Notes of a Medical Maverick
By Allen B. WeisseiUniverse, Inc.
Copyright © 2010 Allen B. Weisse, M.D.
All right reserved.ISBN: 978-1-4502-5933-0Contents
1. Why "Maverick"?.........................................................................................12. The Phoenix Phenomenon in Medical Research..............................................................53. In the Service of the IRS...............................................................................174. The Elusive Clot: The Controversy Over Coronary Thrombosis in Myocardial Infarction.....................255. Confessions of Creeping Obsolescence....................................................................436. On First Looking Into Jarcho's Leibowitz: The Clinician as Medical Historian............................517. Names...................................................................................................638. Drawing The Line........................................................................................699. The First Heart Operation: The Surgical Treatment of Mitral Stenosis....................................7710. Absolutely the Last Word on Physical Diagnosis. Not!....................................................9311. Noble, Not Nobel: How Not to Win the Most Prestigious Prize in Medicine.................................10112. Dreamwork...............................................................................................12913. The UMDNJ Debacle: A Scandal in Academia................................................................13514. Greek, Latin, English and All That: The Languages We Live In............................................14715. A Fond Farewell to the Foxglove ? The Decline in the Use of Digitalis...................................16116. I Was a Mole in an IRB..................................................................................17117. A Skeleton in Obama's Medical Closet: The Doctor Dilemma................................................18118. Publishing Without Perishing............................................................................189About the Author: Allen B. Weisse, M.D......................................................................203
Chapter One
Why "Maverick"?
In my other life, that of an academic cardiologist, I came to a fork in the road fairly early in the game. In 1963 I had just been appointed an instructor of medicine at the medical school where I would remain for the rest of my career and had to decide which professional path I would follow. To the left lay the path of super specialization; I could select a rather abstruse cardiovascular condition and devote myself unremittingly to it until I had a good chance of becoming one of the world experts on it. There was the risk, however, as some cynics might postulate, of getting to know more and more about less and less until I knew all there was to know about nothing at all. To the right lay the path of uncertainty; I could let my efforts wander in whatever direction my curiosity led them. Although I might have to settle on becoming a jack of all trades instead of a master of one, there was the compensation that "jacks," after all is said and done, might have a lot more fun than "masters."
I deliberately veered to the right and never really looked back. The expectation of never becoming a world class expert was certainly fulfilled, but I was rewarded with the opportunity to explore fields far beyond clinical and experimental cardiology while still maintaining credentials required for my day job as a member of our medical faculty. Ethics, philosophy and especially history, a great love of my life, were given free rein in my writings often flavored by large dollops of humor.
As a result of this, although many of my efforts fell into the conventional modes of medical publishing, others found it difficult to find a home within the pages of learned or even popular journals. If an article touched on an aspect of medical history the historical journals were more than likely to reject it. Oftentimes the reviewers would remark on its interest and literary quality, but the final judgment would be "not for us." Medical journals, cardiological and otherwise, would come up with the same decision. My penchant for humor was particularly self-defeating. Although laughter is supposed to have a healing quality, it rarely finds its way into serious repositories of professional medical writing. So it is that although some of the essays appearing here have previously been published in scholarly journals many of them have remained in limbo until appearing here for the first time.
The term "maverick" has been overused as of late, especially in politics in describing some of its practitioners and probably should be given a rest. However, it so neatly describes what I have often been about that I could not resist using it to describe what is contained within these pages.
You may be interested to learn that the term harks back to a living person. Samuel Augustus Maverick (1803-1870) was a Texas lawyer, politician and rancher who refused to brand his cattle, probably because he was not all that interested in this aspect of his life. The term "maverick" came to be used to describe the independently minded although I prefer to think of it more metaphorically; his cattle had no brand to mark them and therefore could not be identified or categorized as part of any group. Thus each retained its uniqueness and individuality.
Proceeding within this Western context of the term I look upon much of my work as unbranded stock that may wander far beyond the local spread. Since you, dear reader, have already gotten this far along the way I hope that your interests, like mine are far ranging. I trust that you will not be inclined to ride off into the sunset but choose rather to saddle up and join me on this trail of discovery, surprise, and inspiration enjoying an occasional chuckle along the way.
Chapter Two
The Phoenix Phenomenon in Medical Research
SOME YEARS AGO IT was suggested that "The Phoenix Phenomenon" might be a term suitably applied to ideas in science and medicine that, although presented as original concepts, actually had been proposed in the past, rejected and forgotten until now arising again like the mythical bird, the Phoenix, from its own ashes. Some recent readings however suggested that this term might even be better applied to instances in which some investigator may have suffered some devastating loss – critical data, the ability to reproduce results, one's personal health or special knowledge – despite which he or she was able to overcome this debacle and move on to ultimately achieve the treasured final goal.
Stimulating this revised conception were retellings of two instances of this kind, one not actually involving medicine; the other more appropriately described as being within the general field of biology.
The first concerns the Scottish essayist and historian ThomasCarlyle (1795-1881) and the writing of his masterpiece, a history of the French Revolution (1837), which established him as a major figure in Victorian England. An intriguing aspect of this massive effort concerns its near derailment at an early stage in its production.
When Carlyle had completed a draft of the first volume of what would become a three volume account of the events leading up to, occurring during and then at the end of the great political conflagration across the Channel, he turned the manuscript over to his good friend John Stuart Mill for comments and suggestions. In March of 1835 Mill appeared at Carlyle's home overcome with grief and remorse. Somehow Mill's housekeeper had mistaken the manuscript for wastepaper and only a few charred pages had survived the fireplace. One can only imagine the anguish that this most assuredly must have caused in Carlyle, but to his everlasting credit he was able to overcome his own feelings of despair in order to comfort his friend. A letter followed in which Carlyle wrote "You left me last night with a look which I shall not soon forget. Is there anything that I could do or suffer or say to alleviate you? For I feel that your sorrow must be far sharper than mine ... Courage, my Friend."
Although in later years their friendship would suffer because of differences in philosophical and social outlooks, the magnanimity of Carlyle under these trying circumstances was never forgotten by Mill. Although Carlyle at first despaired of ever being able to recreate this beginning of the great work, following the completion of the second and third volumes of the trilogy he managed to turn back to the first and accomplish its rewriting.
Closer to the field of medicine was the career of Alfred Russel Wallace (1823-1913). It was an early incident in his long life that merits inclusion here. Wallace, it might be remembered, was the naturalist who came in second to Charles Darwin in recognition for the theory of natural selection (i.e. evolution). Wallace, after considering the subject for some years, solidified his beliefs about all this during a sojourn through the Malay Archipelago from 1854 to 1862. It was his early reports from this expedition and correspondence with Darwin about them that finally galvanized the latter into publishing The Origin of Species in 1859. Although the contributions of both men were acknowledged at a meeting of the Royal Society in 1858, it was Darwin who received primary recognition. Wallace was apparently grateful just to be mentioned at all given Darwin's high social and professional status at the time in contrast to his own penurious upbringing and checkered employment background up to that point.
In the present context it was an earlier episode in the long career of Wallace that was so striking as a reflection of his indomitable will. Having begun some efforts as a naturalist in England, obtaining biological specimens for interested collectors, Wallace, at the age of 25, took off in 1848 for a four year trip to Brazil and up the Amazon to explore the Rio Negro and collect samples from the plethora of exotic natural specimens that awaited him there. After these years during which he suffered from various fevers, disabling physical injuries, near starvation at times and even the loss of a brother to yellow fever, Wallace left Brazil in 1852 with sixteen crates containing perhaps hundreds of preserved specimens and dozens of live birds and monkeys along with copious notes describing his discoveries. Unfortunately the ship that contained both him and his hard won cargo caught fire and all was lost to Wallace with the exception of a few of his notes. After ten days in an open lifeboat Wallace was rescued but "Four years of work dropped away like a cinder in a barrel."
Such a personal tragedy might have deterred another person from persisting along a path that had rewarded him only with hardship and failure. However Wallace, thanks to a small insurance policy on the cargo, was able to keep himself going for over a year upon his return to England and then, undeterred, embark on that trip to the Malay Archipelago where his evolutionary theories took final form.
In the light of these heroic episodes in the lives of Carlyle and Wallace it was tempting to seek similar demonstrations of resilience among pioneers in the field of medicine. Even within the experience of a single medical historian they have been found to be a not uncommon component to such careers.
Reminiscent of the Carlyle story concerning the loss of his early manuscript is an incident involving cardiologist Eugene Lepeschkin (1914-1994). Born in Russia, the son of a distinguished professor of plant physiology, Lepeschkin's early years were notably peripatetic as his father relocated from one academic appointment to another in Europe and the United States. Living in Arizona from 1927 to 1932 Lepeschkin actually graduated from high school in Tucson. However, when it was decided that Eugene was headed for a career in medicine his father took the family back to Europe so that his son might benefit from a medical education in the leading medical center of the time, Vienna.
At the outbreak of World War II, therefore, Lepeschkin was trapped in Europe and unable to obtain permission to return to the United States. Finding himself in a state of limbo in 1939 upon graduating from medical school, he devoted himself to compiling an all-inclusive monograph on the electrocardiogram. This was published in 1941 in German as Das Elektrokardiogram. It was not until 1947 when, invited by Dr. Wilhelm Raab to join the medical faculty at the University of Vermont that Lepeschkin was able to return to America. In the years between the publication of his German tome and his arrival in the States Lepeschkin had continued to collect thousands of new publications flooding the medical literature on the increasing use of electrocardiography in clinical medicine. These were all to be included in an updating of his text, now to be printed in English. What happened can best be described in his own words.
"I had prepared the translation of my German book soon after arriving in the U.S. but had in the meantime been making so many additions and corrections that I did not want to have the manuscript typed until all the corrections were finished. Accordingly, when it became necessary for me to take the manuscript to the prospective publisher in Baltimore for clarification of certain points I took with me the only copy I had. On the way through New York City I stopped at the residence of Dr. Bruno Kisch on the West Side to discuss some of his papers, and while I was talking to him someone broke into my car and stole the entire briefcase with the manuscript. I advertised in all the N.Y. papers offering a reward, but to no avail. I therefore had to rewrite the entire book, but in the process it became a much better work."
For those who think this might not have involved a major effort consider that Das Elektrokardiogram had 400 pages and 4000 references while Modern Electrocardiography published 10 years later in 1951 had 600 pages and nearly 10,000 references.
Vital elements other than accumulated papers concerning research can be lost; such as the loss of a critical formula or technique. Consider James B. Collip (1892-1965) and the discovery of insulin. At the end of 1921 Canadian surgeon Frederick Banting and his medical student assistant Charles H. Best were working under Prof. J.J.R. Macleod at the University of Toronto, attempting to isolate and purify insulin from beef pancreas for the treatment of diabetes. Since these two lacked the biochemical expertise needed to succeed in this attempt Macleod assigned Collip, a young physiologist and biochemist, to assist them. Collip had already established himself as a skillful and resourceful individual in his field and was rapidly advancing through the academic ranks. Collip did not disappoint; in about a month or so he succeeded in purifying the insulin obtained from the beef extracts. Soonafter, with the cooperation of Connaught Laboratories, they planned to mass produce the hormone in Toronto to meet the urgent requests of clinicians throughout Canada and the United States who had learned of their efforts.
Just as production was about to begin Collip found that he could no longer produce the purified insulin that had been the result of his earlier efforts. Somehow or other he had simply lost the knack. The strain this produced for all four individuals can only be imagined and most severely in Collip who would nevertheless not give up but rather frantically persisted in trying to reproduce his earlier results with multiple variations in laboratory technique, some of these suggested in consultation with the other principals. Providentially Collip succeeded after several more weeks of effort and the rest, as they say, is (medical) history.
In 1923 the Nobel Prize in Medicine or Physiology was awarded to Banting and Macleod, a story in itself with a major brouhaha ensuing in which Banting publicly challenged the decision by giving half of his reward money to Best. Macleod responded in kind with a similar gesture to Collip. Whatever the controversy surrounding the full extent of Collip's role in the affair, he became a major figure in Canadian science, often looked upon as the father of Canadian endocrinology with a long and successful career to prove it.
Loss of technique is one thing, loss of "data" still another.
For many years it had been known that dietary deficiency could cause heart disease with heart failure related to severe thiamine deprivation (beri-beri) a prime example. It was also recognized that some alcoholic individuals, who often suffered multiple dietary deficiencies could occasionally develop heart muscle disease (cardiomyopathy). What was undetermined was whether these patients who developed heart disease did so because of the lack in their diet of essential nutritional factors or as a result of a toxic effect of the alcohol itself.
Timothy J. Regan (1924-2001) was keenly interested in this problem and for many years was chief of the cardiology division at the Seton Hall School of Medicine, (later the New Jersey Medical School) in Jersey City, New Jersey. It was there that he began his early studies on alcohol. One of his approaches to the problem was to develop in dogs a model in which the dietary element and the possible effects of alcohol could be separated. This involved maintaining a cohort of dogs with carefully determined adequate nutritional components in their diet as controls and another group that received all the necessary dietary supplements but whose total caloric makeup was altered to include ample amounts of alcohol, similar to those reported in alcoholic patients.
Modern animal facilities were not a high priority back in the 1950's through the early 1970s especially at a new school struggling to establish itself in Jersey City. Fortuitously, however, on the top floor of one of the three towers that constituted the Jersey City Medical Center there was space available for animal quarters. Despite the unusual location and its lack of conventional animal care amenities Regan took pains to keep his dogs well cared for including adequate heat in the winter and air conditioning during the summer.
Since it may take many years for cirrhosis of the liver, heart disease and other end-points of chronic alcoholism in humans to manifest themselves the dietary conditioning of Regan's dogs involved as many as 22 months. However, over one beastly hot summer weekend the air conditioning in the animal quarters failed and almost all of Regan's dogs perished. When I met him the following Monday I was prepared to find him in the depths of despair after such a loss. "What will you do now, Tim?" I asked. He smiled, "Get some more dogs, I guess." As a result he was finally able to demonstrate in the animal model both hemodynamic and histological effects of alcohol upon the heart. These findings, along with the reports of studies involving humans from Regan's laboratory and others firmly established alcohol as a toxic agent for the heart as well as liver and central nervous system among patients addicted to its use.
(Continues...)
Excerpted from Notes of a Medical Maverickby Allen B. Weisse Copyright © 2010 by Allen B. Weisse, M.D.. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
