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WATER

An old saying goes like this:  “Whiskey is for drinking, and water is something to fight over.”  In 1913 the Los Angeles Aqueduct started to divert the Owens River water to Los Angeles, and the Owens Valley that used to be called “The Switzerland of California” began to be transformed into a desert.  The man most responsible for this transition was William Mulholland.

In 1877 when Mulholland arrived, Los Angeles was all of 9000 inhabitants.  He was born in Belfast, Ireland, and ran away from home to join the British Merchant Navy at age 15.  He became a civil engineer, by mostly self-education, and worked for the LACWC (Los Angeles City Water Company, eventually to become the LADWP) of which he became superintendent.  Mulholland’s vision was to see a “megalopolis” in the desert climate of the Los Angeles basin.  What prevented LA’s growth was lack of water!

His famous line was, “If you don’t get the water, you will not need it!” He tried to get water from the Colorado River but was denied.  He then looked to the Sierra Nevada, and realized that he could get all the water he needed, by gravity feed, from the Owens Valley.  He promised the farmers that he would only take the excess water they would not use anyway, and then built the Los Angeles Aqueduct, a 233-mile system to move water from the Owns Valley to San Fernando just north of Los Angeles.  He deceived the farmers and actually took all of the runoff from the Sierra Nevada!  The Owens Valley dried up. 

The farmers took up arms and explosives and fought back violently, which became known as the “California Water Wars.”  The aqueduct was blown up with dynamite in several locations, and people went to prison.  But Mulholland prevailed, and commented it was too bad that all the trees in the Owen’s Valley died because there were not enough trees left to hang all the malcontents that opposed his grand design!

With more water, Los Angeles grew.  By 1920 the population was 576,673.  Another large reservoir was needed to store the water.  Mulholland picked a narrow canyon north of Los Angeles. The San Francisquito Canyon was ideal as it narrowed at a spot that would not require a very large dam.  What was not known then was that there was an ancient landslide that was the likely cause of the narrowing and contained rock, called Pelona Schist, that was soft, at the eastern abutment of the dam. This did not serve as a strong enough foothold and later would have devastating consequences. 

It took two years to build, and the  St. Francis Dam started taking water on March 12, 1926.  It took nearly two years to fill.  Almost immediately, cracks and leaks were noted.  On the morning of March 12, 1928, Tony Harnischfeger, the dam keeper, telephoned Mulholland that he noted a larger leak on the west abutment of the dam that was discharging dirty water.  This would indicate that the leak was eroding foundation cement.  Mulholland came out himself to inspect the dam by 10:30 AM.  For two hours he walked around and by 12:30 PM declared the dam was safe. Two minutes before midnight a brief flickering of the lights in Los Angeles marked the dam’s failure in a dramatic collapse of the right and left parts of the dam, leaving the center stand, later called the “tombstone” by the steady stream of spectators that came to see what was left of the dam.  A 10,000-ton piece of the dam was found a mile downstream,   and 12.4 billion gallons of water surged down the San Francisquito Canyon and then through the Santa Clara Valley on its 54-mile path to the Pacific Ocean that started as a 135-foot high water wall. The communities of Castaic, Piru, Fillmore, and Santa Paula were devastated. It barely took 70 minutes to empty the reservoir.  

Harnischfeger, who had misgivings for some time, had built a set of stairs to higher ground to give him and his six-year-old son an escape route should the dam break, which he never got to use.  He, along with his son, were the first victims.  Their bodies were never found.  Fourteen months after the tragedy, the dam claimed its last life.  An eighteen-year-old man climbed the remaining central monolith, by now, called the “tombstone” and fell to his death.  After that, the City of Los Angeles decided to demolish the remaining pieces to prevent any more accidents. Only the 1906 San Francisco earthquake caused more destruction and deaths in California.  The dam disaster cost at least 431 lives, bodies having been found as late as 1994! 1200 houses and 10 bridges were washed away.  An unknown toll of animals drowned.

We are always fascinated by the worst, the best, the first, etc. This was “the worst disaster” ever that was due to the failure of a human-built structure.  There is a sculpture near the Santa Paula train station memorializing the heroism of two motorcycle police officers, Stanley Baker and Thornton Edward, that at the risk of their own lives, rode ahead of the wall of water to wake people up and warn them to get to higher ground, saving hundreds of lives.

Mulholland took full responsibility for the dam’s failure.  His statement to the board of inquiry was telling, “The only ones that I envy about this whole thing are the ones that are dead!” He resigned as Supervisor of the LACWC in November 1928, and lived in relative seclusion, devastated by the disaster. He died in 1935. 

 The financial cost of the St. Francis Dam collapse was estimated at 13.5 million dollars ($196,281,000 in today’s money).  The coroner’s inquest declined to prosecute Mulholland criminally, but blamed him for poor construction.  His home was in Acton about 35 miles from the dam.  It was entirely constructed with massive amounts of concrete that, some say, was diverted from the dam. 

To demonstrate the difference between then and now, all the claims were settled out of court and not one lawsuit was filed.  Los Angeles became the second-largest city in the US by population (4,000,000), but the largest by square area (502.7 square miles). 

I owe a debt of thanks to John Nichols’ book,  St. Francis Dam Disaster, that served as a source for this essay.

Medicare For All

Medicare for All (MFA), a proposal for a single-payer system for universal health care without any premiums, along with no deductibles or co-pays, has been introduced by Bernie Sanders as well as Elizabeth Warren, two of the Democratic front runners for the 2020 presidential election.  The program would be fully funded through taxation of the citizens of the USA, as well as newly arrived (legal) immigrants who would also be eligible for coverage.  This would finally bring about the long fought for “single-payer system” that has been proposed by every left of center political organization from the Clintons on.  Hillary Care did not succeed because it was too much too fast and a very effective PR campaign, “Harry and Luise” that emphasized government control over all of health care. Obama Care (the ACA of 2010), although an attempt to cover more of the population, is a significantly watered-down version that still does not cover everyone and is funded by premiums paid by the enrollees, nowhere near what MFA (over) promises. 

What would such a system cost? And what would such a system look like? 

Taking cost first, let’s look at the Urban Institute, an organization founded by Lyndon B. Johnson, to be a “non-partisan” independent economic think tank that studies the economic problems of our society.  Their take on the cost of a single-payer system puts the increase in spending of MFA to between 32 and 40 trillion dollars over ten years, depending on if it included long term care.   The Federal government now spends 1.1 trillion a year for health care (22% of the total budget). So, over 10 years that comes to 11 trillion, now add another 39 trillion (my rounding the numbers) making it a grand total of 50 trillion (50,000,000,000,000).  If you stacked up $100 bills it would be a stack that would be 31,550 miles high, or nearly one and a quarter times around the circumference of our earth.  The US budget spends almost 5 trillion dollars a year. If nothing changed, the new health care spending would consume nearly all the budget just for health care of all the population,  nothing for debt reduction, military, social security, education, housing and urban development, infrastructure, etc.  From where would that money come?  The proponents of MFA claim that it would not be as much as the Urban Institute claims as through the economy of scale, comprehensive payment reform (translated into English- cutting reimbursement and services), bundled payments (which has not worked under ACA) and bargaining power from being a monopoly, which forces hospitals and providers to accept the only game in town payments, the cost would come down.  Of course, the filthy rich would be called upon to pay “their fair share” of taxes. The corporate tax rate would have to go back up to 35%, along with the marginal tax rate, as in England and the Scandinavian countries.  Sweden, for example, has a marginal tax rate of 70% for any income over $98,000, and an even higher rate for the millionaires.  This tends to discourage an income above that amount and encourages moving to countries that don’t soak the rich quite as much. Elizabeth has promised a new annual tax on future (unrealized) capital gains for assets you have not sold yet. The death taxes have crept up to $11,000,000 which are due to sunset in 2025, back to pre-2018 levels, another way to thwart small businesses and farms to pass on their assets to their offspring. We are better off having large impersonal corporations and mega-farms anyway!  They are much more empathetic to the working people, and if the evil corporations get fed up with the taxes they move to Ireland, Mexico, or some other places that want to attract companies that provide jobs for their citizens.

There is always the Weimar Republic’s answer to money problems, PRINT MORE OF IT!!  After World War I, Woodrow Wilson, Georges Clemenceau of France, David Lloyd George of the United Kingdom, and Victor Emanuele Orlando of Italy cleverly crafted the Versailles Treaty that decimated Germany and Austro-Hungary economically, which ultimately was responsible for the rise of Adolf Hitler according to many historians.  The French and English even sent in troops when Germany fell behind in the war reparations to force payment.  Hindenburg, the then German chancellor, ordered the printing of more money to pay off those debts.  I remember, as a child, those banknotes were still around even after World War II, used as play money by us children.  The banknotes were pretty and fun to play with, because it looked like real money because it used to be real money.  People used that money to wallpaper their houses and the price of a loaf of bread was 50 million marks.  Money became worthless.  People did not want to work for worthless paper, and didn’t accept it for goods, services, or food.  Printing more money, in the long run, does not pay off; additionally, you need a wheelbarrow to go shopping to replace your wallet. 

What about the structure of the new single-payer system as far as the impact on the consumer and providers of health care?  Hospitals run on a very tight budget because the profit margin is squeezed from all sides.  The average profit margin has reached 1.7% in 2018.  The payors are angling to pay hospitals less.  The workforce, nurses, physicians, respiratory therapists, etc. want a better salary. Vendors are looking to make a profit, and surgical equipment, CT scanners, even hospital beds are constantly costing more to buy.  The basic hospital bed now costs $50,000, more than most cars.  How the government is going to squeeze any more blood out of the proverbial turnip (hospitals) is still held a closely guarded secret by  Bernie and Elizabeth.

Physicians are also a target.  20% of health care costs go to physicians. Practice costs are on average half the physician’s gross income, and steadily growing with employees’ salaries, malpractice, rent, equipment, etc. all continually increasing. This does not even consider paying off student loans which are higher in the US, as schools are not tuition-free as in many European countries. The average medical school debt was $196,520 in 2018 according to the Association of American Medical Colleges. This is because the training period has grown to multiple years now: pre-med college is 4 years, medical school is 4 years, an internship has grown to 2 years in some states, and residency 3 to 6 years, and a fellowship 1 to 3 years. The individual cannot start paying their loan off sometimes for a decade, as the interest keeps accumulating at compound interest rates. Half of one’s earning life can be taken up by training.  A bright individual who can get into medical school will think twice before embarking on a long educational road with now increasingly questionable financial benefit.  He or she can do better, not only financially, but in lifestyle as well in other lesser demanding occupations that allow starting a family sooner, earning a living wage right away, no night call, and no constant legal, and governmental scrutiny.

The single-payer system would alter our economy.  Health care is currently one-fifth of our economy.  That would grow significantly.  If nothing changed in terms of taxes and spending, it would become 100% of the economy!  Obviously, that could not happen, but the economy would shift dramatically with health care occupying a larger slice of the pie and the increased taxes that would be necessary to cover the cost of all the non-discretionary spending the government is obligated to pay to keep the doors open.  Of course, military spending would be a logical place to “borrow” some of those funds that are spent in purchasing $500 hammers and such.  I am sure that ISIS, Boko Haram, and other terrorist organizations with less to fear from a weaker US force would take the opportunity and cut back their budgets accordingly; don’t you think!

Now, what about the consumers. Would there also be a shift in the quality of care? With less money going to hospitals and doctors on the horizon, the dictum of “You get what you pay for!” looms dangerously in the background. Other countries that have government-sponsored health care can be used as examples of what that could mean in terms of what is or is not covered, what you may or may not get for treatment of rare or not so rare diseases, and what surgical procedures are approved. Total joint prosthesis and artificial heart valves last way too long anyway.  It would be more economical to use the less expensive ones and just replace them if the individual lasts long enough to wear them out. There is a reason why every country in the world that has government-run health care uses rationing to control costs, as directly quoted from the Wall Street Journal Nov.3, 2019.  How expensive drugs would be paid for, and how long before you get your procedure, appointment, or test approved would you wait?  A friend of mine living in Canada developed headaches and wanted a brain CT scan.  He was put on the waiting list for a year.  He complained that if he had a brain tumor it would be too late in a year.  He was informed that in that case, he wouldn’t be needing the scan after all, and it would be canceled.  In England, for example, dialysis for kidney failure is not approved for the old.  And who are the old?  Anyone over 50 years of age.  It does remind you of the “Death Panels” that got Sarah Palin into such hot water.  Be careful what you wish for; you might just get it!  

The Naked Ape

They say that only one-third of Americans believe in Evolution, and two-thirds believe in Creationism, just the reverse of Europeans. So if you do not want to burn in hell, stop reading right now because you risk damnation.

Why do I believe in Evolution, and gamble on spending the rest of eternity surrounded by fire and brimstone?   I can’t ignore what I see that is so obviously obvious.  If you don’t see the resemblance, you must be blind-sighted or seriously brain laundered. But I will nevertheless forgive you.  There are plenty of very smart people that missed it too.  Charles Darwin and Alfred Wallace stumbled upon Evolution just a bit over a hundred years ago, almost simultaneously.

What about Aristotle 2400 years ago? He founded logical thinking and was an observer of plants and animals.  He even classified 500 species of animals and arranged them in order, suggestive of evolution with man at the top.  Very close, but not the whole enchilada. He is considered to be one of the smarter humans that ever walked on earth, but he did not come up with the rather obvious resemblance of monkey to man.  

Archimedes, a math whiz with lots of bright ideas, whose comprehension was on an intellectual plane much more sophisticated than what Darwin had.  Aristarchus of Samos who figured out the sun was just another star that was the center of our solar system long before Copernicus and Galileo did. Eratosthenes, the chief librarian at the Library of Alexandria, calculated the circumference of the earth accurately, as well as the distance of the earth to the sun. Hero of Alexandria, who invented the steam engine, and  Hipparchus of Nicea who invented trigonometry, additionally the first analog computer, the Antikythera mechanism, and the Astrolabe that determined at what longitude a ship was located without which navigation would have been impossible. 

Some of us look more like them, or they like us, and others less, but in all of us, there is an unmistakable resemblance that we are at least cousins.

Then there was Isaac Newton, the author of Principia Mathematica, which set the foundation for physics for hundreds of years. Principia had decidedly more ingenious ideas than Darwin ever had.  Did I mention that Newton also invented calculus? Did those folks not look, did they not see that we very much resemble apes, and especially when looking at baby chimps or gorillas.  Galen, the Roman surgeon, had no excuses. He dissected monkeys to learn anatomy because he knew they had the same design as humans, since Lex Romana did not allow human dissection.  

A little more subtle are all the organs we share that have an almost identical appearance and function in us and the apes. But there are organs we share that are still present in us, but have lost their ability to function in us but not in them.  The hair follicles have tiny muscles attached to the follicle that can raise the hair (Arrector pili).  In us, it is just the goose-bump with one small hair sticking out on top of the bump, but we all have them.  It used to serve the function to puff us up and give us a more substantial, scarier appearance and to give us a layer of protection with the raised hair trapping air all around us to keep us warmer in the cold season.  So what would be the Creationist’s explanation of goosebumps? Or did the Creator get confused in what must have been a horrendously busy week of Creation, and give us some of the monkey skin as well? 


There are several other vestigial organs that still reside in our bodies that have no function in us, but we still have not evolved out of those organs.   The appendix may have some purpose in our immune system, especially in our embryonic stages, but in several species, such as rodents, the appendix serves to digest cellulose. We have lost that ability as cellulose is not a food for us, so the appendix serves primarily to give surgeons a means to make a living.  

The ear is a curious remnant of our distant past.  It serves to orient itself to the source of sound as to better catch the sound waves, especially if there is danger lurking nearby such as the stealthy tracks of a leopard or the slithering of a snake in the grass.  Unfortunately for most of us, the muscles that redirect the ear have atrophied to such an extent that they can’t move the ear anymore, except in a few very talented humans that can still wiggle their ears with the special muscles that still function in those lucky individuals.

The Mammary Ridge

Have you ever wondered why males have nipples? Well, both males and females develop them because we are mammals. All mammals feed their young with breast milk. Some women have more than two nipples along the mammary ridge, just like dogs and cats. These can also have accessory breast tissue along with the nipples. In my previous life as a surgeon, I was called upon more than once to remove those accessory breasts. Why do we have them? They are vestigial leftovers from our past. That is another tough one for Creationists to explain.

The palmaris longus muscle exists in the forearm of 90% of humans. The other 10% have lost that muscle along the evolutionary path.  Its function was to grip onto a branch for swinging from tree to tree, something we don’t have to do anymore.  The levator claviculae muscle is present in only 3% of humans.  Leonardo DaVinci’s drawings of the neck anatomy show it. The levator claviculae is present, however, in all apes.  Does that mean anything? Or is it just there to confuse us?

Not only can we have numerous breasts, but we also have a vestigial tail.  Most of us just have two or three extra vertebrae at the end of our sacrum, but the record holder had a tail that was nine inches long. Cool! Especially if you were naked wandering around the Garden of Eden to keep the flies off the anus.  Well, do you have a better explanation?

Every infant has a reflex called the “palmar grasp reflex.”  If you put something into an infant’s hand he/she will grasp on to it and not let go.  This happens in both the upper and lower extremities.  When the mother had to get out of a dangerous situation, she could not hold onto the baby.  The infant was on his own and grasped onto the mother’s hair.  That left the mother’s hands and feet free to get away from the danger.  We don’t have enough hair to grasp onto, but luckily our mothers don’t have to make a run for it like our ancestors did, but we nevertheless hold onto that grasping reflex.   

When we were still living in and swinging from trees, our diet had more fibrous plant content that needed to be ground up.  For that, we had three molar teeth in the back of the upper and lower jaw on each side.  As our diet shifted to more high-grade protein, we needed tearing and cutting teeth, the canines and incisors.  Now the third molars often need to be removed by your friendly neighborhood dentist because the third molars get impacted and are very prone to tooth decay. 

Not only do we have vestigial organs, but there are even vestigial genes in our DNA.   Most animals, but not humans, can make their own Vitamin C, the lack of which, in us, is lethal, as the sailors crossing the Atlantic at the time of Columbus found out.  There is a gene that makes the enzyme L-Gulonalactone Oxidase.  In us, this gene necessary to make Vitamin C, although present, just as the muscles that move the ear, was disabled by a previous mutation.  We have to depend on exogenous Vitamin C from citrus or other vegetables such as fermented cabbage (sauerkraut). The British Navy used to serve sauerkraut at least once a day on shipboard but later made every sailor eat a lime instead every day to prevent scurvy. Hence they (and by association all British people) are called “Limeys.”  The name “Krauts” is reserved for another nationality.

All the  vestigial organs within us that have no function:  the arm muscles that no longer are able to help us hold on to branches, and are missing in one of ten humans, the ear muscles that are no longer able to turn our ears to the source of sound, the molar teeth that no longer can grind plant fibers into food because they are overgrown with gingival tissue, the appendix that cannot digest cellulose, the goosebumps that have no useful function, the extra breasts in females that are there to feed the litter that never comes, the reflexes that are not needed for the infant to hold onto their mother, tail bones that are not long enough anymore to serve any function, and the genes that cannot manufacture Vitamin C are either mistakes, but I prefer  “evolution in progress” as the explanation.  Which will it be? Could the Creator really have made that many errors?

 The final icing on the cake is that we share 98.8% of our DNA with Chimpanzee DNA.  Does that happen by coincidence? Or could that be the ‘missing link” we have all been searching for, that gives us the evidence that we are indeed related!

ALFRED NOBEL (1833-1896)

I recently came upon an article by Dr. Don Nakayama, historian of the American College of Surgeons, that reminded me of Alfred Nobel’s clever ploy. 

Alfred Nobel is one of those iconic humans whose legacy is associated with the most significant achievements of our recent history.  His story is interesting because his main achievement is that of creating dynamite, a substance that killed and maimed thousands, if not more, humans through wars and accidents. Although Alfred Nobel was agnostic and later in his life an atheist, he worried about how he would be remembered by humanity. Alfred cleverly diverted the attention away from his homicidal reputation to one that associates the name “Nobel” with significant human accomplishments.  He bought a better legacy for himself.  It only cost him three BILLION dollars!

Alfred was a Swedish chemist who had a fascination with nitroglycerine,  which is an oil that was invented by an Italian, Ascani Sobrero.  Alfred and his family started a business in making this substance they called “blasting oil.” He had factories on both sides of the Atlantic.  Alfred, while experimenting with this dangerous oil, managed to blow up several houses, including one that had his younger brother Emil in it along with four other people.  After that the city of Stockholm no longer allowed him to experiment within the city limits.  He took his lab to a barge on a lake outside the city.  Nobel tried a variety of substances to mix with the nitroglycerine to make it more stable, and finally settled on diatomaceous earth that not only made it stable but allowed it to be molded into rods to which he attached a blasting cap to trigger it.  He invented dynamite! But he continued to create many other things, including synthetic rubber, leather, and silk.   By the time of his death, he had 355 patents to his name. 

In 1888 another of his brothers, Ludwig, died in Cannes, France, of natural causes. Alfred happened to read the French obituary that reported on the death of Ludwig, but they got the names wrong, and instead of Ludwig the newspaper reported that it was Alfred that had died, and wrote: “Le marchand de mort est mort” (the merchant of death is dead). They went on to say, “Dr. Alfred Nobel who became rich by finding ways to kill more people faster than ever before, died yesterday.” His portrayal as a murderer deeply wounded Alfred.  He made it the rest of his life’s task to change this, which he perceived to be, an unjust view of him. To add insult to injury, the French government convicted Alfred of high treason for selling explosives to Italy, and he had to move from Paris to Sanremo, Italy, in 1891.  By the time of his death in 1896, his amassed fortune was more than three billion (with a “B”) dollars.  He had never married and had no children, so he crafted a will that took 94% of his total worth and created the Nobel Foundation, which gave awards to the most deserving people in the fields of chemistry, physics, medicine and physiology, literature, economics, and peace.  Each person received approximately $1,000,000 along with the coveted 24-carat gold medal (which now is 18 carats with 24-carat gold plating). 

My interests in the Nobel prize involve the things that dealt with the sciences and especially as they affected my profession of medicine and surgery.   Every year in early October, the overlords of the Swedish Academy of Sciences, with input from the Karolinska Institute for physiology and medicine, announce the winners for that year’s Nobel Laureates. Many noteworthy prizes are milestones of human accomplishments. Those stories are interesting to me and are worthy of comment, because some have changed our lives while others are just curious, historical, or heroic. As is so often true, “Truth is stranger than fiction!”

On November 8, 1895, Wilhelm Conrad Röntgen exposed his wife’s left hand on a photographic plate, to a tube with very low pressure, through which he passed an electric current.  On the picture he produced, he could see the bones of her hand.  The first X-Ray was taken.  X-Rays revolutionized diagnosis and as a consequence, treatment of human disease processes.  In 1901 he received the Nobel Prize in Medicine for this discovery.

In 1903 Madam Curie was the first woman ever to receive the Nobel Prize, which she won for physics.  She was a Polish native sent by her government to study in Paris.  She and her husband, Pierre, came up with two new elements, Polonium and radium.  Polonium named for her native country. Unfortunately, he was no longer living, run over by a horse carriage on the Rue Dauphine during a heavy rain in Paris.  She won again in 1911 for chemistry.  These prizes came with a substantial sum of money.  Poland supported her through grants to pursue her studies in Paris.  She gave that all back and wound up giving most of the rest of it to found the Curie Institute in honor of her late husband for the research on radioactive materials, the words she actually coined. Albert Einstein said of her that she was the only human he knew that was not corrupted by money, fame, or glory. Ultimately, she gave it all, including her life, as the radioactivity destroyed her bone marrow without which she could not survive.  It was Madame Curie that originated the idea that radiation could kill bacteria to sterilize surgical instruments and cancer cells in humans.  During World War I she founded a brigade of trucks outfitted with X-ray machines that drove into the battlefield, risking her own life to pick up wounded soldiers.  Before bringing them to the surgeons, she would X-ray their wounds to see where the shrapnel was to make it easier for the surgeon to find.  Few people are more worthy of a Nobel Prize than she. 

Robert Koch, a surgeon during the Franco-Prussian War and a staunch ally of Louis Pasteur, fought for the acceptance of the germ theory of disease.  His four postulates of disease causation remain the standard to judge whether or not a particular agent is causative.

  1. The bacteria must be present in every case of the disease.
  2. The bacteria must be isolated from the host with the disease and grown in culture.
  3. The disease must be reproduced when the bacteria is inoculated into a susceptible host.
  4. The bacteria must be recovered from the infected host.

Robert Koch identified the causes of anthrax, cholera, and tuberculosis.  He developed the skin test for tuberculosis, the PPD that is still used.  He refused to patent it as he did not want to have financial reasons to hamper its use to save lives or prevent progress against the disease.  It was for his work in diagnosing and treating anthrax and tuberculosis that garnered him the Nobel Prize in 1905.

Theodor Emil Kocher was one of the early greats!  He came from a race of giants, Billroth, Virchow, Lister, and Langenbeck were his teachers. He, in turn, mentored, Harvey Cushing, William Halsted, and Fritz de Quervain.  He did over 5000 thyroidectomies and learned how to do them right.  From a mortality risk of 75%, he reduced it down to 0.5%.  The Russian ideologue, and eventual leader, Vladimir Lenin entrusted his wife to Kocher when she needed a thyroidectomy.  Kocher earned his Nobel Prize in 1909.

Robert Bárány was an Austro-Hungarian physician who served as a surgeon in World War I.  He discovered the physiology of the vestibular system of the inner ear while he was trying to treat symptoms of vertigo and nystagmus by intermittent injecting warm or cold water into the ear canal of the patient.  By circumstance, he had been turned down by Sigmund Freud for postgraduate training as Freud thought he was odd.  Despite this when Barany was awarded the Nobel Prize in 1914 but did not receive it until 1916 as he was a prisoner of war.  He immediately exercised his right as a laureate to nominate others for the Nobel awards.  Who would you think he chose?  None other than Sigmund Freud!

In the field of physics, one of the greater lapses of the Nobel Committee occurred.  In 1905, a minor functionary at the Bern office of patents in Switzerland, named Albert Einstein, worked in sorting and registering new inventions.  During his day job, he had time to work on his hobby, nuclear physics. He wrote two monumental papers that revolutionized physics, going back to Isaac Newton 200 years before, the Special Theory of Relativity and the General Theory of Relativity.  Special Relativity relates time and space as a single entity he called spacetime.  The faster you travel, the slower time passes.  Also, the closer you are to a large mass (i.e. gravitational force), the slower time passes.  The Special Theory further explains that mass and energy are interconvertible with the now-iconic formula E=mc2.  Ten years later the General Theory of Relativity explained gravity as the distortion of spacetime.

 In August of 1939, a letter drafted by Einstein and other physicists delivered to President Franklin Delano Rosevelt personally by Einstein, detailed the concern that Germany was developing a nuclear weapon.  This led FDR to approve the Manhattan project that evolved to the actualization of the theoretical E=mc2 formula resulting in the vaporizing of two Japanese cities, Hiroshima and Nagasaki.  This left only dust, ashes, and human agony as evidence that mass can be converted to pure energy, but did end World War II.  The theory for this was all laid out by Einstein by 1915, but the Nobel Committee chose to ignore it because one of the jurors deferred his support for several consecutive nominations of Einstein.  His reasoning was that he doubted Relativity would stand the test of time – so much for the wisdom of the committee.  Instead, they threw the man who gave us the nuclear age, a bone, by giving him the Nobel Prize in 1922 for the photoelectric effect, a comparatively minor discovery Einstein made that electrons are released by exposing metals to specific wavelengths of light.  The prize money was, however instrumental in Einstein being able to purchase a divorce from his first wife.  Einstein did nevertheless keep the gold medal. 

Speaking of medals, a curious story involved the medals of two laureates, Max von Laue (physics 1914), and James Franck (physics, 1925)).  Both medals were housed at the Neils Bohr Institute in Copenhagen.   When the German occupation posed a risk to the medals because both physicists were notoriously anti-Nazi, they were dissolved in acid and hidden from the Nazis.  After the war, it was simple chemical precipitation to recover the gold and re-mint the medals. Another brush with National Socialism came with laureate Gerhard Domagk, who was not allowed, on the personal order from Adolph Hitler, to attend the 1939 Nobel Prize ceremony for his contribution to the discovery of Sulfa drugs, the first antibiotics.  But Domagk did eventually get his award after Hitler bit the cyanide pill in his bunker in Berlin. 

Frederick Banting was educated as an orthopedic surgeon but practiced general medicine in rural Canada.  Because his practice was not very successful, he turned to academia at the University of Toronto.  He and a medical student, Charles Best, did experiments in isolating a pancreatic hormone, the lack of which they thought was the cause of diabetes.  They extracted this from specialized pancreatic cells found in the islets of Langerhans.  The department head J.J.R. Macleod provided the lab facility as well as Banting’s assistant, Best. Because of this, Macleod, not Best, got to share the 1923 Nobel Prize for medicine in the discovery of insulin.

Alexander Fleming was a Scottish physician and microbiologist, although he did serve as a captain in the Royal Army Medical Corps and did duty in field hospitals filled with injured soldiers that required a surgeon’s skills.  His talents, however, were along the lines of bacteriology.  In his own words, “One sometimes finds what one is not looking for… but I suppose that is exactly what I did.” Fleming noted that one of the bacterial plates he was studying had killed the bacteria through accidental mold contamination by Penicillium notatum. He was knighted for this achievement, the discovery of Penicillin, and received the Nobel Prize in Medicine in 1945. 

Charles Huggins was a Canadian-American surgeon who noted that prostate cancer could be controlled by castration and estrogen hormone administration.  In 1966 he was awarded the Nobel Prize in Medicine.

Few surgeons garnered the Nobel Prize, but one Antonio Caetano de Abreu Freire Egas Moniz shared the 1949 prize with Walter Rudolf Hess.  Antonio devised an operation that is now abandoned in the historic wastebasket of discredited operations,  the frontal lobotomy.  When I was in high school, my father, who was a physician in a mega psychiatric institution of 7000 patients in central Illinois in the 50s, would take me to operations.  One of the very memorable ones was watching a neurosurgeon do a frontal lobotomy.  The extraordinarily violent patient was brought in leather restraints into the operating room, and strapped to the operating table.  Once the anesthetic was administered his restraints were taken off.  The surgeon drilled two holes in the front of the skull just behind the now clean-shaven hairline.  With a long electric cutting knife (Bovie) he made sweeping motions through both sides of the brain, disconnecting the front of the cortex from the rest of the brain.  The patient was awoken.

An amazing transformation had taken place.  He was a vegetable, didn’t talk, and made no intentional movement, but he would get up and walk when prompted.  One of the best Hollywood movies I have ever seen was “One Flew Over the Cuckoo’s Nest” directed by Miloš Forman with Jack Nicholson in the lead role. It portrays realistically and graphically what frontal lobotomy is all about. It won all five major academy awards: best picture, best actor, best actress, best director, and best screenplay.  It is considered by many to be one of the best films ever made.  I sincerely believe it is a major factor that frontal lobotomy was abandoned, also calling the Nobel Committee’s decision to give Antonio a gold medal into question.

Other surgeons whose medals remain un-besmirched are: Alexis Carrel (1912) for inventing vascular surgery after being witness to the assassination of French President Marie François Said Carnot in the streets of Paris, who died of a laceration of the portal vein for which the surgeons of the time didn’t have the means or knowledge to repair. Werner Forssman and André Cournand for cardiac catheterization (1956) and Joseph Murray (1990) for the first kidney transplantation, who all need to be included.  

It is surprising how many great surgeons have been left out:  Alfred Blalock for his shunt that has saved thousands of infants’ lives, and C. Walton Lillehei, aptly named by his residents, the King of Hearts, for his work on correcting congenital heart disease. Also what about Michael DeBakey, who gave us coronary bypass, carotid endarterectomy, and ascending aortic dissecting aneurysm repair, not to mention his contributions to the Mobile Surgical Army Hospital (with the successful TV and movie versions of the MASH Unit). Furthermore, the first heart transplant was done by Christiaan Barnard, and Thomas Starzl did the first liver transplant. 

Often at the end of a challenging operation, while teaching young surgeons to operate, there is a less tense moment while placing the last few sutures in the skin when the surgeon in training can be quizzed on surgical trivia. I liked Dr. Nakayama’s suggestion of asking them who all the surgeons are that had received the Nobel Prize.  It is not a long list and, by rights, ought to be much longer. The Nobel Committee has its work cut out for them.  So many more years, and so many deserving surgeons.

#westandontheshouldersofgiants

 

The Green New Deal

Our teachers of history have seriously duped us.  How did I deduce this?  There is good evidence that there were several times in history when the earth was much warmer. Actually, it was much warmer than it is now during our own global warming crisis, which will destroy our way of life as we know it!  Two periods, first the Roman Climatic Optimum from 250 BC to 400 AD caused the retraction of Alpine glaciers that allowed Hannibal to cross the Alps with elephants. Furthermore,  Tacitus noted that it was so hot in Greece that none of the date trees could set fruit, which is also the case now during our current global temperature anomaly.  This is seen as strong evidence that the temperatures now and then were similar. Do you suppose that the Romans had gas-guzzling SUV’s just like us, or was it motorized chariots? Something our historians must have missed.

Second, there was the Medieval Climate Anomaly (MCA)  from 950 to 1250 AD, where the ocean temperatures exceeded today’s devastating sea temperatures that are melting the ice caps giving rise to sea levels that will soon inundate New York and San Francisco.  It allowed the Vikings to settle in Greenland, which actually was GREEN at that time, unlike now when it is completely covered by ice. Proof positive that it was hotter then. The Vikings actually landed on the North American continent way before Cristóbal Colón.  One more black mark against our history teachers. The north and south polar ice caps on our planet have occupied their places for only 20% of the existence of the earth, but 80% of the time the poles were totally ice-free, covered with megafauna and flora, as evidenced by geologic finds under the frozen arctic tundra of skeletal remains of rather large polar bears that surprisingly survived the ice cap’s melting, mammoths, sabre tooth tigers, and of course the legendary vast oil deposits that had to come from somewhere.

 AOC (Alexandra Ocasio Cortez), the former Bronx bartender and now the youngest member of Congress, but wise beyond her years, has introduced legislation to save us from ourselves, the “Green New Deal.”  She has concluded that we must radically change our wicked ways with fossil fuels to dramatically reverse the rapidly rising CO2 levels that will cause algae to bloom, reduce the oxygen in water, kill the fish and coral in the ocean. Furthermore, all the tropical diseases will migrate from the equatorial regions to infect us with malaria, elephantiasis, allow the Tsetse fly to move north and spread sleeping sickness, and a variety of other parasitic diseases that will significantly reduce our numbers. 

What must we do to survive? We must “de-carbonize” our environment by adopting the “Green New Deal.”

  1. 100% of our energy needs must come from renewable nonpolluting sources such as solar, wind, water, but heaven forbid not nuclear power. After all, the combined worldwide nuclear accidents have killed 42 people to date in the last 50 years.
  2. We must eliminate the use of fossil fuels for transportation, agriculture, construction, energy generation, and defense,  by 2030.
  3. We must eliminate the sources of greenhouse gases, CO2, and methane. This translates into making the internal combustion engine obsolete (most automobiles, airplanes – propeller-driven and jet, farm equipment, generators, Harley Davidsons, Vespas, golf carts, etc.). Mining and use of coal would be mothballed.   Eradicating livestock, especially farting cows who produce much of the methane is high on the list.  Faux beef would go a long way to reduce methane.
  4. Reforestation would provide a way for CO2 to be converted back into water, oxygen, and plant tissue that could be substituted for animal tissue for food.  An all-vegan diet for everyone would go a long way to rejuvenate the planet, not to mention the health benefits.
  5. The funding for this would come from taxing the overly rich and the evil corporations.  As it stands now, the top 50% pays 97% of taxes. The bottom 50% pays 3% of the collected taxes.  But if the marginal tax rate would go up to 70%, as AOC suggests, meaning that after some arbitrarily set amount, let’s say an income of $100,000 which ought to be plenty to live a good life, anything above that amount would be taxed at 70%. If that is not enough the Swedish or British tax model actually goes above 100% with incomes above $1,000,000. Then the leeches would finally pay 100% of the taxes as the left has always envisioned fairness. It is high time for these rich parasites to pay their equitable share.  Being forced to pay their fair share is why the Beetles moved away from England despite John Lennon’s lyrics:

Imagine no possessions
I wonder if you can

No need for greed or hunger
A brotherhood of man
Imagine all the people sharing all the world
.” reminiscent of the lyrics written by that great song writing team, Marx and Engel.

Similarly, Gerard Depardieu left France because he was getting taxed at a 110% marginal tax rate.

Life would be simpler and healthier.  A meat-free diet would decrease cardiovascular diseases such as stroke and heart attack. More exercise by bicycling or walking instead of driving the SUV would reduce obesity. We would get more sleep as turning on electric lights after sunset would be a crime.  Going out to movies and stage shows that use up a lot of electricity would be a thing of the past, and people could get back to reading books by candlelight. Waterskiing would go the way of chariot racing unless you could get a super-strong crew team to pull you.   The jet-set would have to make do with a walk in the park rather than the circumnavigational jetliner vacation. Just like getting rid of guns would eliminate all the gun-related homicides, getting rid of tanks, bombers, rockets, and aircraft carriers would get rid of mass casualties of war.  Swords and the bow and arrow would be less lethal in conflict.

There are so many factors that affect the weather: El Niño, La Niña, Milankovitch cycles, volcanos, clouds, the sun being a pulsar star puts out variable energy, as represented by sunspots.  Other factors are distance from the sun, the jet stream, ocean currents, ocean temperatures, plate tectonics, planetary multi-decadal cycles of position in relation to earth, greenhouse gases (of which CO2 is the weakest, and water vapor is the strongest) and many more, all of which have variability that depends on a myriads of other factors impossible to predict.  What the weather will be tomorrow is a crapshoot, but knowing what the weather will be in 50 years is a certainty.  All the scientists agree! And science has never ever been wrong, just as Galileo was strongly advised to avoid being burned at the stake, and to accept the science of Aristotle and Ptolemy and forget heliocentrism.  It may already be too late unless we listen to the wisdom and warnings of AOC.

Explaining Trump and Why Impeachment is not Wise

2016 Presidential Election

Ever since the last election, Democrats have tried to find a reason to “dump Trump.”  The womanizing scandal, the Putin affair, the Mueller debacle, and now the Ukrainian intrigue. This is all in the face of a President who does not follow the rules: he tweets, he swears and is crude, he goes through aides like a mother changes diapers.  But America does not quite understand the Democratic game plan the way the Democratic leadership sees it now as the prior position of Nancy Pelosi demonstrated.  The people of the heartland are “Trumpists” through and through.  It is the left coast and the northeast coast, along with Illinois and Minnesota, that was anti-Trump in the last election, as you can see on the map. The heartland does not see why going after a politician and his son, who was getting $50,000 a month payment from Ukraine, are not fair game for corruption suspicion. Just that amount of money raises eyebrows. Even if that individual is a competitor, it does not exempt him from public scrutiny. Texans and other plain-spoken Americans do not think that being a political competitor is sufficient reason to ignore potential corruption.  Investigating potential crime does not equate to bringing charges of corruption, which if proven true, would make a difference to the stature, perception, and power of the United States of America, something not to be ignored! Pressuring foreign powers into US politics is another issue entirely, not without prior precedent by both Democrats and Republicans. However, does it reach the level of jeopardizing this country’s economy, with almost no chance of achieving a victory at trial?

Trump is perceived, rightly or wrongly, as a fighter for America and the common man, a champion for American goods, American labor, American intellectual property rights, and against countries that take advantage of the American business community, manipulate the global financial structure for their benefit, and want unfair financial aid and military dependence from the US to protect them.  This is something that other presidents, both Democrats, and Republicans, have ignored.  The unemployment rate is the lowest it has been at historic lows of 3.5% something for which the president is often given at least partial credit.  The African-American and Hispanic unemployment rates have superseded the lowest levels since records have been kept starting in 1972. 

If anything, the Democratic efforts for impeachment have been seen as harming the economy. The stock market, although up and down despite the China tariff threats, had reached record heights until the impeachment threat had deflated those heights, and is not supported by the majority of the country if we are to believe the polls.  

The Baby Boomers who are entering the golden years worry about their retirement nest egg.  Without question going through an impeachment trial would impact those retirement savings negatively.  This in the face of a Republican senate, the responsible body for prosecuting a president.  It is not likely the Republican senate would convict a Republican president if it came to trial.  It makes the entire impeachment effort appear to be a Quixotic show trial to influence the 2020 election, which may succeed but it also has an excellent chance of backfiring.  If the economy tanks because of insecurity related to uncertainty, the instigators of impeachment would get a large part of the blame, which would reflect negatively on the Democratic slate of candidates for president.

Trump would not be the first crude leader. America has had examples of crude leaders who have been excused precisely because of their perception of being fighters for the country.  General Ulysses S. Grant was a notorious drunk, and there were demands for his removal, yet Lincoln would not take him out of the command position in the Civil War.  Lincoln’s response to Grant’s detractors was “I want to know what brand of whiskey Grant consumes so that I can give a barrel of it to each of my generals!”    In 1869 Grant became the 18th president of the United States.  Similarly, General George Patten was a bad boy: rough, crude, eccentric, impolite, notoriously profane, and politically not correct. He made a point of being crude and always injected four-letter words into his speeches. He called it “elegant swearing”, but he won battles, including the decisive battle of World War II, the Battle of the Bulge. Near the end of the war, there was a strong movement to get him elected president against Franklin Delano Roosevelt.  Unfortunately, Patten died in a car accident, where there is good evidence that it was really an assassination perpetrated by the Russians who did not want him as president under any circumstance, as Patten was no friend of the Soviets. They apparently may have been messing with our elections for some time!

I hope that the more politically savvy segments of the leadership will resist pandering to the far left and recognize that they are playing with fire with explosive potential, and will steer the helm of the nation back into safer waters with less risk for the economy! And let the next election decide the merits.

Can Feminism be Toxic Too?

What is the opposite of Toxic masculinity? Toxic feminism?  I don’t get it.  Feminism led us down a path that somewhere got twisted into a male hating philosophy.  Feminism was supposed to provide women with equal opportunities as men.  Instead, it created a bunch of men-hating bra-burning women . And furthermore, it did not achieve what it was intended to do.

Was that really the purpose? Women did have a point.  They were discriminated against.  And societal changes were in order.  But have they overshot the target and gone beyond their mission, and their intention?  Men are now afraid to compliment a woman on how she looks.  If a male says to a woman, “Nice dress!”, some women consider that a “mini rape.”  If a joke is just slightly off-color, you have to keep it to yourself, because that is now harassment. 

Where did the humor and humanity go?  You dare not touch a woman, other than your wife.  That could be unwanted sexual advances.  Humans touch each other, just like all other apes do. The back slap, or the touching of the shoulder, that is what the handshake is all about; it shows we do not carry a weapon.  It is genetically ingrained in all apes to groom each other.  It is meant to show friendship.  I do not imply that we should become that familiar, besides we have better ways to get rid of lice. But we did come from apes; we are apes!  Apes touch each other all the time.  It is a sign of caring!  Somehow it has now become aggressive.  I know that certain touching is clearly off-limits, but the whole escapade of Joe Biden, an old grandfatherly edentulous man, kissing the back of a former close associate’s head, has now been escalated to sexual aggression! Where have we gone so wrong?

The whole “income gender gap” is often pointed out as the continuing inequality of men and women.  If a woman makes a few pennies less than a man, the immediate conclusion is that there is an evil male conspiracy to suppress women. Never mind that on average women work fewer hours, never mind that they usually retire earlier, never mind that they have duties that men do not have, and for which they do not get monetarily compensated. Never mind that they often do not negotiate themselves into a higher pay scale, as they do not seem to be as aggressive negotiators as males, and are more incentivized to accept positions that have non-monetary benefits that fit more with their life goals and life situations.  Also, they are likely taking less money because men are more often the primary breadwinners and are therefore more motivated to negotiate harder.  If there is a disparity in income, there are many other possible reasons besides “male privilege.”

Being male has negatives that are not fully appreciated by women or society.  Males get jobs that are more dangerous, more physically demanding, more likely to have injuries, more likely to risk life and limb, such as cops or firefighters. Men are killed on the job ten times more often than women, according to the US Bureau of Labor Statistics.  Furthermore, four times more men commit suicide than women do. Men take jobs that do pay higher, naval military design, engineering, construction, computer design, orthopedic surgery, and many more, some that require more physical strength, and because of the nature of the job have higher compensation.  Women have more jobs in social services, teaching, or business management, that have a lower pay scale. Indeed, there are women cops or orthopedic surgeons, just not very many. Also, if you consider all the factors, such as hazard exposure, hours worked, time off, number and difficulty of cases for surgeons, and you get down to unbiased specifics, the gender pay gap disappears.  If there are not precisely 50% of the job positions split equally between men and women there is not a male-dominated corporate conspiracy at some nefarious purpose at work to hold women down.  I was the program director of a surgical residency for five years.  We did look at gender equality, but more importantly at academic achievements, letters of recommendation, manual dexterity, and impressions on personal interviews. In other words, real qualifications.  If one year we had 66% of women, the next year it was often reversed. Also, the number of applicants of one or the other gender shifted the likelihood of our gender makeup.    

The sensitivity of women has been dialed up to a level that is no longer comprehensible.  It makes the woman a victim, instead of a “Wonder Woman.”  A favorite term that has become overused is “micro-aggression,” which is defined as, “a casual degrading attitude or language towards any perceived marginalized group, such as different racial, gender, nationality, or disabled group, etc.”  This, no question exists, but negativity is a tool not necessarily to degrade, but to elevate as in teaching, in humor, and in motivation. If the glass is half empty, we try harder. Anticipating the worst prepares a person better for adversity, than glowing praise.  I have often seen so-called “micro-aggression: employed in adult learners, be they male or female, as a useful teaching tool.  It can easily be misinterpreted, instead of an effort to make a point, a means of making casual conversation,  a teaching tool, or just chatter. It has been over-interpreted and over-rated in many instances and should be relegated to the microscopic for which it is named. It further emphasizes that we have become too sensitive.

It is a shame that this can no longer be used, especially since it is often quite effective.  The reason for abandoning this useful method is that the epidermis (skin) of so many groups has gotten so thin.  The “D” word (discrimination) is so quickly used when it was often meant to educate and enlighten and help that individual. The teacher, so labeled, cannot overcome that accusation.  It is like being accused of thinking evil thoughts or being a witch.  You cannot refute it.  I was a poor foreign-born kid with a heavy Austrian accent, often called “a Kraut” when I was growing up.  That was macro-aggression.  My response was, “sticks and stones can break my bones, but words will never hurt me.” Inside I knew I could be better than any of them.  On the contrary, it made me more robust and more inspired to prove my worth.

Why have so many women become snowflakes, instead of what the other half of humanity should be that have the gentler touch, the more reasoned and less dangerous view, and the peaceful solution rather than war?  There is good science to back the observation that higher estrogen levels lead to more risk-averse behavior and that high testosterone levels lead to riskier or even criminal behavior. 

The “Me Too” movement is, in my view, a clever PR ploy to emphasize women’s victimization.  The poor aspiring starlet had to get raped by the monster mogul producer to get the lead role on the silver screen.  Yet it was that very act that gave that producer the power to continue abusing women.  All she had to do was to kick him in the groin and walk out, but that was not in her playbook! She chose victimhood vs. woman power. She would have paid the price for that role, but she would have saved the next woman. 

The far extremes of both the right and the left give a voice to the lunatic fringe, from the right it invites misogyny, and from the left, it demands that there is absolutely no difference between men and women.  To have a legitimate scientific conversation of women and men’s differing talents strengths and weaknesses are now not allowed for fear of men being branded as male chauvinists and harboring male privilege. 

Feminism has feminized the male.  Boys should play with trucks, not dolls, while girls should be caring and nurturing, and for them playing with dolls is a good thing. There are plenty of opportunities for girls to be tough in ways that don’t castrate the boys.  A lost art form that needs to come back is “sophisticated shaming.”  This is a witty retort to a male, saying what you mean pleasantly and respectfully pointing out the shortcomings of the male’s insensitive or passive-aggressive remarks. It could go a long way in bringing back gentile, but firm femininity.   Society still needs a strong father and a loving mother to raise a child, be it male or female.  Admittedly the gender roles have blurred, and that has softened maleness and toughened femaleness, and that is not necessarily bad if it does not cross the lines. I think we all have a good idea where those lines are drawn.  After all, there is still and should be a difference between men and women, and as the French say Vive le différence.

RETIREMENT

I stepped back from clinical surgery the day I turned 75 years of age.  I still do some didactic teaching and administrative work for the surgery residency I founded just 6 years ago, but have not touched the scalpel exactly one year ago.

I have had a gratifying run for 51 years in this job, 9 years as a GP in a small town doing the gamut of medicine, along with some surgery and obstetrics, with about 100 deliveries a year.  I still see people on the street that come up to me, telling me that I delivered them. Occasionally I see a girl, now a woman, that I delivered with phocomelia of her right arm, a condition where an extremity does not fully develop in utero, and a malformed hand that does not work very well grew from the right shoulder.  I see her in the grocery store shopping for her family and she seems to do quite well without one arm.  I have to be careful so she does not catch me watching her as she might misinterpret my reasons. I can’t get over how agile she is.  My mood is always enhanced when I encounter her, as it is a 100% reversal of my attitude when I delivered her, which was quite brokenhearted.

My last 42 years have been as a surgeon. It has also been an exciting and rewarding experience that I would not trade for anything.    I changed from my general practice to surgery by going back into training, as surgery requires the acquisition of skills that a GP does not possess, at least not in the last quarter of a century.  My wife and I just had our first (and only) child when I decided to become a surgeon. I asked her permission to go back into training, to which she lightheartedly agreed.  In 6 weeks, however, she said to me, “What have you done to our lives?” I was on call every other night in the first few years and every night my last year as chief resident.  But we, our child and our marriage survived. 

I started the practice of my newly acquired occupation in a small town in Southern California.  I had some help initially from the surgeon I replaced until he retired. Later I had some partners. First, a retired two-star Navy admiral who was demoted to a one-star admiral, which mandated his leaving the Navy (but that is another story), and then a woman surgeon shortly out of training. But there was a period when I was the only surgeon around, back to being on call every night.  One night, I had gone to bed early as I had some kind of viral illness with fever and dizziness.  The emergency room called; they had a patient with appendicitis.

I got up with difficulty and had to crawl on all fours to the closet to get dressed because of the dizziness.  My wife was aghast. “You can’t go like this!” she said.  But I was the only one around, and I was pretty sure I could do an appendectomy as long as I got propped up against the operating table so I would not lose my balance.  I had to have my wife drive me, though.  That I could not do, and she reluctantly agreed.  My biggest concern was that the operating nurses might think I was drunk, even with an explanation.  As long as I focused on a single point and walked straight towards it, I did not stagger.  The appendectomy went fine, and my wife drove me home. 

My town was along one of Califonia’s most dangerous highways, State Highway 126.  It had the euphemistic name of “blood alley” for all the accidents it produced.  I had at least one major accident a week, often with multiple injuries.  That kept me busy all the time. “Dead Man’s Curve”  was the worst.  One accident for which I had no bag of tricks was when six men drove under an eighteen-wheeler semi-truck, and all six were decapitated.  They brought the heads up to the ER! That was way above my paygrade!

The variety of surgery I saw was overwhelming.  I even had to do C-sections at times when no one else was available to do it.  A woman in labor had a prolapsed cord,  which is when the umbilical cord precedes the baby,  When the head engages the pelvic ring, the cord gets trapped and shuts off the blood supply to the baby, a lethal situation.  Someone has to push the head up, to allow the cord to be decompressed.  I got the call to come quickly!  There was no time for the niceties to meet the family, or introduce myself.  The patient was on the operating table when I first met her (as it turns out for the second time in my life).  The anesthesiologist did what is called a “crash induction.”  The anesthetic was administered and the baby had to be out before the anesthetic drugs got to the baby, a couple of minutes, max.  I had not done a C-section in some time, but it came back quickly, just like riding a bicycle.  The baby was fine and when I went out to meet the family, the patient’s mother exclaimed, “You delivered her!”  “Yes, I just did,” I answered.  “No, no!” she said.  “You delivered her from me 25 years ago!”  I did have mixed feelings about that. It definitely implies getting older when you are delivering women whom you delivered as babies. 

There are operations I have done that I keep reliving in my mind, often in my dreams.  One such operation was on a young woman who was planning on getting married within a week.  She liked to do competitive barrel racing on her quarter horse.  She was winning when she fell and struck her right upper abdomen on the barrel.  She was in deep shock when I first saw her.  In the operating room, the injury was a horrendous one.  The liver was torn off the vena cava.  Every time I tried to see exactly what the damage was I was met with a rush of blood that you could actually hear from above the liver – audible bleeding.  I did a maneuver that was called the Schrock Shunt, a plastic tube inserted from the heart down past the injury in the vena cava.  They say that there are more papers written about that shunt then there are survivers of that injury.  Unfortunately, that was the case in this operation, she did not survive. 

A happier case was a 10-year-old boy who was riding “the grasshopper.”  That is what they called it.  An oil well that is in production looks like a giant grasshopper moving its head up and down as it sucks that black stuff out of the ground.  He climbed up to the “head” and when that moved down he fell off, and his knee was crushed by the “head.” I had just had an anterior cruciate ligament repair done on my own knee by my orthopedic surgeon friend Tom.  It was an old ski injury that finally got too bothersome with the knee giving out at the most inopportune times.  I had worked all day in the office and did not eat or drink anything, walked down to the hospital at 4:30 PM, hopped up onto the operating table and had my ACL replaced with a graft fashioned from a portion of my kneecap and patellar tendon.  Tom gave me lots of Norco (this was before the opioid crisis) and sent me home with a knee immobilizer with strict instructions to elevate the extremity, keep an ice bag on it, and not bear any weight on that leg by using crutches.  Being on the sharp side of the knife was a new experience for me, but I tried to be a good patient, until 2 AM.  Tom called.  I was initially a bit disoriented because of the time and the Norco, and thought he called to check on me.  I was pleased that he cared, but he could have waited until the morning.  As it turned out, he was not checking on me! He wanted me to come back to the hospital to help him, as he was operating on the boy with the crushed knee.   Unfortunately, the “grasshopper” had destroyed his popliteal artery which courses behind the knee joint and is the sole blood source for the leg and foot.  I told Tom that I was full of Norco and could not walk without crutches, and was trying to do precisely what my surgeon had instructed me to do, ice and elevate the leg.  Again I was the only one available, even though I was impaired for several reasons.  Again  I had to impose on my wife to drive me, which she reluctantly did, continually reminding me that if things didn’t go well, I would get crucified for operating under the influence of drugs, as well as being disabled with my leg.  My malpractice carrier would likely disclaim responsibility for such wanton disregard of common sense and unconcern for the standard of care.  The problem was that I was the only surgeon in the area that had the technical ability to fix this.  I recognized the risk, but as Tom emphasized to me if I don’t do it, this boy will lose his leg.  I did what is called a reverse saphenous vein graft bypass, using his veins from the opposite leg of the injured leg. This was actually not in my field of surgery and the last time I had done it was under supervision in my residency and at that on an adult, not a 10 year old.  All went as it should, and his leg was nourished by blood that was now coursing through the new conduit that I installed.  I risked my own operation’s success by ignoring my surgeon’s instruction of not walking on the leg. My malpractice carrier who would rightfully refuse to cover me and my reputation which would suffer if my judgment proved that I was not successful in saving the boy’s leg. But seeing this boy walk on two normal legs was worth it!  Speaking of worth, a 10-year-old boy playing on an oil rig after midnight might give you a clue that he had no health insurance, no support and parents that didn’t either.  So I didn’t get paid, although several months later he did qualify for Medi-Cal, the state-sponsored welfare health program, and I did get $74.93 for the surgery and all the risks I took.

Interestingly, the family sued the oil company 5 years later because the fence surrounding the oil well was not high enough, allowing their son to climb over it.  The final settlement was $4,000,000 despite the fact that he had no evident disability except for the surgical scar.  I had already been paid by Medi-Cal so none of that came my way. But the lawyer got 40%.  I knew I should have studied law instead.

As you get older, you do get wiser, but you also start to forget stuff.  Professional and life experiences have taken off the rough edges, having a woman surgeon as a partner, a daughter, two granddaughters, and many female surgery residents have made me lose my last shreds of white male privilege and bias.  As an old German proverb says, “You get too soon old, and too late schmart.”    I had decided that I would stop working at age 70.  I had many reasons.  The practice was getting more complicated with rules, paperwork, governmental oversight, malpractice risks, and malpractice insurance costs, $60,000 a year for me.  That is a lot of gallbladders at $600 a bag.  More of my friends were no longer working, and I had a harder time running up and down the stairs.  It was also not as much fun anymore.  I clearly had an element of “burnout.” 

Then an opportunity came up that I had not considered, teaching!  I was offered a job as the founding program director of a newly minted general surgery residency.  Much of the practice bureaucracy was lifted from my shoulders, but new ones with the regulating organization of residency programs, the ACGME (Accreditation Council for Graduate Medical Education) was substituted, a new challenge.  But at least my malpractice was paid for.  Dealing with young doctors who want to learn the art and science of surgery was the crowning experience and achievement of my career, challenging, fun, rewarding, and unforgettable.  But all good things must come to an end.  I went for advice to one of my mentors, who taught me to operate, and asked him the right time when to retire is?  His sage advice was, “You will know!”  At the time, it didn’t sound like wisdom, but it was.  There are subtle hints to which you must pay attention.  Getting up at 6 AM to make a 7:30 OR time gets more and more difficult.  Likewise, that post-midnight call from your chief resident that the patient we did in the afternoon is not looking so good gives you heartburn or is it chest pain?  Challenging cases become a heavy burden to carry. Simple cases become much more desirable. Watching the sunset with a glass of Cabernet Sauvignon is more appealing than picking up the Journal of the American College of Surgeons.   And finally, when your residents question you more and more often, and their percentages of being right are going up, it is a mandate to watch more sunsets.

The Ibiza Affair

Austrian Imperial Eagle

I came to the USA with my parents, from Austria, when I was 11 years old, a real culture shock for me.  With almost no knowledge of English, I was transplanted from the heart of the Alps into the middle of Chicago. I sat in the classroom of my fifth grade in silence for three months, but immersion does work, and I started talking, and never stopped, and eventually even lost the German accent. At age 17, I became a US citizen and was required to renounce my Austrian citizenship.  That, as it turns out, was not exactly how it should have transpired. Both the US and Austria do not consider a 17-year-old to be capable of renouncing or accepting any citizenship of any country.  You must be of legal age, which was 18 at the time, and still is.

Nevertheless, that is what happened. In 2011 I decided, on a whim, that I should become a dual citizen.  I thought there would be some potential advantages for being a citizen of the European Union, as Austria was a member.  If I had Austrian citizenship, I would get an EU passport.  With that comes going through the line much quicker when you go through the passport check in Europe. Also, the EU requires you to be a citizen of some EU member state to own property in any EU member country.  Not that I could afford it, but who knows when I win the lottery?  

I embarked on the quest to become a dual citizen.  The US does not care if you hold several citizenships, but Austria is pickier. They do not want people that are not qualified to assume the mantle of citizenship of Austria unless the prospective citizen meets Austria’s criteria. I gathered all my parent’s documents, my birth certificate, and citizenship papers of Austria, as well as Germany, as my parents had that documentation for the war years, and that included me because I was born in 1943. Austria was already annexed to Germany by Hitler on March 12, 1938, in what was called the “Anschluss.”  Technically I was a German, having been born in Germany, but today’s Austria sees itself as another victim of Hitler, and Austria takes the position that the “Anschluss” was not acceptable by then-existing Austrian law nor in Austria’s interests and therefore I was, de facto, born in Austria even though it was called Germany at the time.   Besides, my parents became Austrian citizens after the war, and I too was swept into Austrian citizenship by that event.

To be considered for Austrian citizenship, I had to be interviewed by the Consul General of Austria.  On the appointed day I went to Los Angeles and dressed as Austrian as I could, Edelweiss tie and the classic grey felt jacket with the green lapels, but not “Lederhosen” as I thought that would be over the top and unseemly.    My German was not perfect and had the vocabulary of an eleven-year-old, but still passable.  I spoke German during my interview, which impressed the Consul General, Consuline Fischer.  She inquired as to my reasons for wanting dual citizenship.  I went into the legal arguments as to why I thought that I had never actually could have given up my citizenship as I was underage at the time and not legally entitled to do so.  The word in German for underage is “minder jährig” (minor years).  But my eleven-year-old vocabulary did not have that on the list.  I used a word that I thought meant underage, “minder wertig”  which means of “lesser worth” literally translated, but the street meaning was “imbecile.”  “But I was an imbecile!”  I said in German.  She corrected me, knowing what I was really intending to say, “You mean “minder jährig.” “Yah, yah,” I murmured, “I mean “minder jährig (under age).”  I was embarrassed. The lady Consul smiled and let it pass.  I got my dual citizenship.   And I got to walk through the EU line at passport control.  It didn’t help a whole lot as I had to wait for my wife on the other side as she only had her US passport.  I am still waiting to buy that ski chalet on the slopes of my hometown when the Megalotto hits, which has not happened yet.

In 2021 my Austrian passport outdates and will need to be renewed.  I have no good reasons to do that, but nostalgia urges me, for reasons best stated by Alex Haley, author of Roots, “In all of  us, there is a hunger, marrow-deep, to know our heritage – who we are, and where we came from.” I have always had a longing to maintain a connection to my “Heimatsland,” the landscape made famous by Jullie Andrews in the movie, The Sound of Music.  I will renew my EU passport, but I will need to document some need to do so.  I have not done anything for decades to justify my reasons for maintaining that passport.

However, through international skullduggery, the opportunity presented itself in June 2017 – the “Ibiza Affair.”  This was a politically set up scandal where the Austrian deputy chancellor was caught in a “honeypot trap” with a Russian woman oligarch, at a five-star resort on the Spanish island of Ibiza in the Mediterranean Sea, to become involved with Austrian journalism for a bribe.  This was dramatically aired with videotape and soundtrack which were irrefutable several months later and led to the collapse of the Austrian government!  New elections were mandated.   I gleaned an opportunity for me to do my civic duty and vote, which I did, and established my continued interest in the land of my birth.  To do so was a bit of artful manipulation with the Austrian consulate.  But Austria was very anxious to include “all Austrians” within and outside of the country,  to neutralize this dirty stain on Austrian integrity.

Most of you would not know or care about the “Ibiza Affair” were it not for my essay; it is, after all, a minor footnote of history, but for me, it was the gift that allowed me to vote in a historic Austrian election and will permit me to renew my Austrian passport!