Category Archives: History

Existential Pain and History

mte5ndg0mdu0otg3mjq1mdcx“I am a dead man!” Alexander recognized immediately that his condition was mortal.

At first, the patient suffered such exquisite pain that Dr. Hosack did not strip off his bloody garments…When [the patient] complained of acute back discomfort, [the doctor] and other attendants took off his clothes, darkened the room, and began to administer [medicines] to dull the ache.

[The patient] was preoccupied with spiritual matters…No sooner was he brought to the Bayard house than he made it a matter of urgent concern to receive last rites from the…Church.

When [the pastor] entered the chamber, he took [the patient]’s hand, and the two men exchanged a ‘melancholy salutation’… He explained that…”It is a principle in our churches never to administer the Lord’s Supper privately to any person under any circumstances.” [The patient’s] friends thought it heartless to refuse a dying man’s last wish.

As befits a great orator, Alexander roused himself for one last burst of persuasion.

At that point, [the pastor] relented and gave holy communion to Alexander, who then lay back serenely and declared that he was happy.

——————-

One common felt pain for patients at the end of their lives is existential or spiritual pain. Though difficult to define, most of us practicing palliative medicine recognize it when we see it. The proper intervention for it is not additional opiates, but rather appropriate spiritual support.

It always impresses me, when reading history, just how often our common humanity binds us across time. The patient above is Alexander Hamilton, lying on his death bed following his infamous “Interview at Weehawken” with Vice-President Aaron Burr . This slightly edited account, taken from Ron Chernow’s masterful biography, Alexander Hamilton, is a dramatic rendering of a man in existential crisis at life’s end. Hamilton recognized instinctively, as he so often did, his need for spiritual input to his pain. Unfortunately, in today’s medical world, we too often fail to recognize this need, delivering the wrong intervention, in the form of another dose of dilaudid, to patients needing spiritual uplifting.

This is not the first time I’ve noticed this in reading through historical biography. U.S. Grant eloquently describes a palliative approach to end-of-life care, as he completes his famous Memoirs while dying from head-and-neck cancer. John Adams describes a receding of the fear of dying, to be replaced by a fear of dementia. Human life, and death, resonates across the ages.

As I prepare for another stint on our Supportive Care Unit, a typically draining two weeks full of existential pain, I find reflecting on our common humanity, and the special role physicians are privileged to play in it, helps sustain me through the experience.

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Filed under Books, End of Life Care, History, Palliative Care, Uncategorized

“I hope to have God on my side, but I must have Kentucky.”

Becoming a lay expert on a specific historical period, the American Civil War, two related methods for learning history have become crucial to me. First, having broad-based knowledge about this period deepens my understanding of specific local history. Second, travelling to a place to imbibe the local atmosphere where important history happened, brings the sights, smells, sounds and imagination to bear on that history. Both improve the richness of my full understanding of that time – and the human experience overall.

When travelling, I’ve taken to purchasing a book about local history, preferably about Civil War history, to bring these two learning tools together. My most recent experience in central Kentucky was especially delightful. The area we visited was Bowling Green, a place that switched hands several times throughout the war, as both sides tried to bring this crucial “neutral” boarder state into their fold. As newly-elected President Lincoln said about his birth state, “I hope to have God on my side, but I must have Kentucky.”

The book I found is Josie Underwood’s Civil War Diary, edited by Nancy Disher Baird. A passionate 20-year old woman from a prominent Kentucky family, whose father was a leader of the pro-Union elements in the state, writes movingly about the shattering impact of the war on the families in Kentucky. As the country descends from arguments about preserving the Union, the principles of the Constitution, and the status of slavery to outright war, the dissolution of families, friends, and communities into outright hostilities is heartrending. The articulate and beautiful young woman finds her life pulled apart as the miasma of a country in upheaval at a fulcrum point in history throws her life into disarray.
A favorite part of the book was her one-time meeting with Abraham Lincoln when in Washington with her father, who was being appointed by the President as Ambassador to Glasgow. Like many contemporary accounts of Lincoln, its cinematic quality is captivating:

“As we returned to the city, about sun down, there were no other people in sight on the road [from the Soldiers House] except a lone horseman we were meeting. He was on a long-tailed black pony (the horse looked so small) galloping along – a high silk hat on his head – black cloth suit on, the long coat tails flying – behind him. Pa called our attention to him—saying ‘some farmer – who has been in the hot city all day and is now eager to get home to supper and his family.’ So Miss Bell and I thought the man and he looked it. As we met, Pa had the carriage stop. The man did the same and Pa introduced us to Mr. Lincoln. He leaned over, shook hands with us, then slouched down on one side of the saddle—as any old farmer would do, as he talked for ten or 15 minutes with us.”

Can you imagine it? She captures so many historical facts in this one little story. Lincoln’s notorious lack of concern for personal safety, chillingly foreboding—His “everyman” demeanor of an uncouth Westerner—His benevolence toward humanity. It’s all there in this brief, personal account. She goes on…

“Pa and Mr. Etheridge thought is very imprudent and unwise risk for him in such a time of warfare and especial hatred of Mr. Lincoln himself for him to be riding unattended, unguarded out a lonely country road – and called his attention to the dangers—Mr. Lincoln’s smile—expressed kindliness to all men and fear of none—as he said—he ‘did not think anybody would hurt him that way’—shaking hands again with us—he galloped on, neither did we meet anybody else for quite a little way so it was very evident there were no guards—following him.”
Finally, she summarizes her impressions of the man she, and her contemporaries from the South, even those “Unionists” who supported the war effort.
“Lincoln in appearance certainly falls far short (though he is so long) of my idea of how a President should look. In fact a very common-looking man he is—but I must confess there was a kindliness in his face—that does not fit the tyrant—unfair man I have been thinking him…Thinking of his kind, troubled face I can’t believe it is.”

Absolutely spellbinding.

Much of this moving account, especially for a Civil War buff, is infused with details and examples of the local consequences of the war in the border states. I urge anyone with an interest in the times or who is visiting the area to read this mesmerizing account, especially during this 150-year anniversary of Lee’s surrender to Grant at Appomattox Court House. And to remember the 150-year anniversary of Lincoln’s untimely death at the hands of one of the people he so confidently believed wouldn’t “hurt him in that way.”

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Filed under Civil War, History, Lincoln, vacation

Vacation Kinetics: Purging the Matrix, Cleansing the Senses, Awakening the Spirit

Overloading

Vacations are a way to get away – in every way.  Yet in today’s hyperconnected, hyperkinetic modern world, it is more difficult than ever to disconnect, decelerate and rejuvenate.  Our two-week family vacation was strategically planned by my lovely wife to allow rejuvenation of mental energies away from work concerns near the end of summer, including long stretches in the car; in remote rural areas; and being out the country – in part, to discourage on-line time.  The 24/7 maw of the social media world that is drawing us into a Borg-like meta-community has a gravitational pull into its growing sphere of influence.  Disentangling from it has become the primary challenge for a successful vacation.

Academic physicians seem evolutionarily conditioned to have our attention swallowed up by the immediacy of our daily work lives.  Our nervous systems seem finely-tuned to reflexively respond to our daily sensory input of general need.  At work, we are confronted with the “emergencies of the moment” that consume our carefully planned schedules.  For me, this includes urgent emails from my boss, cell phone texts from mentees needing deadline-driven feedback on a paper, voicemails from professional groups on sudden changes to upcoming conference calls, faculty members unexpectedly out for personal reasons needing coverage, or a page[1] from a nursing home on an immediate patient concern.  The amygdala-jarring, guilt-reflex that each of these inputs ignites, reinforced by years of professional acculturation demanding immediate responses to all needs, makes ignoring them genetically impossible. Adding the barrage of input from overseeing a section in a department of medicine at a large academic institution (read: middle management) only raises the cortisol levels further. It is no wonder why, among academic physicians, burnout and turnover are so high.

Sometimes the only way to break the cycle is to eliminate the sensory input.  Everyone I told that I was going on an extended vacation enthusiastically encouraged me to “avoid all work-related activities”. Easier said than done!

Weaning

I was excited about our planned trip, even with the prospect of being locked in a car with my Eveready-bunny young boys for hours on end.  When I was a kid, we would jump in the old Datsun station wagon and drive to grandma’s house, twelve good hours of complete family immersion and outer-world isolation.  Playing “counting cows” and finding state license plates are over.  In our car, there are three smart phones, three tablet computers, and 2 regular computers, all internet-connection compatible. Perhaps the one advantage of my cell-phone service with Sprint is the relatively poor coverage it provides in non-urban areas and the ghastly charges they have for international service.[2]  Even worse, having identified “internet access” lying at the very base of Maslow’s hierarchy of needs, every place you stop along the way provides WiFi services.  It’s truly amazing watching people wander slowly about public places, slack-jawed staring at a phone, bumping into things.  In protest, I carry a book around with me everywhere, sitting and reading something in the open periods available.  Like other addicts, I spent hours each day in a cold sweat, trying not to connect my nervous system into the Matrix, slowly weaning myself off the electronic juice.  At the beginning of the trip, I wasn’t sure two weeks would be enough time.

Everything triggered a reflexive need to connect.  In reading a rest stop sign on the local history of Rome, NY – was it really the starting point for the building of the Erie Canal?  In seeing someone wearing a LeBron James jersey in Cleveland – how were the FIBA team practices going?  Had we heard back from anyone on our journal articles, especially the one to the Health Affairs Blog?  Slow, deep breaths…count to ten…ask someone a question…read your book…  This was work!  When did vacation become such hard work?!?

Purging

Recognizing the challenge ahead, my wife had brilliantly planned for us to spend many hours a healthy distance from the Matrix. First, living cozily in a small, rustic two-story motel on Old Orchard Beach — a lovely, genuinely historic locale inhabited primarily by thin, smoking French-speakers from Quebec. Meandering a mile barefooted down the silica, confronted by the sine-wave eternity of sandy saline, is a wonderful psychic purgatory.  We spent the first part of the trip at a local joint, catching an unexpected glimpse of a favorite celebrity, and hanging out with the bride and groom, moves the electronic buzz into the hazy periphery.  Being forced to stop at a local gas station, all gussied up, to get directions to the ceremony at “The Barn at Flanagan Farm” from a woman with a knowing smile, because the GPS won’t connect,  injects a healthy dose of humanity.  Spending the day-after brunch with across-the-country friends you’ve only interacted with on Facebook in over 20 years, and discussing foreign policy among the wild flowers with an intensity social media precludes, reconnects the vivid present to the unseen future through the past.  Hiking up a mountain, along sheer ravines with my adventurous sons, calves aflame, unable to send a reassuring text to my wife, calls forth a focus of intensity to block out the world. Staring through the cool, swirling mist of pulverized water on rock from the deck of a boat staring up at Niagra’s relentless falls, unable to snap pictures with your smart phone, forces you to simply enjoy the moment. Exciting the senses and calming the soul.

Awakening

As the sensory apparatus was revived by salty ocean breezes, fresh seafood, bright wild flowers, prickly briars, and cool mist, the cognitive gears began turning again.  Freed from the character confines of Twitter chatter, narratives of new friends emerged.  Shared struggles up a steep, rocky mountain invited bonding discussions of oceanside views.  Meeting Ricki inside her beachside Place, quicky, discombobulated bookstore/motel/knick-knack/beach-equipment rental encouraged bibliophile bonding, and some more books for the collection. Open enjoyment of a new marriage in a field of clover led to wide-ranging discussions of the entrepreneurial spirit altering the landscape of international relations. Touring the Joshua Chamberlain museum, some more pieces of history clicked into place, as the WWII-vet docent filled in more details.  And another Civil War history book went into the collection. Stopping at the Fort Erie historical site, engagingly led by a young local woman in period clothing, and punctuated by the firing of a mortar shell ordered by my son, I could almost feel the neurons reignite.

Contemplating

As the vacation flowed along, as my senses revived, as my brain engaged, I found the need to write creatively emerging.  Using my long-dormant blog, I spent time each night piecing my thoughts together, gratified to find others who shared my thoughts.  Why was I so intrigued by professor-turned-soldier Joshua Chamberlain?  What did I enjoy so much about used book stores? Why was   I found myself feeling happier than I have for some time, enjoying the simple vitality of being alive, letting my inner self choose the topic, rather than responding to the “emergency of the day”.

I finally had some space and energy to contemplate – to, as Dr. Suess would say, “think about thinks”.  The true value of an extended vacation is less to get away from things like the matrix, but to get close to one’s inner self.  The “getting away” is really just the first part, to clear the playing field, to blow out the engine, to pull the plug on the tub full of dirty water.  Or like a beach after high tide, when all the sand sculptures have been melted down, and the canvas again lies pristine. Once that’s done, one can really get to work, focusing all of one’s energy on the creative task at hand.   I now feel like I imagine my kids do when they start on the new sandcastle or master a new skill, happily creating something anew from nothing, investing all of one’s ample energy in the project at hand.

I’m grateful to my wife for planning this vacation, finding a way to detach us from the persistent buzzing of our Web-ensnared devices, nudging us out into the wilderness of reality, allowing us to engage with the wider world.  I’m thrilled that she was rewarded in many ways: recognizing a favorite sit-com star who flashed across her field of vision, re-engaging with an old friend at the wedding (both wearing beautiful lavender dresses), playing on the beach with her boys, and enjoying another birthday dinner with me.  We’re now a little older, a bit wiser, and more thoughtful – and perhaps, a smidge happier.

[1] Yes, a pager. I suspect doctors are the only professional group that has failed to give up this antiquated, annoying form of communication.  Mostly symbolic, like stethoscopes and white coats, that allow physicians to maintain a professional identity, to the detriment of job function.

[2] As we discovered during our recent trip to the Black Hills of South Dakota, Sprint has absolutely no interest in providing any cell service whatsoever in that area.  They really ought to change this into a “feature” for vacationers like me, guaranteeing “absolutely no service, no matter the urgency of the matter”.

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Filed under Aging, History, Philosophy, psychology, vacation

Visiting Joshua Chamberlain’s House (Part 2)

(Part 1 can be seen here).

A Remarkable Life

By any measure and for any time, General Joshua Chamberlain lived a remarkable, dramatic life of adventure – especially for a professor of religion.  Most famously, he was the colonel leading the 20th Maine Volunteer Company in the Civil War who defended the far left flank of the entire northern Army of the Potomac on Little Round Top at Gettysburg. With a left-wheel, bayonet charge down the rocky hillside, they are credited with saving the army, and perhaps the war, on that July 2nd day.  He endured one of the six serious wounds he ultimately received in the course of the war, leaving him in constant pain for most of his long adult life.  One of those wounds was a .50 caliber minie-ball through two pelvic bones, which nicked his bladder, and was universally considered fatal.  When General U.S.Grant heard about the grievous wound, he had Chamberlain promoted to General on the spot in the field, in order for him die as a general. From the hospital, Chamberlain wrote a lovely “last letter” to his wife as he lay awaiting death.  Against the odds, he recovered and rejoined the war effort, despite a significant limp and severe difficulty in riding his horse.  He continued to lead his regimen so well, as fate would have it, he led them to trap General Lee and the Army of Northern Virginia as they retreated from Petersburg to Appomattox Court House.  The Fighting Professor was then asked by General US Grant to be the regimen to receive the official surrender of Lee’s army.  At the crucial moment of the surrender, as Lee’s army approached to lay down their swords, heads’ bowed in grim defeat, Chamberlain ordered his men to “present arms”, a gesture of honor and respect to a worthy opponent.  It memorably altered the moment’s tenor, converting it from a conquest of a hated enemy to a hat tip to a future colleague, and becoming a symbolic offer of “charity towards all” harkening back to Lincoln’s Second Inaugural Address. Chamberlain had a kind of “perfect pitch” for history’s pregnant moments.

Following the war, Chamberlain returned to Maine, serving four terms as Governor, followed by a lengthy stint at President of his alma mater, Bowdoin.  Much of this time he spent writing his memoirs, particularly of his exploits in the Civil War, mostly from within the house on Potter Street, just off the Bowdoin campus.  This is where the Chamberlain Museum is now located.  We turned in.

A Remarkable House

We arrived just in time to sign up for a tour of the facility, which overlooks the Bowdoin campus.  The tour is enthusiastically led by a loquacious volunteer, an 80-something docent – my absolute favorite kind of historical guide.  The WWII vet, so reminiscent of the men I cared for during my clinic during residency at the University of Pittsburgh VA hospital, is full of facts, opinions, and a gleaming eye for the kids on the tour. As he limps through the house, holding on for support, he offers an authoritative opinion on anything and constantly asking, “What other questions do you have?”

The lovely old mansion is somewhere between dilapidated and magnificent, with cracked walls competing with restored, original furniture.  The on-going, underfunded restoration effort is battling with an on-going process of weathered decay, with the final outcome standing in the balance, a distant echo of Little Round Top itself.  The lady up-front tells me they just received a small private grant to restore the chimney, but need about 50 times that much to complete the full restoration. Two of the rooms have significant recent water damage, making one of them, the kitchen, off-limits for the tour.

The house itself has an unusual history.  Built originally in early 1800s, the original structure was later moved en masse and pivoted, rotated from facing Maine Street to facing Potter Street and the Bowdoin campus.  Later, when Chamberlain became college president, his wife refused to move into the official president’s house a short distance away.  In order to maintain the desired living quarters while adding an area to conduct official business, the entire structure was then jacked up 11 feet, and a new ground floor was added, a predecessor of Chicago’s later raising of its downtown buildings from the sinking muck they were built upon.

A Remarkable Collection

In the first room, the docent asks the kids, what U.S. President with the initials J.Q.A. was in office at the time of Chamberlain’s birth.  To my delight, my 11 year old nails it – John Quincy Adams.  I’m especially tickled because the kids rarely pay attention at these history tours I inflict upon them, but because I’m reading a biography of John Adams right now.  Which leads to another of those “can-you-believe-it?” facts of history – Chamberlain’s wife “Franny” is related, in a tangential way, to the Adams family.  She was born to a relative by marriage of John Quincy’s, then adopted by another, childless member of the family.  A tenuous tie between the Revolutionary Generation and the Civil War generation – I absolutely delight in such connections.  The docent is equally delighted that one of the kids got the answer to his question, and we’re off and running.

The displays within the house mirror the contrasting quality of the overall building. The displays are not the polished work of, say, the Lincoln Museum in Springfield; rather, they are competent descriptions of the items. They are arranged loosely by themes in specific rooms, but they are not thematically arranged or organized into a narrative.  Our guide points to items that strike his fancy, but completely overlooks some others.  But what a selection of items!  There is a room that contains his actual Medal of Honor – the most prestigious medal given by the military, one that Truman reportedly said he’d have given up the presidency to receive.  It hangs, unprotected, on a wall and receives a short mention by the docent.  In a case, there is a bullet fragment – that was removed from Chamberlain!  The docent doesn’t mention it, but when I ask, he says it’s from the foot wound he received at Gettysburg while fighting on Little Round Top!  We linger over portrait paintings of his parents, while the original Tojani oil painting of the bayonet charge on Little Round Top goes undiscussed.  I have to confirm the authenticity of the painting as we move out of the room.  The house is simply full of amazing artifacts, openly displayed for inspection, and the docent offers great anecdotes.  But one is best served with a prior knowledge of the relevant history in order to fully appreciate the value of many items.

As we meander through the house, we learn more and more quirky facts. The odd-shaped rooms with rounded walls and no corners was designed by the ship-builder, not an architect.  Among those who sat on the furniture in the dining room are U.S. Grant and Harriet Beecher Stowe, author of Uncle Tom’s Cabin; Ms. Stowe’s father taught as Bowdoin.  Speaking of Bowdoin, Chamberlain had Henry Wadsworth Longfellow as a teacher, and student Chamberlain’s signed book from class is there.  A red velvet-lined chair sitting at a desk looks like a throne – and it is, brought there by Chamberlain as a gift from the Queen of England.  These details provide a rich tapestry to the intertwining lives of history.

Remarkable Legacy

Chamberlain and his wife were something of medical marvels of the age.  His wife had strabismus, which left her with a lifelong vision problem, despite attempts at surgical correction.  Chamberlain’s pelvic wound, which left him with a permanent limb for life, also left him with a damaged urethra, requiring a catheter.  Having received 6 wounds in the course of the war, he lived a remarkably active, long life and was a “happy man”, by all accounts, according to the docent, shaking his head in disbelief.  Like many of the day, several of their 5 kids died of “consumption” – tuberculosis – in part because all 4 boys slept together, since the cause of the disease was not known.  Chamberlain has a personal nurse for much of his later life, to help given his mobility limitations.  The challenges of growing older echo across the ages.

One reason we know so much about Chamberlain’s life is that he wrote so much of it down for us.  While the Civil War soldiers were a remarkable literate lot, Chamberlain was an academic and gifted prose stylist well beyond average.  He left behind vivid, first-hand accounts of his experiences, and he was happy to take a starring role in the script.  Some have criticized him for this, complaining that he, and his defenders like Shaara, have glorified his place in history, while pushing others equally worthy to the side.  People like Gouvernour Warren and Strong Vincent, equally valiant and arguably more important participants on Little Round Top, have been relegated to supporting roles in the story, despite their actual importance exceeding Chamberlain in historical fact.  There’s something to be said for making sure to get your own side of story out – which I try to use as inspiration.  I also encourage those with time and inclination to read the relevant history and decide for themselves the truth.   By any measure, Chamberlain had a fascinating story to tell, and we are lucky to have it to learn from.

Chamberlain’s remarkable life has been an inspiration for this academic over the years.  His bold decision to leave the safe confines of the academy – his took a leave of absence, promising his bosses and his mother he was going to Europe to study – and raise volunteer troops to fight for the noble twin causes of “union” and “abolition” challenges me to pursue my inner beliefs.  That he taught himself the military arts and rose to the rank of Major General, even in those times of rapid ascension via attrition, illustrates true self-sufficiency and personal growth.  His magnanimous gesture to his defeated opponents showed a generosity of spirit, especially coming from someone nearly killed by those adversaries-turned-countrymen.  Would that we all could muster such courage and grace when the telling moment calls.

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Filed under Aging, Civil War, History

Visiting Joshua Chamberlain’s House (Part 1)

My second favorite historical figure from the Civil War, after Abraham Lincoln, is “the fighting professor”, Major General Joshua Chamberlain.  Like many, I became a fan after reading the classic Michael Shaara novel Killer Angels about the Battle of Gettysburg, in which then-Colonel Chamberlain plays a starring role as the rhetorician-turned-soldier who saves the union army on Little Round Top.  Like some Nietzchean philosopher-warrior come alive, he “refuses the line” at the far end of the Union left flank, with a desperate bayonet charge down the rocky hillside, all while contemplating the meaning of it all.  Straight out of central casting, what academician wouldn’t salivate at admiring this action-hero figure?

But was it too good to be true?  Could a rhetoric and religion professor really become a military hero?  The academic skeptic in me just couldn’t rest without separating the rhetorical chaff from the history wheat. In my typical OCD way, I started reading about Chamberlain, Gettysburg, Lincoln, and the Civil War overall in hopes of answering these and other questions. I also made the trip to Gettysburg, stood on Little Round Top – on the very large boulder from which Chamberlain anchored the “wheel” for his company’s charge down the hillside – and tried to imagine that burning hot July 2nd so many years ago.  Would I have been able to measure up?

In addition to spending much time on Little Round Top in Chamberlain’s shoes, while moving about the park, I lingered at two other places that day that invited introspection. The first, not far from Little Round Top was the national cemetery where Lincoln stood to deliver his great speech. It sent chills down my spine to imagine being there that day.  The second was standing in the woodline where the young Confederate soldiers in Pickett’s brigade would have stood, preparing to march across a near-mile long, open field into the teeth of the Union line, looking across the way to tiny copse of trees where the Union lines waited.  How could they do it?  What could possibly motivate them to make that march of death?  Would I have been willing and able to do it?

These questions, and many others, led me to explore a reasonable chunk of the available Civil War literature.  This includes multiple books on Gettysburg, another handful on other battles (and visits to the sites), a dozen or so Lincoln biographies, and another 10 on other significant figures.  Regarding Chamberlain, I’ve read several of his own first-hand accounts of the war he provided, but I haven’t read a full biography.

But I was tingling with excitement about seeing the house he lived in, now converted to a museum about his life.  What items did they have within?  What new facts would I learn about his extraordinary life?

In the next post, I’ll describe the museum visit itself.  As is so often the case, the truth is a little different than what I thought I knew.

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Filed under Books, Civil War, History, Risk

Reflections on the Anniversary of the Flight of the Enola Gay

Walking on the Old Orchard Beach in Maine with my kids, enjoying a break from the challenges of work, preparing to attend a wedding, a plane flew over.  I was reminded that today is a poignant day in history involving a plane.

On this day (Aug 6) in 1945, the Enola Gay, on behalf of the US government, dropped the first atomic bomb in world history on the Empire of Japan.  It is estimated that 50,000 people instantly lost their lives, with many more dying in the coming months directly from the radiation effects.  The instantaneous loss of human life is staggering.

I recently visited Singapore for a medical conference on geriatric-oncology.  Across the street from where we were staying, there was an austere Memorial, a towering, four-sided white spire.  It commemorates the massacre of 50,000 Singaporeans, most of Chinese descent, by the invading Japanese during WWII.  It is a powerful symbol of human tragedy.  Standing there, I was stunned to realize I had no idea about this event, wondering how many other similar examples had been hidden from my awareness. The toll from this war became even more staggering to consider.

Both of these events from WWII are mind-bogglingly sad to reflect upon.  The equivalent of a football-stadium full of people, the majority of which were non-combatants, destroyed in a few moments or a few days.  Considered out of context, it appears to be two more instances of the mental instability of humanity.  So many individual lives wiped out, with us never to know what greatness may have lurked within some of those lost forever. The awfulness of war seems ridiculous when considering these events.

Yet, it is difficult to argue against our countries’ involvement in that terrible war and our efforts to end it as swiftly as possible. The moral worthiness of fighting against the genocidal Hitler and the appropriateness of responding to the bombing of Pearl Harbor seem reasonable responses to irrationality.  If anything, the consequences of failing to respond appear worse than what ultimately occurred.  Considered in this wider context, doling out a utilitarian, Realpolitik calculus of abstract lives lost, individual events like the dropping of The Bomb to end further bloodshed seem justified, strategically. But what about morally?

How are these two views – the unjustifiable loss of largely innocent life from total warfare and the justified use of force to achieve pragmatic ends – to be reconciled?

I’ve long been uncomfortable with utilitarian justifications for actions; it’s too easy in this few to reduce individual human beings to interchangeable, expendable parts.  My original juxtaposition of the Japanese civilian deaths due to the atomic bomb with the Singaporean deaths due to conquering armies hints at such a justification.  In truth, this obscures the tragedy of the lives snuffed out on both sides. It also personifies countries, of nationalistic fervor, as if the loss of a part of a country, a certain number of citizens, is a legitimate “trade” for a similar loss of life by another country.  This way of thinking can’t be right.

More concretely, we too often fail to consider what an individual life is about.  How people are more than interchangeable parts whose further existence is justifiable in the name of “national goals”.  That people like Adolf Hitler can consider certain people, due to happenstance of birth, is an extreme example.  But a similar version allowed the Emperor of Japan to consider those living in Singapore to be extinguished on similar lines.  Whether our use of the atomic bomb to help end the war with Japan was strategically justified, we should not forget the individual lives snuffed out with the effort.

We now exist in a world full of philosophies that too easily think of people as members of specific groups, that those in other groups are “inferior” enemies to be destroyed, rather than as individuals living out their lives as best they can.

Finishing the walk with my kids, I spent an extra few minutes to talk about their individual plans for life, to better understand what makes them each individually happy, and to think about how to better encourage us all to avoid being overly utilitarian regarding others.  My hope is that their future will involve less “trade-offs”, especially at the level national governments, of some abstract lives for other abstract lives – with the consequent loss of too many individual lives unlived.

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Filed under History, Philosophy, Utilitarianism

John Adams on Aging, Illness and Death: A Geriatrician’s Unusual Book Review

“My House is a Region of Sorrow, Inhabited by a sorrowful Widower…The bitterness of death is past. The grim spider so terrible to human nature has no sting left for me.”

–John Adams to his son, John Quincy, upon the death of his beloved wife, Abigail.

A Geriatrician’s Perspective

In First Family, Pulitzer-winning historian Joseph Ellis elucidates the character of our least-venerated, least-appreciated Founding Father, John Adams.  He brings Adams to life by presenting his life appropriately intertwined with one of our most-beloved First Ladies in history, Abigail (Smith) Adams.  As with all Ellis’s books, it is written with clarity, verve, and eloquence, mixing the Adams’ remarkable public career with his no-less remarkable marriage and personal life. How many people can claim that they effectively chose a country’s founding document (Jefferson), Military Commander (Washington), and Chief Justice (Marshall) and to have fathered a future President (John Quincy)?  And these are merely sidelights to a remarkable life of achievement. Rather than discuss the usual political topics, I focus here on a favorite topic of mine: aging.  Among the gems of insight scattered throughout this book are Adams’ (and Jefferson’s) thoughts on getting older, failing health, and death.  For a man who lived past the age of 90, at a time when life expectancy was closer to 40, his thoughts sound remarkably modern, hinting at the universality of these issues.

Adams and Jefferson on Aging

In the twilight of their lives, John Adams and Thomas Jefferson famously corresponded, reflecting on their lives and debating their political differences.  The correspondence had ended when Jefferson and Abigail Adams — John’s lifelong partner in all things domestic and political – exchanged letters, unbeknownst to John.  Jefferson denied paying a known “journalist” scoundrel, James Callendar, to libel John – which was a lie.  Abigail directly called Jefferson out on this lie, writing that, after their many years of friendship, “the Heart is long, very long in receiving the conviction that is forced upon it by Reason.”  After noting that Jefferson’s critics had accused him of being a disingenuous and dishonorable, steely-eyed Abigail says, “Pardon me, Sir…I fear you are.” Nobody he admired had ever been so direct with Jefferson on this point.  The result was that no further correspondence between households occurred for nearly a decade. Wouldn’t we all love to have such eloquent, steadfast support from our partner! After many years of bitter silence over such issues, Adams reignited a conversation, writing to Jefferson that, “You and I ought not to die before We have explained ourselves to each other.”  The resulting correspondence between the two, 158 letters worth in total, memorably did just this, as each posed for posterity, knowing their letters would be read by History.  While most discussions of this correspondence focus on the political ideas between the two, such abstract thoughts were interwoven with other topics.  This included sublime thoughts on aging, health, and death. In one exchange, Jefferson offers (p. 238): “But our machines have now been running for 70 or 80 years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way. And however we may tinker them up for a while, all will at last surcease motion.”  In my clinic, helping my older patients navigate through issues of their “machines” running down, dealing with multimorbidity, frailty and polypharmacy, I often feel just like some mechanic, “tinkering” with their delicate “parts”, hoping to keep them moving as long as possible.  Many patients of mine, especially the men and the engineers, complain about their declining abilities like cars springing leaks, rusting through, and falling apart. In response, Adams worries about something slightly different: “I am sometimes afraid that my ‘Machine’ will not ’surcease motion’ soon enough; for I dread nothing so much as ‘dying at the top,’ and thereby becoming a weeping helpless object of compassion for years.”  Adams’ had an ongoing fear of losing his mental faculties. As Ellis notes, Adams had seen the mental deterioration of his cousin, Sam Adams, and John “feared dementia more than death.”  This is the sentiment I so often hear from my patients, that their greatest fear is getting Alzheimer’s disease. My own experience with patients confirms this as one of their greatest fears as they grow old.

Literary Illness

Among the literary gems unearthed by Ellis are Adams’ colorful descriptions of his various ailments.  He creates a lovely neologism to explain one particular problem:  the “quiverations” in his hands.  These tremors prevented this inveterate, lifelong writer from doing so effectively.  He had to resort to dictating his ideas to whatever grandchild he could convince to listen.  I love this term, which captures the spirit of how tremulousness must feel from within. I’ve had patients say how they simultaneously don’t notice their tremors, but how annoying it is when they have to deal with it.  I’m likely to adopt this term for my patients, as I love the verve it imparts to the condition. In another case, he complains that his “constitution is a glass bubble or a hollow icicle”.  He worries that, “A slight irregularity or one intemperate dinner might finish the catastrophe of the play.”  He was on the brink, in which a new stressor might push him over the top.  I can think of no more poetic expression of Fried’s Frailty, which is a physiological vulnerability to stressors which predisposes older adults to morbidity and mortality.  Thinking of my frail patients as “glass bubbles” is a perfect metaphor for those struggling through another Polar Vortex in Chicago.

Death, Dying, and the Spirituality

When Abigail died, as the quote above indicated, Adams was grief-stricken for nearly a year.  After 54 years of marriage, he was lost without his lifelong confidant.  Grief at the death of a spouse or other loved one is a constant risk for older adults, especially if it leads to on-going depression.  It is a wonderful reminder of the blow such events can deal to our older patients. Adams despite a having a Deacon for a father (whom he deeply admired), had skeptical views of religion and the afterlife. In his later years, when asked about the Christian view on life after death, he jokingly responded that he assumed God would allow him to further debate Benjamin Franklin as part of the experience. Nevertheless, he did assume there was some sort of afterlife: “If it should be revealed…that there is no future state, my advice to every man, woman, and child would be…to take opium.” On the day of the 50th Anniversary of the Declaration of Independence, which Jefferson was chosen to author by Adams, the two Founders died within hours or each other, on July 4th, 1826.  Adams famous last words, “Thomas Jefferson survives,” were incorrect; Jefferson had passed shortly before his colleague.  Like two intertwined spouses, the two friends left their earthly lives together.

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