An Ethical Quandary

Physicians are almost always opposed to abdicating clinical decision-making to non-clinicians. Just ask any practicing doc what she thinks of administrators or insurance adjusters getting involved in patient-care scenarios, those that doctors feel should be solidly in the purview of medicine. I already know the response.

I attended a professional meeting recently, and the presentation of one of the speakers – the chair of the ethics department at a major east coast university – reminded me of an interaction I had thirty years ago, and have never entirely resolved in my own psyche.

In the 1980s, I was in my training at the University of Virginia. At that time, the University Medical Center had a well-established ethics consult team. Coming in the immediate wake of right-to-die cases such as that surrounding Karen Ann Quinlan, the University wanted to engage ethicists and those of related fields – social work, theology, patient advocacy – on the front end of potential problems in order to ‘do the right thing’ and avoid messy entanglements that might register seismically with the national media. CYA.

I recall being a senior medical student on the neurosurgery rotation, and rounding with my team in the NICU. We came to one unfortunate patient; I’ve forgotten the details of the patient’s situation, but I do recall that it was grave at best. The family was emotional and divided, the nursing staff was up in arms, and the attending physician was uncertain how to proceed. Being at that time an idealistic neophyte, I turned to the chief resident and asked if we should obtain an ethics consult on this unfortunate patient?

“No. And don’t let me ever hear you say that again.”

Despite being fully aware of my low rank in the food chain, I was nevertheless caught off guard by his dismissive response. The ethics team was regularly convened for just this reason, and I thought the scenario at hand was as clear-cut for such a consult as I was likely to encounter. He read my perplexity and continued:

“If you call for an ethics consult, you’ll have a bunch of non-clinicians coming down here, pontificating, and then rendering a decision on a clinical situation. Once it’s written, we’re screwed, because if we decide to proceed in a way not recommended by the consult, we’re de-facto ‘unethical.’ It’s a huge risk management and liability issue, and I think the team can come up with a sensible decision and avoid getting outsiders involved who then will be back-seat drivers.”

That exchange occurred ~1988. I’ve thought of it since, but have never yet engaged an ethicist for her input.

So, at the recent meeting, I stood to ask this question of the presenter. His reply:

“Certainly there are some ethicists – hopefully fewer now than was the case 30 years ago – who author poorly-worded consults. A good ethicists will never tell the medical team what they should do. A good ethicist will explore with the team the actual question at hand, and weigh with the team the pros and cons of each available avenue. Remember, a ethical dilemma is usually not about good and bad. It’s about two options – choices that likely each have good facets – that must be balanced against each other.”

This answer reminded me of what I have long said about a savvy psychotherapist: such a practitioner should never tell a patient what to do, but instead should guide the patient in exploring the situations at hand and aiding that person in coming to the decision that works best for her.

Of course, that’s in theory. I know of many therapists who cross the line, and I’m sure there are ethicists who do the same.

In the law, there is a type of civil determination called a declaratory judgment. In such a situation, a court will resolve uncertainty through a conclusive preventative adjudication, essentially affirming the rights, duties, or obligations of one or more of the parties in a non-criminal dispute. It is rendering an opinion on a hypothetical that has not yet been formally brought before the court.

But not all courts will pass declaratory judgments. And I doubt ethicists will do so either. One can hardly approach an ethicist and say, “I’d like to submit a consult on a sticky situation, but only if you’re not going to hog-tie me clinically. Perhaps you can give me a pre-decision off the record, and then I can decide whether I want to submit a formal consult or not.”

In reality, as the old saw goes, one pays one’s money and takes one’s chances.

So, three decades later, I still don’t have a good retort to the chief resident’s premonition.

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[Copyright 2013 @ The Alienist’s Compendium]

My Struggle

“The past is never dead. It’s not even past.” ~Requiem For A Nun

I have always loved Faulkner’s oft-recounted quote, since it is true on so many levels.

With that in mind, here is an odd present-day story that started almost a century ago, and is neither dead nor past.

Adolf Hitler wrote the draft for his 720-page autobiographical manifesto, Mein Kampf (My Struggle), while imprisoned after the failed coup of 1923. It represented his vision and blueprint for a National Socialist world, and was not at first a best-seller when released in 1925 (9000 copies). Once Hitler rose to prominence, however, the Nazis mandated its distribution to soldiers, newlyweds, and schools nationwide, and it started to generate large sums in royalty. Over Hitler’s lifetime, it is estimated that the book sold 10M copies (and ~$430M for its author, adjusted for inflation, all of it tax-free since he was in charge and made the rules).

Fast forward to May 1945. Hitler was dead and the war was fast closing. Bavaria, as the jurisdiction of Hitler’s official residence (Munich), seized all of his property, including the rights to the book. None of Hitler’s distant surviving heirs cared to contest this confiscation. And through assertive de-Nazification efforts, the Bavarian government promptly prohibited the publication of Mein Kampf, now their book, anywhere in (then-West) Germany.

But of course, that had little binding effect on other countries, where the tome continued to be printed and sold to varying degrees, both by previously-licensed publishing houses and bootleg operations [strangely, it has enjoyed strong sales in both Turkey and India]. Those international licensees then generated royalties for the legal copyright holder – the reluctant Bavarian state.

[sidebar: Bavaria holds the copyright for most of the world, but things are a little different in the U.S. and U.K. More on that in a moment…]

So, what to do with the tainted gains? Bavaria started to quietly donate all proceeds to charity.

In the U.S., Houghton Mifflin purchased the rights to Mein Kampf in 1933. The U.S. government seized the copyright in 1942 under the Trading With The Enemy Act – even though Houghton Mifflin is an American company based in Boston – and amazingly held it until 1979, placing the $139,000 generated in sales over those years in the War Claims Fund. In 1979, with no fanfare or press release, Houghton Mifflin bought back the rights from Uncle Sam for $37,254, and then proceeded to pocket over $700,000 in sales over the next two decades. When this was publicly revealed in 2000, the chagrined publisher said that they were distributing the monies to charities that promote “diversity and cross-cultural understanding,” and a host of other things that Hitler would have hated. Still, many of those charities – the Red Cross amongst them – refused to take the cash, leaving Houghton Mifflin wondering if buying back the rights was such a good business idea after all.

In the U.K., Hurst & Blackett (Random House) had purchased the rights to a translated English version from Hitler’s publisher also in 1933, still retaining that right in the post-war years; as with the Bavarians, H&B gifted all proceeds to charity. Interestingly, the Jewish charities initially selected didn’t want the money, so H&B started gifting anonymously (and it remains uncertain if the recipients ever knew the source of the donations).

Under U.K. law, the copyright on Mein Kampf expired in 1995. And under both U.S. and German copyright law, Mein Kampf is scheduled to enter the public domain in seven weeks, on January 1st, 2016. But while that will sever any direct connection between the text and Hitler’s estate, publishers, or those who directly dealt with them, it doesn’t mean that the book will not still be printed and sold.

Meaning that, ninety-two years after first conceived, the hate-filled diatribe of a fallen dictator dead for seventy years is still churning out income… that no one wants.

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[Copyright 2013 @ The Alienist’s Compendium]

What’s In A Name?

There are the names of certain American warships that even the minimally-versed will immediately recognize – Arizona, Maine, Intrepid, Missouri, Bonhomme Richard. And when you find a good name, you stick with it, right? A number of vessels have been christened with these monikers more than once since the U.S. Navy was founded in the late 18th century.

One source maintains that there are over 1400 ships’ names that our nation has used at least twice in the past two centuries; 470 used at least three times; 182 used at least four times; 83 used at least five times; and 30 used at least six times. The titles Enterprise, Hornet, Niagara, and Washington have each been used eight times. Wasp has been used nine times, and Ranger comes in at ten.

What about Chesapeake? It’s a rather all-American name. There’s a reason, though, that you won’t be seeing that nomenclature employed very often or anytime soon.

President Washington asked that the first six frigates of our embryonic navy be named patriotically but generically, in ways that wouldn’t inflame any regional rivalries. His directive resulted in USS Constitution, USS United States, USS President, USS Congress, and USS Constellation. Leave it to Sec’y of the Navy Benjamin Stoddert, though, to stir the bucket and name the sixth frigate, once Washington was out of office, USS Chesapeake (for my foreign readers, that is the name of this country’s largest estuary, located entirely within the boundaries of Virginia and Maryland, the latter being Stoddert’s home state).

Going against the wishes of the Father of the Country proved an inauspicious start; the ship was saddled with bad luck almost from its launch.

Chesapeake was a 40-gun heavy frigate. She was supposed to have 44-guns, but material shortages and budget overruns necessitated last minute changes. After some initial success – capturing in 1801 the privateer La Jeune Creole during the undeclared war with the French being the most significant – she was decommissioned and put into reserve because of a shortage of crew. Once tempers flared with the Barbary Pirates, though, she was re-commissioned and sent to the Mediterranean, arriving off Gibraltar just as her main mast split and her bowsprit was noted to be rotting. The ship remained laid-up in Malta for months while repairs were undertaken. Seeing no action against the pirates, Chesapeake returned to the U.S. in 1803 and was once more put into mothballs. The ship’s captain, Richard Morris, was then court-martialed for his relative inactivity; it seems he brought his wife along on the voyage – derisively referenced as ‘the Commodoress’ by the crew – and allegations that the ship remained at Malta far longer than necessary for repairs while the couple conceived another of their growing brood onboard were never satisfactorily explained to the subsequent board of inquiry.

In 1807, the ship was re-re-commissioned but needed lengthy repairs because of her long period of inactivity. Sailing finally from Norfolk VA in June of that year, she was almost immediately intercepted by HMS Leopard, which demanded to search onboard for Royal Navy deserters. The captain, James Barron, refused, the British let loose a devastating broadside, and Chesapeake struck her colors after only a single harmless retaliatory shot. The Royal Navy was apparently unimpressed with the vanquished, refusing to even take her as a prize, and instead carting off four suspected deserters and leaving behind three dead and eighteen wounded Americans.

Barron was court martialed for this embarrassing outcome, the second of Chesapeake’s commanding officers to suffer the indignity in less than four years.

The ignominy of the Chesapeake-Leopard affair contributed to the United States’ decision to declare war on Britain five years later. Chesapeake set sail for the Mediterranean, and during the first few months of 1813, did in fact capture six British merchantmen. But the crew became restive, wanting prize money, and mutiny was whispered. The captain paid cash out of his own pocket to keep everyone happy.

Shortly thereafter, off Boston, Chesapeake was confronted by the similarly-sized HMS Shannon. The battle-hardened crew of Shannon, however, was vastly superior to the disgruntled hodgepodge on board the American ship. Broadsides were exchanged, riggings, masts, and gun crews were decimated, and when the smoked cleared, the American captain lay mortally wounded, uttering his now-famous words, “Don’t Give Up The Ship!” That was not to be; the British this time did take the frigate as a prize, heading to Halifax in Nova Scotia and imprisoning the surviving Americans until the War of 1812 was over.

The hapless warship was repaired and became HMS Chesapeake. But before she could rejoin the fight against her country-of-origin, the war ended and the British, still unimpressed with her design and construction, decided to put the colonists’ frigate up for sale. A Portsmouth UK timber broker purchased her for £500, totally dismantling her and making a tidy profit when he resold her timbers to a Hampshire merchant, one Joshua Holmes, for £3,450. Chesapeake’s blood stained and bullet-ridden flag, kept by descendants of the British captain, was eventually sold at auction in London in 1908 and now resides at the National Maritime Museum in Greenwich. And several of Chesapeake’s cannons now guard Province House, that of the legislature of Nova Scotia.

The Chesapeake Mill

The Chesapeake Mill

And the timbers? They were used by Holmes to build what he called the Chesapeake Mill in Wickham, a small town southwest of London. After a long and productive industrial life, the grainery went out of business in the 1970s, and is now an antique shop. It sells overpriced tchotchkes, mostly to American tourists, those likely clueless of the history of the heavy wooden beams overhead.

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[Copyright 2013 @ The Alienist’s Compendium]

Pharma Sleight of Hand

Viagra By Mail!
Enhance Your Performance!
Only 99 Cents Per Tablet!

This is what most of us find in our spam baskets, usually written in pidgin English and from strange overseas ISPs. Viagra, as you probably know, is one of Pfizer’s all-time blockbusters, and remains under (very expensive) patent protection in the United States until 2019. Although its sales peaked in 2008, four years later it still earned the mother ship over $2B in global sales. Depending on the insurance/ copays/ deductibles my male readers might possess, a tablet of 50mg can cost upwards of $32 each.

[sidebar, overheard at one pharmacy window: “$32?!? No thanks. The missus sent me. Not worth it”]

So the above e-solicitation is obviously bogus, right?

Not exactly.

confiscated counterfeit blue gold

confiscated counterfeit blue gold

Viagra, patented first in the U.K. in 1996, came on the U.S. market two years later. Its active ingredient, sildenafil citrate, was originally investigated as an anti-hypertensive and treatment for angina pectoris. It acts by inhibiting cGMP-specific phosphodiesterase type 5, an enzyme that promotes degradation of cGMP… pretty boring stuff, unless you’re a biochemist. But it was only during clinical trials that its other, far more lucrative and now famous, physiologic effect was discovered. Now ubiquitous in late night comedians’ monologue punchlines, aging men (think Hugh Hefner, Bob Dole, Pelé) sing its praises, and a robust grey market has developed. Not a few marriages have been saved, and probably more destroyed, by its easy (albeit expensive) availability. It is said to be the most counterfeited drug anywhere. In short, Viagra’s pop culture notoriety has done for American – nay, world – sexuality in the 21st century what The Pill did for the Sexual Revolution back in the 1960s.

But it’s so damned pricey!

[sidebar: now working with the Veterans’ Administration, I’ve noticed that a majority of my male patients are prescribed Viagra by their primary care docs. However, the VA puts a strict limit on how many Vitamin Vs a patient can receive, likely because of cost. In case you’re wondering, Washington allows twelve tablets per 90 days. I’ve had more than one vet come to my office fuming, saying something to the effect of, “I served honorably for [x] years in [insert Third World hellhole]. And now Uncle Sam tells me that I can only get lucky* once a week?!?”]

[*“get lucky” is not the actual phrase used]

I have written before about off-label prescribing, the (perfectly legal and widely practiced) mechanism by which drugs approved for one indication can be used for whatever the prescriber wants, once the Rx is on the market. In a related vein, many medications were first envisioned for one role but quickly segued to other uses as clinical findings and needs dictated.

Thorazine was at first a veterinary anesthetic before it was an antipsychotic tranquilizer

Monoamine Oxidase Inhibitors were being applied to treat TB before their antidepressant effects were realized.

Minoxidil was used for hypertension and then was found to grow hair on bald scalps.

The moiety Bupropion has been marketed as both Wellbutrin (for depression) and Zyban (smoking cessation).

Fluoxetine is best known when prescribed as Prozac, another antidepressant, although it also is the active ingredient in Sarafem, for monthly pre-menstrual symptoms.

[sidebar: I remember a time when Wellbutrin and Prozac were on formulary, while Zyban and Sarafem were not. Easy to get around that, however… just prescribe the formulary agent for the non-formulary indication and everyone is happy except the accountants]

In short, if it’s FDA approved, on the market, and you have a medical license and can prescribe, go for it!

Why this is germane: Viagra for male erectile dysfunction loses its U.S. patent protection in 2019. But sildenafil, its active ingredient, has already been available to internists and pulmonologists as a generic for the treatment of pulmonary arterial hypertension since 2012. And as a generic, sildenafil’s cost has plummeted, now running about $1 per 20mg tablet (or $3 for three of them, roughly approximating the dose of sildenafil in a costly 50mg Viagra)

To make matters even more interesting, local pharmacies can usually order generic sildenafil with little effort, and will often mail these meds to one’s home if the doctor calls in a prescription and you provide a credit card number. These are not fly-by-night foreign mail order pharmacies. These are (licensed) pharmacies here in the US of A providing an accepted pharmaceutical for a recognized medical use – the treatment of pulmonary arterial hypertension.

Although seen in other illnesses as a related finding (e.g., pulmonary embolus, scleroderma, lupus), at a frequency of only 3 per million, idiopathic pulmonary arterial hypertension is a far less common condition than, say, middle aged erectile dysfunction.

So, with a wink from your doctor and pharmacist, what one does with the cheap sildenafil when it arrives with your electric bill and copy of TIME magazine is entirely up to you.

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[Copyright 2013 @ The Alienist’s Compendium]

Death Takes A Holiday (XVI)

to wit, a middle-aged peripatetic shrink undertakes the Great American Cross-Country Road Trip with help from little leaguers, German bikers, the King of Rock ‘n Roll, porn stars and an abandoned brothel, a flock of domesticated ducks, the Department of Homeland Security and the West Memphis police, a decommissioned atomic warhead, some dodgy motels… and a strange rider in the back of a 2013 Ford Fusion.

The Grim Reaper and I headed for Interstate 40 to make the dash east. It had been a long exhausting trip, but we were on the final stretch at last. Though Raleigh was now directly in front of us across the breadth of both Tennessee and North Carolina, I once lived in in the Volunteer State, so Nashville, Knoxville, Asheville, Winston-Salem, and Greensboro are all very familiar to me. Cruise control set on 70mph, now it was just an 11 hour straight shot to home.

The Explorers’ Adventure and our travelogue had come to a close.

No, wait. There is one part still that I have left out.

On 26 January 2014, in my first installment, I mentioned being stopped by the Border Patrol. For those of you who don’t remember 13 months back, here is what I wrote:

“The day was clear and sunny as it began its fade into impending twilight. I was driving along a secondary road in the far southwestern corner of Arizona, less than a dozen miles north of the Mexican border. There was little traffic, just clear sailing, no obstacles, and a tank of gas as the sun started to dip behind the nearby hills. In short, a perfect and relaxing early evening for a drive. That is, until I saw it up ahead – ‘it’ being a U.S Border Patrol check-point. A sign by the side of the road commanded those traveling north to stop ahead to submit to inspection, and I could see that the armed federal agents had a dog which was sniffing each and every vehicle.

Normally, this wouldn’t present a problem. I wasn’t in a hurry to reach my next destination, the car wasn’t stolen, I don’t do drugs, I wasn’t intoxicated, and I’m a natural-born U.S. citizen.

I did, however, wonder if the revolver sitting on the passenger seat next to me might present a problem. That… and the human remains boxed up in my back seat.”

You know already about the human remains if you’ve been reading this series. As for the gun… I had purchased several months prior a M1851 Colt Navy, and as it happened, the dealer was going to be in Las Vegas for the big antique militaria show that occurs every January. I told him I’d pick it up in person rather than chance entrusting it to the USPS.

So it was a 150 year old black powder firearm. And I have a license. But it was a gun nevertheless, and I had a dead guy in the car with me.

But what happened next was really amazing.

I put the revolver in the armrest. Glancing back, I could see that my calcified friend was boxed up with his lid closed, and thus entirely hidden. What could go wrong?

The officer approached my window and asked for my drivers license, while the Belgian Malinois and its handler inspected the car from the rear, out of my vision. The officer kept glancing back at the dog handler. After exchanging a few words, he said to me, “our dog has alerted on this vehicle, and I’ll need for you to pull over to the side so that we can examine your car more thoroughly.”

Alerted?! On what?! And through a closed car door?!

I pulled over and the officer asked me to step out of the car. He was very professional, but never smiled and was all-business.

“Our dogs are trained to alert to drugs and also to humans who are inside the vehicle but not visible. Do you have either in your car?”

I explained that there were no drugs in the car. I then paused. Adding, “but I have a corpse in the back seat” somehow didn’t seem the correct thing to say to an armed federal agent.

I told him about the dried bones and that I am a physician.

He still wasn’t smiling.

“Sir, I’m going to have the dog come over here to further investigate. Please remain outside the vehicle.”

Over came the dog and handler. The handler and the officer conferred. The handler, who seemed more chatty, then approached me.

He told me that the dogs – even the veteran canines – are routinely put through exercises where they encounter unusual items or situations to see how they react. The handler was very interested in the story of the ancient relic and wanted to see how his dog would behave up close.

You see, research into the chemical odors released by decomposition has provided scientists with a powerful tool to detect a body and then determine how long that person has been dead, a term known as post-mortem interval (PMI). Using mass spectrometry, scientists have been able to characterize the volatile organic compounds (VOCs) associated with cadavers, including carboxylic acids, aromatics, sulfurs, alcohols, nitro compounds, as well as aldehydes and ketones. The combination and quantities of these VOCs change as a function of time as a cadaver goes through decomposition. And while detecting various combinations of VOCs don’t provide a foolproof way of locating bodies or estimating PMIs, the process can help search-and-rescue and law enforcement enormously.

But mine were dried bones, totally denuded of tissue and with a century’s worth of handling having rubbed them clean!

I had been eating a sandwich when stopped, and I had wrapped it back in its paper and put it on the dashboard when exiting my car, leaving the drivers door open. The dog was brought over to the car and allowed to walk once around it. Then he was taken off the leash, at which time he leapt into the drivers seat, not 18 inches from that delicious ham and cheese which he ignored. Instead, he made a beeline for the back seat. He then proceeded to whine and paw at the box.

I was truly amazed. An antique desiccated cadaver had emitted enough odor for a dog to initially sense it THROUGH a closed car door!

More feds had walked over. They all peered inside the box. They thanked me for the training opportunity and bid me farewell.

And they never asked about the gun.

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[Copyright 2013 @ The Alienist’s Compendium]

U.S. v. Paramount Pictures, et al.

In the early days of Hollywood, a handful of studios and distributors controlled nearly all movie theatres in the United States. They employed a system called “block booking,” whereby theatres owned by the major producers showed only their own company’s films; if an independent showhouse wanted rights to movies from a particular studio, they had to reserve in advance – and exclusively – thereby foregoing the products of rival conglomerates. In controlling distribution through such strong-arm tactics, these leviathans dictated not only where and when their movies would be shown, but set non-negotiable admission prices as well.

Clearly anti-competitive – the Federal Trade Commission opined that 98% of domestic films were thus monopolized – the U.S. Justice Dept brought suit in 1929 against Paramount, First National Pictures, Metro-Goldwyn-Mayer, Universal, United Artists, 20th Century Fox, Pathé Exchange, FBO Pictures, and the Motion Picture Producers and Distributors of America. Declared monopolistic in the lower courts, the Supreme Court affirmed the decision in November 1930.

That was right at the start of the Great Depression. And then there was the war. Studios ignored the decision. The government didn’t enforce it. But once the economy began to improve and hostilities ended in Europe and the Pacific, the Justice Dept filed a second suit. Many prominent individuals not originally party to the first suit (e.g., Charlie Chaplin, Samuel Goldwyn, Orson Welles, Walt Disney) were deposed this time around. Settlement negotiations faltered. And in May 1948, in U.S. v. Paramount Pictures, et al., the U.S. Supreme Court again agreed with the lower courts on most counts, including affirming the prohibition against price-fixing and block booking.

This high court decision still controls movie distribution and exhibition in the U.S. to this day, and it permits all theatres to negotiate with all studios for all movies.

But the playing field is hardly level – the major studios are still 800lb gorillas, the Supreme Court be damned.

So most modern contractual agreements runs like this: during a movie’s initial release, the bulk of gross ticket sales go to the studio, often as much as 95% of the revenue from a film in its first week, 85% in the second week, and so on.

By the end of a movie’s run, when the fewest people are going to see it, the theaters are taking the lion’s share of the gross. But when averaging earnings over a film’s entire run, a theater might only realize 20% of overall ticket sales.

This system provides a strong incentive for studios to make movies with much buzz and built-in demand from popular stars; they want films that can open with a bang during that period when they, the studios, are raking in most of the revenue. The theatres then get the left-overs as the film heads for DVD and large-screen oblivion.

Over time, it’s not even uncommon that theatres will take a loss on a given movie based on ticket sales alone. There’s really little that theaters can do about this; they still have limited leverage in negotiations, regardless of what the Supreme Court says. The theatres can’t make movies themselves, and certainly they can’t turn away major blockbusters from their screens, lest people stop going to their theater altogether.

This means that theaters must find other ways to make money outside of ticket sales.

The solution was, and remains, to charge ridiculous prices for concessions. This is from where much of a theatre’s profits come.

Or, as Jack Oberleitner, a long-time veteran of the business side of Tinseltown, once observed, theaters have “left the movie business and [are] in the popcorn business.”

Now, is there an explanation for the outrageous prices charged in airports for food and drink?

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[Copyright 2013 @ The Alienist’s Compendium]

The Doctors’ Riot

The practice of medicine is considered an honorable profession. This was not always the case. One of the first major civil disturbances in post-Revolutionary America was precipitated by popular anger directed at the discipline. The so-called Doctors’ Riot began on 16 April 1788 and killed as many as two dozen people.

Oddly, the incident is almost entirely forgotten today.

In the late 18th century, the state of New York had a single formal medical school (Columbia). But if one wanted to practice as a doctor, another avenue was to attend lectures at local hospitals and enroll in sketchy private schools of anatomy, hoping to learn enough to muddle through patient care.

Anatomical dissection was a major facet of early medical education, though many saw the practice as sacrilegious. In early 1788, New York City newspapers ran several sensational stories about medical students stealing corpses from local cemeteries (usually potters’ fields and the so-called Negro Burial Ground). While some of the reports were rumor and hearsay, there was definitely a kernel of truth to the allegations.

In February of that year, a group of the city’s free and enslaved blacks submitted a petition to the Common Council complaining of “young gentlemen in this city who call themselves students of the physic… [who] under cover of the night, in the most wanton sallies of excess… dig up bodies of our deceased friends and relatives, carrying them away without respect for age or sex.”

Astoundingly, the group didn’t ask for a cessation to the practice, only that it be “conducted with the decency and propriety which the solemnity of such occasion requires” !!

The tepid petition was ignored; it seems that stealing poor black bodies was no big deal. But on 21 February 1788, the Advertiser reported that the body of a young white woman had been stolen from Trinity Churchyard.

THAT was a different story.

A group of angry (white) locals went to Trinity and exhumed several graves upon hearing this news. They found at least one of the coffins empty. Enraged, they descended on New York Hospital, which was known to host private anatomy lectures and demonstrations.

An officer in the local militia wrote what happened next:

“The cry of barbarity… was soon spread, [those] young sons of Galen [a poetic allusion to a physician in Ancient Greece] fleeing in every direction. One took refuge in a chimney. The hospital apartments were ransacked. In the anatomy room were found three fresh bodies – one boiling in a kettle, and two others cut up with certain parts… hanging in a most brutal position. The circumstances, together with the wanton and apparent inhuman complexion of the room, exasperated the mob beyond all bounds, [resulting in] the total destruction of every anatom[ic specimen] in the hospital.”

Although most of the doctors and medical students fled when the shovel-wielding rabble appeared, a handful remained to guard the valuable collection of anatomical and pathological displays, many imported. Their efforts were in vain, and the specimens were dragged out in the street and set ablaze.

A mob then went around town looking for other (entirely uninvolved) doctors and medical students. They descended on Columbia, where they searched the anatomical theatre, museum, chapel, library, and even student’s bedrooms for signs of dissection. Finding no bodies (students had removed them when forewarned), the men searched several other doctors’ homes, and then marched down Broadway to the jail. By later that day, thousands of angry men were demanding that the doctors hiding inside the jail be brought outside.

The militia was called to restore order. Bricks and stones were thrown. Shots were fired. People fell dead.

In the aftermath, vigilante groups set up night watches at cemeteries. And worried prominent physicians in town took out ads saying that they were uninvolved and had never robbed bodies in the city – ‘in the city’ being an important distinction, since the potters’ fields and Negro Burial Ground were outside the city limits.

A grand jury never returned any indictments, but the reputation of the medical profession in New York was sullied for decades.

In the year after the Doctors Riot, the New York legislature passed “An Act to Prevent the Odious Practice of Digging Up and Removing for the Purpose of Dissection, Dead Bodies Interred in Cemeteries or Burial Places.” And although the number of crimes eligible for post mortem dissection was increased in that same statute, there were still major shortages of specimens. It wasn’t until the early 20th century that grave robbing ceased altogether.

But the riot did produce another long-term effect. It led to one of the earliest medical licensing systems in the country, by the terms of which would-be doctors had to apprentice with established and respectable physicians or else attend at least two years of formal medical school in addition to passing a rigorous state exam. This signaled the death-knell for the private and unregulated fly-by-night anatomy schools that were once so common throughout the colonies.

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[Copyright 2013 @ The Alienist’s Compendium]

Nellie Bly

[Today’s post is sponsored by my good friends, Monika Vainoriene MD, and Enrikas Vainorius, MD, of Morrisville, NC. We were talking about this very subject recently, and now here is a bit more detail…]

Though likely apocryphal, there’s a story told by psychiatrists over drinks at happy hour that goes something like this: years ago, an employee of a mental asylum in Johannesburg, South Africa, was transporting twenty patients in a bus from one psychiatric facility to another. He stopped (on company time) for a few drinks while en route, and when he got back to the bus, all of the patients had eloped. Fearing for his job and not wanting to admit to his incompetence, the driver proceeded to a nearby bus stop in town and offered everyone waiting there a free ride. He then delivered these unsuspecting passengers to the second asylum, telling the receiving staff that the ‘patients’ were very excitable and prone to bizarre delusions of abduction. The deception wasn’t discovered for almost a week.

It’s long been a joke amongst psychiatrists that if a healthy person were ever committed to a psychiatric facility, they might have a difficult time getting out, since those predictable statements that they’d make – “I’m not crazy!” – are the same utterances that the truly disturbed would say.

Well, we know of at least one situation where this did, in fact, happen.

Elizabeth Jane Cochran was born in 1864 near Pittsburgh PA. She was one of fifteen children, and was always known as the rebellious one. This made her stand out during an age in which women were meant to be seen and not heard.

Her father died when she was 6 years old, and the family was thrown into poverty. By the age of 14, Elizabeth was having to work outside the home to help support the family. She held brief gigs as a schoolteacher and a maid in a boardinghouse, but nothing seemed too permanent.

Around this time, she read an op-ed piece in the Pittsburgh daily newspaper by one Erasmus Wilson, then a well-known journalist. He wrote that working women were “an abomination,” and should be home, pregnant and tending to their husbands. This annoyed Elizabeth, who knew that many working women – she and her mother amongst them – had no such option. So Elizabeth replied to Wilson with a strongly worded letter about the offensive article. The newspaper loved her chutzpah, and subsequently hired her as a writer and giving her the pen name Nellie Bly.

Elizabeth/ Nellie started writing about the plight facing working women, but the newspaper decided she should be writing about fashion and home economics. Nellie wasn’t interested in that, so she quit and headed to New York. Luckily, her reputation by then proceeded her, and it wasn’t long before she was hired by the New York World. They had a plan for Nellie. On 22 September 1887, Nellie was approached by her new editor to write an article about the state’s notorious Blackwell Island Insane Asylum. They wanted to know what went on behind the barred doors, and Nellie agreed to find out. The editor offered no solid plan to get her out of the institution once her observations were completed, but promised her it would be achieved somehow. Her instructions were simple: “Write up things as you find them, good or bad; give praise and blame as you think best, and tell the truth all the time.”

But first, Nellie had to get herself committed, which meant she had to feign insanity convincingly. She decided to pose as a poor girl looking for work at the city’s Temporary Home for Females, under the name Nellie Brown. There, she started displaying ‘insane’ behaviour. She said she was afraid of the other women, spoke vaguely, and spent that first night staring blankly at a wall rather than sleeping. She reported having nightmares of attacking people with a knife.

The plan worked. The ass’t matron called the police and Nellie was hauled away. The next morning, a Judge Duffy ordered a mental examination, and the court’s alienist declared her insane. A second specialist concurred, adding, “[the patient is] positively demented. I consider it a hopeless case. She needs to be put where someone will take care of her.”

Nellie’s first observation: it’s not very difficult to fake mental illness and get admitted to an asylum.

Once at the asylum, Nellie met a number of other women who didn’t seem to have anything wrong with them either. She watched as those women were brought before doctors for follow-up examinations. One woman only had a fever as far as Nellie could tell. Another was German, and as no one at the asylum spoke her language, the staff thought the woman must be crazy. When it was Nellie’s turn, she decided to drop the charade and act/ talk as she did in everyday life; however, the doctor ignored her comments and kept flirting with the nurse instead. Nellie noted that, “the more sanely I talked and acted, the crazier I was thought to be.”

Nellie determined quickly that the food was horrible and sleeping arrangements were chilly and uncomfortable. Asylum life, Nellie soon found, was unsuitable for anyone. She was forced to endure ice-cold baths, freezing nights, both verbal and physical abuse at the hands of the nurses, isolation, and the fear of fire (doors were individually locked from the outside, and windows were barred, so if a fire broke out, it was likely that a majority of the patients would die.) “What, excepting torture, would produce insanity quicker than this treatment? Take a perfectly sane and healthy woman, shut her up and make her sit from 6 a.m. to 8 p.m. on straight-back benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will take to make her insane. Two months [of that] would make her a mental and physical wreck.”

Towards the end of her stay, Nellie pressed the doctors for answers. How could they determine whether or not the women were insane if they didn’t listen to them? She insisted on a full examination to determine her sanity, but the doctors only brushed her aside, thinking she was raving. She wrote that “the insane asylum on Blackwell’s Island is a human rat-trap. It is easy to get in, but once there it is impossible to leave.”

Luckily for the intrepid reporter, her editor made good on his promise to get her out. After ten days in the asylum, she was freed and on her way back to the newspaper’s offices (details of her release remain sketchy). The first installment of Nellie’s report on the conditions in the asylum was published a few days later; the entire expose ran over 17 issues (and was later compiled into a book, Ten Days In A Mad House). Readers were horrified, and Nellie Bly was made a celebrity of sorts, praised for her bravery during her time in the asylum.

an illustration from Nellie Bly's book

an illustration from Nellie Bly’s book

Predictably, the medical staff offered many excuses for the allegations in Nellie’s articles. But the public was outraged. Nellie’s writings produced many changes and better treatment for those institutionalized, including more funding for the Department of Public Charities and Corrections. One involuntary patient later wrote, “ever since [Nellie left], everything is different. The nurses are very kind and we are given plenty to wear. The doctors come to see us often and the food is greatly improved.”

Interestingly, her asylum stint wasn’t the last of Nellie’s adventures. She later traveled solo around the world in 72 days, a much bigger deal for a woman in the late 19th century than it would be today, trying to ‘beat’ other reporters and the 80-day mark set by the Jules Verne novel of the same name. Not only did she succeed in her global circumnavigation, but she actually was able to meet Verne in Paris while passing through town!

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[Copyright 2013 @ The Alienist’s Compendium]

Major Gen’l Daniel Sickles

Over his professional life, Daniel Sickles (1819-1914) was both a House Representative and Senator, the U.S. ambassador to Spain, and a controversial general in the Union Army during the Civil War. Less known is how Sickles shot to death the district attorney of Washington DC, one Phillip Barton Key (son of Francis Scott Key of ‘Star Spangled Banner’ fame)… and got away with it based on a novel legal defense.

Sickles married his wife, Teresa, in 1852 when he was 33 and she was just 21. He proceeded to have numerous extramarital affairs, but became incensed when rumor reached him that his neglected spouse had herself taken the younger Key as a lover. He confronted her and forced her to write a confession:

“I have been in a house on Fifteenth Street [in D.C.], with Mr. Key. How many times I don’t know. I believe the house belongs to a colored man. The house is unoccupied. I commenced going there the latter part of January. I have been alone with Mr. Key. We usually stayed an hour or more. There was a bed on the second story. I did what is usual for a wicked woman to do… an intimacy of an improper kind.” She acquiesced to her incensed husband’s demands to cease such behavior.

But on 27 February 1859, Sickles learned of Key’s attempts to contact his wife yet again. He accosted the would-be Romeo in Lafayette Park, just across from the White House. Twelve witnesses later reported that Sickles yelled at Key, “you scoundrel… you have dishonored my home, and you must die!” A pistol was flashed. The first shot fired by Sickles missed, and Key threw an object at his attacker (later determined to be a pair of opera glasses that Key used to see if Mrs Sickles had left him a signal). The fight became hand-to-hand, but Sickles pulled out a second pistol and this time hit Key in the thigh. Sickles pulled a third gun and fatally shot Key in the chest for good measure.

"take that!"

“take that!”

Sickles then went to see Jeremiah Black, the U.S. Attorney General, at his home, where he surrendered himself to the law.

Sickle’s stay in jail pre-trial was rather unusual. He had many visitors from the upper strata of D.C. society, all of whom he was allowed to entertain in the warden’s private quarters. The accused murderer even rec’d a handwritten note, albeit not a visit, from President James Buchanan.

At trial, although he confessed to the murder, Sickles’ legal team came up with a novel defense – that of temporary insanity triggered by the ongoing infidelity (note: one defense attorney was none other than Edwin Stanton, soon to be Lincoln’s Secretary of War – eat your heart out, O.J.!) The newspapers of the day jumped on the bandwagon, heralding Sickles for protecting the virtue of the women of Washington from the ravages of the lusty Key and others like him – never mind that Mrs Sickles was fully complicit. And although legally inadmissible, Sickles leaked his wife’s earlier forced confession to the press to further sway the court of public opinion.

“You are here to fix the price of the marriage bed!”, roared another defense attorney, John Graham, in a speech so packed with quotations from Othello, Judaic history and Roman law that it lasted two days and later appeared as a book.

The jury bought it hook-line-and-sinker. Sickles was acquitted. And as his affliction was ‘temporary’ insanity, by then resolved, he didn’t even have to spend any time in an asylum. His was the first such use of this novel defense in American jurisprudence. He basically got away with murder.

Sickles and his wife remained estranged for the rest of her short life. She died of TB in 1861 at the age of 31.

Sickles attempted to rehabilitate himself by enlisting in the Union Army at the outbreak of the Civil War. He commanded a corps at Gettysburg, lost a leg to an artillery shell, and was awarded the Medal of Honor. Still, he was accused of insubordination and disobeying orders during that pivotal battle. He spent the rest of his life trying to put a positive spin on his decisions while under fire, and his prickly relationships with commanding officers.

But he always made time for the ladies. Serving with an American diplomatic legation in London in the 1870s, he introduced his date, a high-priced prostitute, to Queen Victoria. He is also said to have had an affair with deposed Queen Isabella II of Spain while on mission in Madrid.

He died at 94 in New York City and, controversies aside, was buried in Arlington National Cemetery with full honors. His battle-severed leg resides to this day in the National Museum of Health and Medicine in Washington, D.C.

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[Copyright 2013 @ The Alienist’s Compendium]

The Alleged Lunatics’ Friends Society

[Today’s post is sponsored by our very own Audrey E. Alford – welcome back to state government!]

Georgina Weldon (1837 – 1914) was an accomplished British soprano of the 19th century. Classically trained in Florence, she ran afoul of her rich father by going against his wishes regarding marriage. Unfortunately, her new husband was no more supportive of his bride than was her father, and the former then forbade Georgina to appear professionally on stage. Disinherited from wealth and prohibited from earning by her own skills, Georgina was relegated to the occasional performance, gratis, for local charities.

Georgina Weldon

Georgina Weldon

Before long, Georgina and her husband divorced so that he could cohabit with his mistress. Harry Weldon then reneged on his alimony agreement, and Georgina promptly sued – a rarity for a woman in 19th century Britain. Harry immediately tried to have Georgina declared insane and committed to an asylum (freeing him from alimony). On flimsy testimony the court agreed with Harry, and the order was signed. Georgina caught wind of this and hid until the warrant for her commitment had expired. She then immediately filed suit against Harry and his confederates for attempted assault on her person.

Thus started Georgina’s second career as a repeat and oft-annoying litigant. Sometimes she was successful, but many times she was not – once even spending time in jail when convicted in countersuit of libel. There was a time in the 1870s when she had 17 concurrent lawsuits pending against a series of defendants for a variety of slights, real and perceived. However, by then unshackled of her husband, she started singing professionally to finance her legal ‘habit.’ She also found time, in 1882, to publish The Outpourings of an Alleged Lunatic, or How I Escaped the Mad Doctors.

While not an official member, Georgina Weldon’s efforts coincided chronologically and conceptually with those of the interestingly-named Alleged Lunatics’ Friends Society. The ALFS had been founded in 1845 in London to address what its members saw as abuses in then-enforced British commitment laws. Miscarriages of justice were rampant, especially since doctors at the time relied on subjective hearsay from biased sources when testifying at commitment hearings. They often equated benign eccentricities and perceived immoralities as insanity per se – keep in mind that private for-profit madhouses then still existed, and there were profits to be made as well.

The commitment laws were used to muffle those who were odd at best and socially irritating at worst. “Uppity” women were often targets of the commitment laws, as in Georgina’s case; those foolishly contesting inheritances against powerful and well-placed relatives were often another targeted group.

In a particularly egregious case litigated (successfully) by the ALFS, one Jane Bright, a member of the wealthy Brights of Skeffington Hall in Leicestershire, had been seduced by her physician, who took most of her money and left her pregnant. Soon after the birth of her bastard child, Jane’s brothers had her committed to Northampton Asylum to get her out of the way. On her eventual release, she enlisted Gilbert Bolden, the ALFS’ solicitor, to help her recover the remains of her fortune from her family.

Sadly, Georgina Weldon’s operatic career flagged, and she became known more as an eccentric than as a crusader for women’s and patients’ rights. And the ALFS eventually went defunct, having failed to garner much public support. However, to the Society’s credit and Georgina’s legacy, both were successful in initially drawing attention to widespread abuses in the mental health system of the 19th century United Kingdom. They were amongst the first and most vocal advocates dedicated to greater protection against wrongful confinement in the Western world.

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[Copyright 2013 @ The Alienist’s Compendium]