do magic things by simply life made sense and a certainty of to the United States to try to carry being present and laying on hands. Since its basic goodness. In the village the forward the same compassion and most symptoms have a major psycho- needs were obvious. If you worked commitment to the poor that we logical component, such success is not hard enough, the dying might live, learned from him? Or would it be unusual. the suffering might be relieved, and the scandal? p233 As Sklar writes, you could feel good about your part in it. . . . I wanted to discover what The prose is colorful and the narra- In those days, I carried with me a led me to make the choices that tive quite fascinating at times, but the bag of equipment, a light, some pills, were now causing so much pain and book leaves a disquieting, unfulfilled af- and a conviction that, whatever gaps to determine whether my image of tertaste and ends on an inane downbeat. in my knowledge, I was better than the village, the clinic, and the re- nothing; I could make a difference. lationships with the people there Dr. Moser is a member of the editorial Now I wondered what had made me was based upon real memories or board of The Pharos. His address is: so sure and why I hadn’t questioned fantasies. Maybe that would help me 943 E. Sawmill Canyon Place myself—questioned all of us there— discern the next step away from the Green Valley, Arizona 85614 for pretending to know more or be fog enveloping me.p4 E-mail: [email protected] more than we were.p3 On several occasions Sklar reveals in- It would seem a prime example of the teractions with his long-time colleague,

The Pharos/Spring 2011 51 Reviews and reflections

as arthritis, disc disease, pinched nerve, for financial settlement. The conjunc- pulled muscle, joint subluxations, and tion of Workman’s Compensation with spinal malalignment fail to withstand the medicalization of back pain has the rigors of clinical testing. Instead, created a snowballing phenomenon of Dr. Hadler introduces the more generic abuse and led many people, who might term “regional back pain,” thus remov- otherwise accept their symptomatology ing any medical diagnosis when describ- and move forward in their lives, to label ing and explaining everyday episodes themselves as permanently disabled. of back pain. Through his exhaustive These combined forces have created a review of the literature, he is able to “Back Pain Industry” in which billions of support his contention that back pain health care dollars are wasted. is simply an unpleasant experience in Dr. Hadler supports his arguments life and of the human condition. It is with voluminous references. No inter- Stabbed in the Back: not a pathologic condition requiring vention has been shown to have any Confronting Back Pain in an diagnosis and treatment. The role of the long-term benefit in the care of people Overtreated Society physician should simply be to “provide with regional back pain. The care of Nortin M. Hadler a port in the storm: empathy, wisdom, these individuals has become very pro- p53 The University of North Carolina Press, reassurance, and constructive advice.” vincial, with each specialty organization Chapel Hill, North Carolina, 2009, Stabbed in the Back guides the (spine surgeons, physical medicine and 224 pages reader through the evolution of the rehabilitation specialists, chiropractors, medical profession’s involvement in the physical therapists) all aggressively lob- Reviewed by Paul Levin, MD care of individuals presenting with com- bying for insurance reimbursement for plaints of back pain. This involvement their modalities and resisting any at- transformed people with common back tempt by the government to establish o one would choose to be in pain. pain into patients and, by necessity, “best practice guidelines” or evidence- Pain is, well . . . painful! People changed the perception of their dis- based management. seekN explanations. If something hurts, comfort from an annoyance of life to I do have a single criticism of Dr. human nature tells us there must be a pathologic condition. Adhering to Hadler’s treatise. Chapter Six, “Invasion a problem. Patients and health care Sydenham’s principal that symptoms of the Spine Surgeons,” extensively providers become frustrated when they (illness) must represent anatomic or outlines a history of abuse of surgical can’t get an explanation. Individuals physiologic malfunction (disease), phy- interventions for regional back pain. who are experiencing pain are a willing sicians rushed to identify pathologies Undoubtedly, a large volume of spine prey for anyone who offers them a solu- that “fit” their conceptual frameworks. surgery is being performed without any tion. In many ways our present health Allopaths, osteopaths, and chiroprac- scientific basis. Despite the excesses, care system has created the perfect tors, among others, have developed I am concerned that the reader might storm: a needy and sometimes desper- their own explanations and theories be left with the belief that there are, in ate patient population, interacting with of the pathologic processes that lead fact, no indications for spine surgery. a variety of health care providers who to back pain. Even more disturbing, However, while patients with regional are eager to help, but who also make health care professionals have helped back pain are best treated with educa- their livelihood providing the services create disability in patients diagnosed tion and reassurance, a very small per- they recommend. with a “disease” for which the “cure is centage of individuals with back pain Stabbed in the Back: Confronting elusive” p29 and many of whom “see no do have conditions for which operative Back Pain in an Overtreated Society is better option than to be patients for intervention is appropriate. Much of a very sobering analysis of the American predicaments they perceive to be abnor- the confusion lies with the lax use of approach to the management of back mal but that others consider normal.” p29 terminology. For example, disc hernia- pain. Nortin Hadler, MD, has spent Simultaneously, while the medical tion becomes significant only when it his thirty-year professional career ana- profession was pursuing and analyzing results in radiculopathy or acute neuro- lyzing the evaluation and treatment the etiology of back pain, the Workman’s logic deficit. Spinal stenosis is an imag- of back pain in the United States. Dr. Compensation system was created. This ing finding that is only significant if it Hadler notes that essentially everyone system requires that any worker re- leads to neurogenic claudication. Simple in Western society experiences episodes porting symptoms of back pain must lumbar discectomy performed for a true of back pain. Although a wide variety of demonstrate injury. If no injury can radiculopathy (not a generalized radiat- health care providers treat back pain, be demonstrated, workers are neither ing pain, or a herniated disc without ra- their commonly used diagnoses, such eligible for compensated treatment nor diculopathy) has been demonstrated to

52 The Pharos/Spring 2011 have an extremely high success rate. The to respond to observation and expectant References SPORT trial (Spine Patients Research patience. . Weinstein JN, Lurie JD, Tosteson Outcomes Trial), although partially Stabbed in the Back is a superb TD, et al. Surgical versus non-operative flawed with crossover patients, and the analysis of the treatment of back pain treatment for lumbar disc herniation: four- Leiden-The Hague Spine Intervention in the United States. Beyond that, year results for the Spine Patient Outcomes Prognostic Study Group have demon- it is an eye-opening synopsis of the Research Trial (SPORT). Spine : : strated a definite benefit with lumbar American health care system and how –. discectomy in appropriately selected we approach our patients’ complaints. . Peul WC, van Houwelingen HC, van patients.1,2 It stimulates us to analyze and question den Hout WB, et al. Surgery versus pro- Likewise, decompression surgery for commonly-accepted treatments utilized longed conservative treatment for sciatica. patients with true neurogenic claudica- in the management of self-limiting con- N Engl J Med ; : –. tion (not simple spinal stenosis) can be ditions for which patients consult us. extremely effective in restoring func- We need to consider carefully whether Dr. Levin is the Vice-Chairman of the De- tion, and decompression surgery for we are treating disease or, alternatively, partment of Orthopaedics at the Albert individuals with cervical myelopathy creating disease and disability. This Einstein College of Medicine/Montefiore can restore function and prevent de- book should be required reading for any Medical Center in the Bronx. His address is: terioration. It is incumbent upon the health care provider treating back pain. Department of Orthopaedic Surgery health provider to develop the appropri- In fact, this should be required reading Montefiore Medical Center ate clinical skills to identify this select for all health care providers, regardless 3400 Bainbridge Avenue population that could possibly benefit of their areas of expertise! Bronx, New York 10467 from a surgical intervention after failure E-mail: [email protected] Letters to the editor

Re “Cost of a Life” more people are not getting the basic “Humanism,” defined by Dictionary. I am writing a note in response care required. com, is a mode of thought in which hu- to the article on Health Policy in the While I may agree that limiting man interests, values, and dignity pre- Autumn  issue of The Pharos (pp. care may not ethically make any sense, dominate. Enough said re Sartre. –), written by Benson Shih-Han I do think economically it does have While one may not agree with its te- Hsu, MD. an impact and has to be discussed. As nets, existentialism is considered a phi- I think the essay was extremely physicians we certainly share in the re- losophy and taught in the philosophy timely and a topic that needs to be sponsibility of the cost of medical care. departments at most major universi- discussed considerably more by physi- ties. It is not an “anti-philosophy.” Few Hilari L. Fleming, MD, PhD cians and perhaps somewhat less by comments could be more subjective. (AΩA, University of North Carolina at politicians. However, I do take issue Existentialism, in philosophy lingo, Chapel Hill, ) with Dr. Hsu’s ultimate conclusion. is described as being opposed to two Reno, Nevada He states that resources spent or not more traditional branches, those of E-mail: [email protected] spent on JR’s care have little or no rationalism and empiricism. To turn immediate impact on the care of oth- around and therefore say existential- ers. Unfortunately, I think that is not Au contraire: Response to ism is “irrationalism” shows ignorance. precisely accurate. When such extraor- “Neither/Nor” Such a statement is ludricous. dinary expenses are paid on behalf of Dr. Miles Otto Foltermann’s lengthy Ultimately, to have experienced and one individual, it raises the overall cost letter entitled “Neither/nor” in the witnessed humanistic despair, as is of health care and the cost of insur- Autumn  issue of The Pharos (p. ) present throughout our world, cannot ance. As the cost of health insurance utilizes the extraction of quotes, out of help but make us better physicians. “To rises, fewer and fewer people are context, and inaccuracies in the condem- practice medicine independent of this insured. Businesses and insti- nation of an entity, i.e., existentialism. philosophy” is a terrible mistake. tutions opt to drop insur- Jean Paul Sartre’s treatise Samuel J. Chmell, MD ance for their employees L’existentialisme est un humanisme is (AΩA, Loyola University of Chicago, ) and we have a higher properly translated Existentialism is a Chicago, Illinois proportion of unin- Humanism not as Existentialism and E-mail: [email protected] sured. Therefore, Humanism as Dr. Foltermann purports.

The Pharos/Spring 2011 53 When he was under the dome, spinning core of the earth, they awaited him, drapes around where he would surface. And he squirmed a knot, effortless, into Um!i"icus the helix that flooded him with blood, retied the tether of his foaling. The mottled purple mantles — chorion, amnion, and triad of vessels — pulsed like magma inside his crocus mother. After a day she labored choppy, the restless green flock of doctors rush into gowns over gowns, gloves over gloves, and masks to become invisible. Each face has disappeared. The sterile room is intimate. Her eddied waters quake when the cocoon is slit open. Quicksilver fish glides into flesh for fist-grabbed Josiah, who wakes up. Jennifer Stella “Many of us are never born— We live in a private ocean for hours” —Sharon Olds, “Everything” from One Secret Thing

Ms. Stella is a member of the Class of !"#! at the University of California, San Francisco, School of Medicine. This poem won honorable mention in the !"#" Pharos Poetry Competition. Ms. Stella’s address is: $%& Kirkham Street, San Francisco, California '%#!!. E-mail: jennifer.stella@ ucsf.edu. 54 The PharosIllustration/Winter Erica Aitken 2011 Minutes of the  meeting of the board of directors of members on page . Alpha Omega Alpha Reports of officers The meeting in Chicago, Illinois, on Saturday, October Reports of the president, executive secretary, and man- , , was convened at :  by President Rae-Ellen aging editor were presented. Kavey. Present were: • President Kavey expressed thanks to everyone for pull- President Rae-Ellen Kavey, MD, MPH ing together to continue to the work of AΩA after the death Vice President Donald E. Wilson, MD of Executive Director Ted Harris in May. Secretary-Treasurer C. Bruce Alexander, MD • Dr. Alexander and Mr. Nichols presented the financial Members-at-large Robert G. Atnip MD; Ruth-Marie review. Fincher, MD; Don W. Powell, MD; Joseph W. Stubbs, MD, • The board will be more involved with The Pharos FACP because it is tied to the strategic direction of AΩA. Editor Medical Organization Member John Tooker, MD, MBA, Richard Byyny, working with the board, will set editorial FACP policy. Councilor members Richard B. Gunderman, MD, PhD; Reports of programs Anne T. Mancino, MD; Sheryl Pfeil, MD Programs funded during the / year were listed Residency Initiatives Coordinator Suzann Pershing, MD in the Autumn  issue of The Pharos, which is available Student Members Alicia Alcamo, MS IV; William E. at http://alphaomegaalpha.org/pharos/AOA-ThePharos- Bynum IV, MD; Cason Pierce, MD Autumn.pdf. National office staff: Executive Director Richard L. Byyny • The Public Relations Committee chaired by Dr. (effective November , ); Assistant Treasurer William F. Mancino gave a report on their findings on surveys of the Nichols; Accountant Ani Rooney; Managing Editor of The AΩA chapters. Pharos Debbie Lancaster; and Administrator Judy Yee • The Professionalism Project was renamed “The Absent and excused were: Member-at-large N. Joseph Edward D. Harris Professionalism Project”. The direction Espat, MD; Member-at-large Douglas A. Paauw, MD; of this project will be better defined for / by Drs. Councilor member Amy Goldberg, MD; Student member Byyny, Wilson, and Paauw. Natalia Berry, MD; Administrative Assistant Carol Wong. • The Resident Initiatives Project was created to reach The meeting opened with a moment of silence in mem- out to residents to help them to stay connected with AΩA. ory of Executive Director, Edward D. Harris, Jr., MD, who A Resident Initiative Committee has been given the direc- died in May . tive to deploy this initiative to a pilot group. Recognition of retiring members • The New Councilors meeting was chaired by Dr. Eric The board acknowledged retiring directors Amy Gall to acquaint new councilors with their duties and the Goldberg, MD, and Natalia Berry, MD. national programs. Dr. David Dale presented a slideshow Extension of president’s term, new board members, and highlighting the history of AΩA. The lively discussions honorary members revealed that meetings to share best practices were desired Nominations for the / board of directors slate by all councilors. were reviewed and voted upon. President Rae-Ellen Kavey’s New business term was extended by one year until the  board meet- • New medical schools that have achieved LCME ing to facilitate the smooth transition of the new Executive Provisional Accreditation status may begin the pro- Director. Re-elected to a three-year term as members-at- cess of applying for an AΩA charter in accordance with large were N. Joseph Espat, MD, and Douglas A. Paauw, MD. Constitution Article IX. A chapter may be formed after Honorary member nominations were reviewed and obtaining full LCME accreditation. Specific information voted upon. Elected to honorary membership were: Daniel about this will be included in the future FAQ page on AΩA’s M. Fox, PhD, President Emeritus of the Milbank Memorial web site. Fund; Osvaldo Hubscher, Associate Professor of Medicine at • The next annual meeting of the board will be CEMIC in Buenos Aires, Argentina; Robert M. Klein, PhD, September , . Professor of Anatomy and Cell Biology at the University of Kansas; Wahid AlKharusi, Ambassador and Advisor to The meeting was adjourned at : . the Minister of Foreign Affairs, Muscat, Oman. See the Respectfully submitted, announcement and brief biographies of the  honorary Judy B. Yee, Administrator

The Pharos/Spring 2011 55

As my eleventh year was ending, I stood silent in my bedroom, watching, shaken by the nightlong struggle of my father in the vestibule of death. While the doctor worked to save his life, I looked on from one to five AM. This is what I saw: purple lips and mottled skin, rasping sounds of labored breathing, fluid bubbling from his mouth, semi-conscious, eyes rolled back, bruises where the doctor drew huge vials of blood to bring his pressure down. Though he lived three years beyond that crisis, not yet twelve, I knew Our time together would be brief. Through that night I chewed the hated cud of helplessness. Neither could I swallow it, nor could I spit it out. At dawn I slept, a child, awakening to be a doctor. Then I learned new words describing that which I had seen: cyanosis, dyspnea, pulmonary edema, phlebotomy, purpura. Strange that merely different names bring me comfort, but they do. Words are simply kinder than the pictures. Michael R. Milano, MD

Dr. Milano (AΩA, Albany Medical College, !"#$) is a psychiatrist living and practicing in Teaneck, New Jersey. His e-mail address is: [email protected].

56 The Pharos/Spring 2011 Nomenclature

Beneath the sterile bulbs, a heart Silenced by science then split apart, Bobs softly on an open sea Of blood, cracked rib, and arteries. Each brilliant node and nerve attests Either to forms within the chest Or glassy, color-printed clones By which the parts had once been known. Recounting these invented terms, A name for each detail, confirms There is no man beneath the knife, And calms the fear of ending life. Jana Lichtenfeld

Ms. Lichtenfeld is a member of the Class of !"#$ at Rush Medical College. This poem won honorable mention in the !"#" Pharos Poetry Competition. Ms. Lichtenfeld’s e-mail address is: [email protected]. Illustration by Jim M’Guinness

The Pharos/Spring 2011 25 In Memory of Edward D. Harris

Medica! Exce"ence W#thout Questi$n

Medical excellence is . . . Relating without hesitancy Dexterity without flourish Trust without bond Love without cupidity Contract without signature Speed without haste Touch without chill Cost without greed Understanding without categories Regulation without dictum Stride without swagger Knowledge without lecture Clean without sterility Steady without rigidity Mastery without slaves Caring without end. Ralph Crawshaw, MD

Dr. Crawshaw (AΩA, New York University, "#$%) is retired from practice. He is a member of the editorial board of The Pharos. His address is: &''( NW Raleigh, Portland, Oregon #$&"). E-mail: [email protected].

Be Worthy to Serve the Suffering” ��� ������ ��������������������������������������������� ���������

Be Worthy to Serve the Suffering” ��