Letters

AAnumber of articles in our Fall issue had readers reaching for their pens or keyboards. Two essays—one by a current student, one by a former resident—drew heartfelt comment. All three features came in for kudos, especially the cover article on the Himalayas. And a story about a DMS-led study prompted a protest regarding the level of detail in the piece. But feedback is "all good," as the saying goes, even when it's not. In other words, we welcome critiques as well as kudos, because our goal is to spur dialogue and reflection. So, many thanks for letting us know when our contents inspire you—or irk you.

'Round the girdled Earth
The Student Notebook essay by Omri Ayalon in your Fall issue—about his elective experience at a clinic in Israel—was mushlam (Hebrew for "perfect"), metzuyan (Hebrew for "excellent"), sababa (an Arabic word that roughly means "cool"—young Israelis use it in casual conversation), and achla (which means "great"—it's another Arabic word used by Israeli youths). I hope Omri enjoys his career in medicine as much as I did mine.

And let me add that the whole magazine is achla.

Harvey Mandell, M.D.
DMS '48
Norwich, Conn.

Memories of a mentor
I had to wipe the tears from my eyes as I read the essay in the Fall issue about Dr. Lou Matthews. When I came to Dartmouth in 1983, Lou was a fixture at the institution, one of two or three "whole-person" internists—focused on treating the entire individual, not just the disease. He rapidly became a terrific colleague and unofficial mentor.

I also recall working with him on a very sensitive institutional matter, on which we sorted out a peaceful solution despite some hard-line positions.

In short, Lou was one of the most wonderful clinicians and human beings I have ever met. His final gift was to grant an autopsy, and I had the privilege of attending the demonstration of its findings. I remember asking everyone to spend a moment of silence, after which we looked at the organs as usual, but of course my mind was elsewhere.

Many thanks to author Steve Hennigan for the reminder of a very special individual.

Jonathan Ross, M.D.
Hanover, N.H.

Ross, a professor of medicine at Dartmouth, is also a member of this magazine's Editorial Board.

Meaningful urge
I very much enjoy your interesting and relevant magazine. I'm a DHMC patient and see Dartmouth Medicine at the Medical Center, as well as in my local library. "Medicine in the Mountains" in your Fall issue was especially moving and informative. [The two-part feature included one account by a Dartmouth College alumna and one by a DMS student; both stories were set in the Himalayas.]

As a former Peace Corps volunteer (in Madagascar, from 1998 to 2000), I felt the urge to go out there and do something meaningful once more.

I'm now a language professor—so I was also glad to see that Dartmouth language expert John Rassias is still out there with his energy and humor. I participated in some of his workshops in New York City 20 years ago.

Joan Marie Davidson
Northfield, Vt.

'Round the girdled Earth, Part II
I happened to stumble on Rosalie Hughes's story "High hopes," in the feature "Medicine in the Mountains" in your Fall issue. Thank you for sharing her beautiful account about the plight of the many Nepalese women who suffer from uterine prolapse.

I am from Nepal and worked as a medical officer at Doti District Hospital for two years. Doti adjoins Jajarkot—where Rosalie's story was set—and the two districts share almost everything, including the culture, the poverty, the hostile terrain, the pathos, the tragedy, and the heroics of its unassuming women.

As the story pointed out, uterine prolapse is a huge problem among women in that area. Last year, we conducted a surgery camp at our own hospital, where surgeons from Kohalpur Teaching Hospital came to operate on some 100 women. Their sense of relief after the surgery had to be seen to be believed, as the suffering pent up inside them for so long finally ceased.

I am sure Rosalie's experiences in Nepal must have had a fair bit of influence in shaping her as a person. Thank you for bringing her story to people who otherwise would not know of such suffering and pathos.

By the way, I am in the U.S. right now and will soon be interviewing at Dartmouth-Hitchcock Medical Center for a residency position. It is a small world, I must say!

Kiran Raj Pandey, M.D.
New York, N.Y.

Questions make a mark
The article by Katherine Kosman, "Monumental challenges" in the Fall feature "Medicine in the Mountains," was very well written and thoughtful. Not only did she share her experiences, but she raised some important questions regarding the relationship between need and service in areas like the Himalayas.

I know an occupational therapist who has made similar visits to Tibet, bringing as much help as she can without formal sponsorship. She intended to focus on critical lessons about sanitation and nutrition but found herself with the same long lines of people in distress that Katherine encountered and so tried hard to offer such help and medication as she could. It is evident that both women have made a difference in that part of the world.

I receive and enjoy Dartmouth Medicine as a member of the Assembly of Overseers for DHMC. I was also the first president of the Friends of Norris Cotton Cancer Center, "volunteered" by Norris Cotton himself at a meeting at the Hanover Inn many years ago. He had earlier appointed me to the professional staff of the U.S. Senate Committee on Commerce during one of his final terms in Washington, where I learned not to say no when he "volunteered" someone for something.

Peter W. Powell
Lancaster, N.H.

Cultural crossover
The cover story about the Himalayas in your Fall issue was fantastic in its description of an incredible cultural crossover. Although the details are different, I, too, have experienced a meeting of different ways of life with that part of the world.

I visited Nepal in 1987, and a friend I made on that trip, Pema Dorje Sherpa, has visited me here nearly every year since then, with his wife, Mingma, accompanying him three times. Their two daughters now live in the U.S.; one recently finished training to be a physician's assistant and the other one is doing her practicum to be a nurse.

Pema (and Mingma, when she comes) work all summer in New England, mostly doing outdoor work and painting. Pema has done this every summer for 20 or so years. The money they make has paid for their daughters' educations and has enabled them to build two trekking lodges in the Khumbu district, the Everest region of Nepal, where they live at 14,000 feet—with no electricity, no roads, no luxuries.

Pema is a very smart guy and has worked hard to build a life and provide for his family. It has been my privilege to know him better and better over the years, so I found the story in your magazine especially moving.

Ed Antos
Merrimac, Mass.

Moved by the mountains
My son-in-law recently gave me a copy of the Fall issue of Dartmouth Medicine. I am a 78-year-old nurse and especially enjoyed "Medicine in the Mountains," as I have been to Nepal.

Please put me on your mailing list to receive future issues.

Lorraine Hockenbrock
Liverpool, Pa.

Cerebrations on brain death
I appreciated Dr. Martensen's excellent article, "Pondering Personhood," in your Fall issue. I was in neurological practice during the period he wrote about and once had a similar experience with a transplant coordinator.

I practically memorized Stupor and Coma during my residency and learned the probabilities of various outcomes after brain injury. For example, decerebrate rigidity [a change in posture that occurs in some comatose patients] 48 hours after an adult suffers hypoxic encephalopathy means severe, irreversible brain injury. Identifying such patients early is key, because the body is still physiologically unstable, and heroic measures such as defibrillation should be avoided. Full measures in such a case risk putting the patient into PVS [a persistent vegetative state], requiring nursing home placement and often raising Karen Quinlan/Terri Schiavo issues that split and devastate families.

Brain death is the only indication for getting a transplant coordinator involved. PVS patients are not brain dead; they eventually die from infection or by discontinuing fluids, the latter the most humane way. Considering a PVS patient as a transplantation candidate is immoral, and I say that as someone who in his career unplugged many ventilators and discontinued many tube feedings in seriously brain damaged—not brain dead—patients, after gut-wrenching conversations with families that left me deeply moved and drained. Knowing when and how to stop, and communicating that to families, was arguably the most important thing I did as a clinician.

My own living will says to "stop all therapy" if I am decerebrate for 48 hours or decorticate [another postural change] for two weeks with a non-metabolic condition. It isn't euthanasia, and those who think it is haven't walked my personal and professional road. I'm an organ donor—but only after I am brain dead, not before. Well done, Dr. Martensen.

In addition, my hat is on as I give a full former naval officer salute (naval officers never salute when uncovered) to the young people profiled in Dartmouth Medicine who are doing so much good in so many places.

Michael S. Smith, M.D.
Dartmouth College '70
Tucson, Ariz.

Pondering permission
I am a chaplain at Samaritan Hospital in Troy, N.Y., and find reading Dartmouth Medicine very helpful. The article "Pondering Personhood" was especially interesting. I would like permission to reproduce the article for our chaplaincy staff.

For some time now I have intended to request a subscription to Dartmouth Medicine. My son, Timothy Lukovits, M.D., is codirector of the DHMC stroke unit—another reason for my interest in the magazine.

Rev. Frank S. Lukovits
Troy, N.Y.

We are not always able to give permission to reproduce articles from the magazine, but we welcome receiving requests and are glad to grant them if we can.

Mulling a mystery
Reading "Pondering Personhood" by Dr. Robert Martensen in your Fall issue brought to mind a case I was involved with at about the same time.

It was fall, and a healthy 12-year-old girl went on a Girl Scout bike trip. She developed a headache, returned home to rest, and soon became unrousable. She was brought to the ER comatose. All available tests at that time were negative—blood, cerebrospinal fluid, etc. She remained unconscious and received excellent nursing care—it was a case of Sleeping Beauty.

A hundred days later, when I was making my night rounds, the nurse stated, "You just missed (this patient) sitting up." But on exam there was no response. The next night, reported the nurse, she spoke. It seemed like a ruse.

But then on the third or fourth night, she wakened and took a few steps. After that, she resumed full consciousness and, after a period of rest at home, returned to school and caught up with her class. She graduated from grade school, high school, and college and, last I heard, was a teacher in Massachusetts! Apparently, there was no deficit.

No exact diagnosis was made. Maybe an encephalitis of some sort—perhaps Eastern equine encephalitis?

Raymond E. Jankowich, M.D.
DMS '53
Stratford, Conn.

A timely topic
The Fall issue feature about biological clock research was a great article! It was nicely written, with the scientific interest interwoven with the human and personal aspects of the story.

William Lotko
Hanover, N.H.

Lotko is a professor of engineering at Dartmouth's Thayer School of Engineering.

Back-ground questions
I read and enjoy Dartmouth Medicine on a regular basis. I was disappointed, however, with the recent article on low-back surgery, "Low-down on low-back surgery"; I wonder if Jim Weinstein read and approved the article, as he is quoted in it.

First, spinal stenosis is the topic, but the title does not make that clear. Also, laminectomy alone is not successful in spinal nerve root decompression, which is really the goal of surgical treatment. Nerve root entrapment is more foraminal, and the overlying facet joint deserves the most critical inspection.

Since your publication is addressed to "Alumni and Friends of Dartmouth Medical School," perhaps a less simplistic approach to the subject matter and closer attention to detail is in order, lest the lay readership be misled.

For example, the article states that "one common age-related ailment is spinal stenosis, a condition in which the spinal canal narrows, causing tingling, weakness, and/or pain in the lower back." I ask, "'Tingling' where? 'Weakness' of what?"

Symptom onset with the upright position is the most important element of patient history in making the diagnosis of spinal stenosis, but this is not mentioned in the article. Comfort when seated followed by onset of symptoms in the erect posture differentiates spinal stenotic etiology from other pathology, such as a herniated disc, etc.

I am a firm supporter of outcome studies and applaud Dartmouth for championing this approach. But to say, as this piece does, that there is "no clear long-term evidence for one treatment over another" and that this is "the first long-term study comparing the effectiveness of surgical and nonsurgical approaches to helping such patients" really dismisses simple and long-known medical knowledge.

There is no effective nondecompressive treatment for spinal stenosis. Treatment controversy is centered, rather, only on the question of adding fusion to the procedure, and this decision must be made on a case by case basis. This, too, could have been addressed in the article.

I would suggest closer expert review. Once in print, misinformation stands.

Sidney Goldman, M.D.
Dartmouth College '60
Key West, Fla.

We acknowledge that a case can often be made for including more detail in articles of this nature, though we don't feel the term "misinformation" applies in the case of this piece (which was, in fact, reviewed by both Dr. Weinstein and a member of his staff). The article wasn't intended as a broad examination of treatments for low-back pain, or even for spinal stenosis, but as a summary of the findings of one study. Reasonable people could disagree as to whether including short pieces about several studies is better than including a lot of detail about fewer studies, but we try to strike a balance that allows us to cover a range of research topics. That said, perhaps we should have taken a few more words to make it clear that this truly was the first long-term, randomly controlled study to compare surgical and nonsurgical treatments in patients who have spinal stenosis with degenerative spondylolisthesis. It had long been assumed that surgery helps such patients but had not been shown in a well-controlled long-term trial. We do appreciate the . . . please pardon us . . . feedback about including enough detail.

Echoes through the halls of history
Thank you for sending me Dartmouth Medicine. After I finish an issue, I take it to the library at our local hospital, where medical students and others may read it.

My connection with DMS is not direct. I am a graduate of Dartmouth College but went to the University of Minnesota for medical school. My brother, Bill, however, is a graduate of DMS, as well as of the College (he attended during World War II), and my great-great-great-grandfather, Reuben Mussey, taught at DMS from 1814 to 1838. His house is where the College's Alumni Relations Office is now located—it was a dormitory named Crosby Hall when I was at Dartmouth, for he sold it to Dr. Dixi Crosby.

My oldest sister, younger brother, and I are the sixth generation of Mussey doctors.

Robert D. Mussey, M.D.
Dartmouth College '38
Urbana, Ill.

Mussey may not himself be a DMS alumnus, but his family tie to the School goes back to the first decade of the 212-year-old institution. His forebear Reuben Mussey graduated in 1803 from Dartmouth College and in 1806 from DMS—which had been founded only nine years earlier, in 1797—and went on to become one of the earliest faculty members recruited by DMS founder Nathan Smith. Reuben Mussey's accomplishments included playing an instrumental role in the education of the first deaf, blind, and mute person in the world who was taught to read, write, and communicate freely. As the Fall 1991 issue of this magazine told the story: "In 1837, a DMS student informed Mussey about a girl in nearby Etna, N.H., who could not see, hear, or speak. Mussey's efforts in behalf of eight-year-old Laura Bridgman led to her being taught to live an active life. A few years before her death at age 60, Bridgman met and served as an inspiration to Helen Keller, then seven years old." Coincidentally, that same issue of Dartmouth Medicine contained a mention of the house Reuben Mussey sold to Dixi Crosby: "In 1853, Dr. Dixi Crosby, a professor of medicine at DMS, and Oliver Hubbard, a professor of chemistry and geology at Dartmouth College, played no small part in the birth of the oil industry. After conducting experiments in Crosby's home, the two men discovered a way of refining 'rock oil' (as petroleum was then known), making it a more effective illuminant than any other fuel." Furthermore, as it happens, Dixi Crosby is mentioned in one of the features in this issue—see "The Most Unspeakable Terror". And see above for photos of Mussey, Bridgman, Crosby, and the house that both Mussey and Crosby owned.

Reform-oratory
The "Road to Reform" by Dr. Elliott Fisher was both timely and significant. It should be brought to the attention of all representatives and senators deliberating on the matter of health-care reform in Washington, D.C. As a long-time advocate of the work of John Wennberg, I cannot conceive of a constructive reform plan without a thorough consideration of this work.

H. Irene Peters
New Smyrna Beach, Fla.

Growing pains are worth it
How refreshing! I just read and thoroughly enjoyed the article "Faculty are fond of a garden-variety avocation" in your Summer 2008 issue. I, too, am a physician (retired) who loves gardening. I started a garden club in my neighborhood, where most of my neighbors have well-groomed yards tended by landscapers. (Some do their own weeding or rake their own leaves, but nothing much.)

I started gardening when my landscaper's bills shocked me. I learned that I enjoyed dirtying my manicured fingers, encountering grub worms (although the first time it was a scary experience), fighting Japanese beetles, shooing bumble bees, and discovering a wasp nest.

Yes, I acquired some stubborn bug bites that had to be treated with oral prednisone and that caused a dormant gastric ulcer to bleed, dropping my hemoglobin so low that I needed hospitalization and four units of blood.

Nevertheless, I am still a happy gardener and am now waiting for a five-year-old blue wisteria vine to flower next year.

I would like to share gardening experiences with other faculty gardeners, or even start a physician gardeners' club. Anyone interested can reach me at doctorsjana@yahoo.com.

Lourdes Romano-Jana, M.D.
Erie, Pa.

Just say NOPE
I recently came across the article in Dartmouth Medicine about the research on opioid abuse in New Hampshire conducted by Dartmouth undergraduate Laura Hester.

I am very interested in her work, because I chair the NOPE (Narcotic Overdose Prevention Education) Candlelight Vigil Committee for Coos County. We organize this annual vigil to raise awareness about the disease of addiction and the need to establish a local chapter of NOPE.

We will find the information and statistics in Laura's report very helpful in that effort.

Doris Pinard
Berlin, N.H.

Copy that
I am very interested in your magazine; whenever I pick up a copy, I find I read it completely. I would appreciate very much being put on your mailing list.

Capt. George S. Grove,
U.S.N. (Ret.)
Newbury, Vt.

Treasure-seeker
As a retired nurse and a patient at DHMC, I truly enjoy reading Dartmouth Medicine. When I miss an issue, I feel I've lost a great treasure. I would love to get the magazine sent to my home so I don't risk missing an issue.

Terri Sherburne
South Deerfield, Mass.

Issuing a request
I just received your Summer issue, and in reading the letters section I realize that I missed a great Spring issue! We go to Florida in the winter, and the post office will not forward magazines, so I must have missed Winter 2008 and Spring 2009. Would it be possible for you to send me those issues?

Sue Broderick
Hendersonville N.C.