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There’s a good bit of history for the date, May 6th.

For instance, Olga Korbut, Sigmund Freud, and Maximilien Robespierre, among others, were born on this day.   In 1527, Spanish and German troops sacked Rome, signalling the end of the Renaissance.  In 1863, Confederate forces defeated the Army of the Potomac at Chancellorsville.  In 1889, the Eiffel Tower officially welcomed the public.  In 1954, Roger Bannister broke the four minute mile.  In 1994, the Chunnel opened underneath the English Channel, better linking Britain and France.  In 1998, Chicago Cubs pitcher Kerry Wood struck out 20 Houston Astros to tie Roger Clemens’ major league record.  May 6th is also police day in Georgia (U.S.), and International Diet Day.

But for whatever capricious reason, the historical factoid that resonates the most with me today is the admission on May 6th, 1757 of English poet Christopher Smart to St Luke’s Hospital for Lunatics in London.  He had developed a religious mania which compelled him to pray continuously, and apparently wandered the city doing so in public.

Samuel Johnson remarked, “My poor friend Smart shewed the disturbance of his mind, by falling upon his knees, and saying his prayers in the street, or in any other unusual place.” And also, “I did not think he ought to be shut up. His infirmities were not noxious to society. He insisted on people praying with him; and I’d as lief pray with Kit Smart as any one else. Another charge was, that he did not love clean linen; and I have no passion for it.”

Smart himself wrote in his work, Jubilate Agno, composed during the years of his confinement (though not published until 1939):

“For I blessed God in St James’s Park till I routed all the company. For the officers of the peace are at variance with me, and the watchman smites me with his staff.”

In all likelihood, Christopher Smart suffered from bipolar disorder.

He was, if excessively ardent in his devotion, harmless.  Certainly, far worse has been done in the zealous demonstration of faith.

Here is a poem for which he is well known.  One can imagine what effect the loss of freedom and bleak ambiance of the asylum must have had on its author.

For I will consider my Cat Jeoffry (from Jubilate Agno)

For I will consider my Cat Jeoffry.
For he is the servant of the Living God, duly and daily serving him.
For at the first glance of the glory of God in the East he worships in his way.
For is this done by wreathing his body seven times round with elegant quickness.
For then he leaps up to catch the musk, which is the blessing of God upon his prayer.
For he rolls upon prank to work it in.
For having done duty and received blessing he begins to consider himself.
For this he performs in ten degrees.
For first he looks upon his forepaws to see if they are clean.
For secondly he kicks up behind to clear away there.
For thirdly he works it upon stretch with the forepaws extended.
For fourthly he sharpens his paws by wood.
For fifthly he washes himself.
For sixthly he rolls upon wash.
For seventhly he fleas himself, that he may not be interrupted upon the beat.
For eighthly he rubs himself against a post.
For ninthly he looks up for his instructions.
For tenthly he goes in quest of food.
For having considered God and himself he will consider his neighbor.
For if he meets another cat he will kiss her in kindness.
For when he takes his prey he plays with it to give it a chance.
For one mouse in seven escapes by his dallying.
For when his day’s work is done his business more properly begins.
For he keeps the Lord’s watch in the night against the adversary.
For he counteracts the powers of darkness by his electrical skin and glaring eyes.
For he counteracts the Devil, who is death, by brisking about the life.
For in his morning orisons he loves the sun and the sun loves him.
For he is of the tribe of Tiger.
For the Cherub Cat is a term of the Angel Tiger.
For he has the subtlety and hissing of a serpent, which in goodness he suppresses.
For he will not do destruction if he is well-fed, neither will he spit without provocation.
For he purrs in thankfulness when God tells him he’s a good Cat.
For he is an instrument for the children to learn benevolence upon.
For every house is incomplete without him, and a blessing is lacking in the spirit.
For the Lord commanded Moses concerning the cats at the departure of the Children of Israel from Egypt.
For every family had one cat at least in the bag.
For the English Cats are the best in Europe.
For he is the cleanest in the use of his forepaws of any quadruped.
For the dexterity of his defense is an instance of the love of God to him exceedingly.
For he is the quickest to his mark of any creature.
For he is tenacious of his point.
For he is a mixture of gravity and waggery.
For he knows that God is his Saviour.
For there is nothing sweeter than his peace when at rest.
For there is nothing brisker than his life when in motion.
For he is of the Lord’s poor, and so indeed is he called by benevolence perpetually—Poor Jeoffry! poor Jeoffry! the rat has bit thy throat.
For I bless the name of the Lord Jesus that Jeoffry is better.
For the divine spirit comes about his body to sustain it in complete cat.
For his tongue is exceeding pure so that it has in purity what it wants in music.
For he is docile and can learn certain things.
For he can sit up with gravity, which is patience upon approbation.
For he can fetch and carry, which is patience in employment.
For he can jump over a stick, which is patience upon proof positive.
For he can spraggle upon waggle at the word of command.
For he can jump from an eminence into his master’s bosom.
For he can catch the cork and toss it again.
For he is hated by the hypocrite and miser.
For the former is afraid of detection.
For the latter refuses the charge.
For he camels his back to bear the first notion of business.
For he is good to think on, if a man would express himself neatly.
For he made a great figure in Egypt for his signal services.
For he killed the Icneumon rat, very pernicious by land.
For his ears are so acute that they sting again.
For from this proceeds the passing quickness of his attention.
For by stroking of him I have found out electricity.
For I perceived God’s light about him both wax and fire.
For the electrical fire is the spiritual substance which God sends from heaven to sustain the bodies both of man and beast.
For God has blessed him in the variety of his movements.
For, though he cannot fly, he is an excellent clamberer.
For his motions upon the face of the earth are more than any other quadruped.
For he can tread to all the measures upon the music.
For he can swim for life.
For he can creep.

Understanding how a patient makes sense of chronic or disabling illness can be critical to the effective treatment of that illness.  Repairing the body doesn’t necessarily repair the life. Patients must confront changes to their bodies and in how they live their lives, psychological dimensions of disease physicians and allied practitioners have appropriately tried to address more vigorously.  But human beings, perhaps uniquely, not only live in the here and now but also in a larger narrative of their existence that includes their past and also projects a future.  Our identity and self-esteem are not only tied up in what we see in the mirror, but in what others see, and in who we see ourselves becoming: our plans and expectations for ourselves in the context of a long and healthy life.  All of this helps us tell the story of who we are. The term “biographical disruption” has been applied to the pernicious ability of disease to damage this narrative.   To fully treat disease one must also treat the damaged story.  There is evidence that poetry can be part of such treatment, allowing patients to creatively frame and perhaps modify their story through dialogue with themselves and with others.

Below is a poem written by a young woman afflicted with severe arthritis, reprinted from Cases Journal (Cases J. 2008; 1: 153).

Where have I gone?

Where’s the woman who weighed less than 9 stone?

Who wore a dress size 12 and didn’t need to wear shapeless clothes or jogging suits?

Who had shaped and tidy eyebrows that would complement her latest hair colour and style?

Whose painted nails, with manicured hands and feet, were perfect for holidays in the sun?

Where’s the woman who had a vocation not just a job, but who exists on benefits, a step away from poverty?

Where’s the woman who owned her own home that gave her safety and privacy, it was her pride and joy?”

Where’s the woman whose hobbies include travel, gardening, decorating, furniture restoring, sewing, reading and studying at home?

Here I am and life before my impairment has gone, the only thing I can do is hold a pen with a special grip and writing is agony.

Where has she gone?

Where has she gone?

WHERE HAVE I GONE?

Do you see me?

How can you ever know me, when all you see is my chair?

My limitations are all you see and you say they complicate your life.

Will you ever see the deep pools of love in my eyes for you?

When you half close yours with pity and turn away from me.

The beating of my heart in expectation of your closeness isquickly cooled by your fleeting hug or, worse, patting my shoulder.

I wait in anticipation remembering the taste and softness of
your kiss, you offer me a warm ‘peck’ on the cheek.

I smell your aftershave … you say I smell clean!

I remember running my fingers through your hair,

Ripping buttons off your shirt but that’s difficult when you
stand behind me pushing my chair, we can’t even hold hands anymore.

The power of my emotions makes me feel strong,

Then I catch that pitying look in your eye,

They die in my heart.

I do not speak, my smile fills my face but you will never know …

You’ll never see the real woman who is me

Who sits and is seen by the world framed by a wheelchair

Cut off emotionally just because I cannot stand or walk.

Thank you

Thank you to those who take the time to listen to difficult and unclear speech, for you help us to know that if we persevere we can be understood

Thank you to those who walk with us in public places, ignoring stares and whispers from strangers, for in your friendship we find enjoyment, laughter and happiness

Thank you for never asking us to ‘hurry up’, but even more special is you don’t snatch our tasks from us or offer ‘Care’ in such a way as to make us feel that we are still children, with no control and respect

Thank you for standing beside us when we enter new experiences and try new adventures
Though our success may be outweighed by our failure, the experience will stay with us forever and there will be many occasions when we surprise ourselves and maybe even you!

Thank you for asking for our help and expertise,
As self-confidence and awareness come from being needed by you and others

Thank you for giving us respect

You acknowledge our value as experts in our fields and that we require to live with equality in society

We shouldn’t have to ask or have laws to enforce it or remind you

Thank you for assuring us that the things that make us individuals are not our medical impairments, as everyone has those and they don’t define ONE’S SELF, it’s people’s attitudes that create barriers that exclude us from you.

Treat us as we treat you.

oedipusDoing 60, 90, 120…ignoring or liberally interpreting the yellow “RIGHT LANE ENDS, MERGE NOW” sign, the driver of a white pick up truck scattering gravel in the break down lane passed us and cut us off, the raised bumper inches from ours, the dual exhaust rumbling.  I was captaining our station wagon.  My beautiful wife sat next to me, her hand proffering reassurance to my shoulder.
     “Just ignore him,” she said, reading my mind (the lower, primitive regions of the limbic system, amygdala and hippocampus) or the adrenalin gauge (not on the dashboard) with its indicator at the redline.

Instead, I ignored her, tailgating and then swerving in front of the truck at the next available opportunity—a straightaway after a service station where the road widened from one lane to three, allowing for left and right turns into strip malls, as well as the occasional drag race.  The lackadaisical evening traffic and numerous stoplights, however, made this particular use tenuous.

Fortunately for us, the driver, after gunning past one more time, swooped off the road into a liquor store parking lot without taking further heed of my challenge.  He probably had a jiggling beer cooler on the front seat in need of replenishment, to go with a (fully legal) handgun in the glove compartment.  I escaped the confrontation with only an earful from my wife for risking my life, and hers: minor damage.

In fact, I’ve mostly gotten pretty good at defusing such situations, mostly by defusing myself in time.   But sometimes caught in the wrong mood at the right moment…I…The funny thing is, were I to come across the obnoxious operator of said truck at a revolving door or in a movie line, each one of us might well have said, “after you.”  Somehow, climbing into a car’s personal space with its anonymity and raw power deactivates the courtesy that keeps us from each other’s throats.

Manners, as a word, suggests a kind of officious veneer associated with prep or finishing schools, a gratuitous expertise in the social graces.  The well-mannered individual always uses the correct fork for his salad, and gets his thank-you cards written punctually.  But I postulate here that at least on the roads and highways of America good manners can save your life.  We’re a short tempered and irritable society (at least while motoring) and a violent one.  Perhaps there’s a connection?  According to the National Highway Traffic Safety Administration, aggressive driving accounts for one third of “accidents” (my quotation marks) and two thirds of automobile fatalities.  That’s frightening.  On the Pennsylvania Turnpike, a thoroughfare I frequent, two women were killed a few years ago after the driver of another car, angered and retaliating over an unintentional “slight,” caused theirs to lose control and crash.  If he’d displayed just a hint of the gallantry he might have on foot, he’d be a free man today and two women would still be alive.

According to Freud, we are motivated by sex (Eros), and death (Thanatos).  I would agree with the first at least, though I think there are often less elaborate, in fact stupidly simple explanations for our behavior.  For example, much has been written about the so called Oedipal conflict, which Freud hypothesized, where a boy subconsciously wishes for his father’s death  because he harbors repressed desire for his mother.  Sex and death, death and sex.  But if we go back to Sophocles, the ancient Greek dramatist, and his Oedipus Rex, we find a much more banal kind of human foible at work.

Remember the story?  An oracle forecasts that Laius will have a son who will grow up to kill his father.  So Laius disposes of this son, Oedipus, binding his feet and leaving him on a mountain to subvert the fate decreed by the gods.  The infant Oedipus survives and years later, as a grown man, finds himself face to face with his father.  Except neither recognizes the other.  Oedipus believes his father is the shepherd who raised him as a boy.  Laius thinks his child is dead.  So they are in essence strangers when they argue at an intersection over who has the right of way.

When Oedipus kills his father it has nothing to do with the superego, or the id, stifled libido.  It’s a simple case of road rage, and fatuous as it sounds, bad manners.  Had either one of them waved the other past with genteel deference, there would have been no bloodshed, no humiliating abdication, no suicide by Jocasta, no self-mutilation by Oedipus in his shame and grief and guilt.  This variety of Oedipus complex isn’t complex at all.  Unfortunately, like fate, neither is it trivial or easily avoided.  And it takes its toll off the road as well, has done so for centuries in petty struggles over honor, pride, saving face.  The gods and the playwrights could always count on us to be impulsive, ill mannered, and self-destructive.  They still can.

MassGeneralHospitalWhat’s wrong with the current system? Gross inefficiency, redundancy of services (generally lowering overall quality because the added programs lack adequate proficiency and don’t significantly improve access), irrational deployment of resources (i.e. too many specialists and too few primary care physicians, simultaneous physician gluts and shortages in different geographies, an excessive density of programs providing complex high cost care in some locations, a dearth of such programs in others), inadequate provision of primary care, psychiatric care, & translational care facilitating recovery once the patient is released from the hospital), increasingly arcane and inscrutable bureaucracy associated with fees and payments, antiquated processes (incomplete and disorganized medical documentation via pen and paper, versus (fully) electronic record keeping utilized by other countries), inadequate validation of processes, a lack of quality assurance, excessive negligence, inadequately investigated bad outcomes, inadequate trending and statistical analysis of outcomes, inadequate safeguards or remedies for negligence, runaway litigation, physician incompetence and impairment, inadequate regulation and/or control of insurance company practices, lack of adequate preventative or therapeutic care for the poor, the elderly, or children, a distorted focus on procedures versus outcomes, a failure to consider the whole person when treating patients, an inadequate focus on the psychological dimensions of illness, on the social and employment aspects of illness, inadequate mechanisms for addressing pain control, especially in terminal illness, inconsistent and arbitrary approaches to end-of-life-care (if you think your grandmother isn’t already refused adequate or compassionate treatment as an elderly patient, you’re sadly mistaken), inadequate recourse for patients denied choice or coverage, inadequate recourse for physicians or hospitals denied payment for indicated services or procedures. I could go on with the list, or expand any of these items in detail, but that would only add to the tedium of this already languid litany. I suspect most of the charges I’ve leveled will not sound unfounded or unfamiliar to you.

What is to be done? Obama’s initiative and what congress has done with it as a reform package is far from perfect and doesn’t begin to go far enough in terms of tinkering with the mechanics of very fouled up health care system. Nevertheless, it’s a lifeline thrown to a drowning person and if we are to have any chance of preserving our wellness—personal, societal, financial—we must grab it avidly and quickly. There is no chance the proposed changes will aggravate our predicament, and every chance they will improve it in manifold and significant ways. The plan will add to our choices as health care consumers, lower costs, and begin the process of trimming waste. The plan will also protect the uninsured (and the insured) from being without adequate coverage to manage catastrophic illness. In doing so, the proposed reforms will protect the rest of us from the high expenses to society associated with refusing to provide care when it is still timely and effective.

Beyond the plan we need a peer review system comparable to that used by NIH (National Institute of Health) which is run by the government yet is highly efficient, effective, and in fact as research systems go, is the envy of the world. Disinterested physicians, and other health care experts, (versus government bureaucrats) need to determine the appropriate use and deployment of finite resources. Simply pretending we can do everything when we know we can’t and can’t afford to (the ostrich approach) has to stop. We need to keep our insurance companies, but regulate and restrict them (like utilities) given their stewardship of a vital public resource. No longer can they be allowed to enrich themselves at our expense while pretending to “control costs” by denying us choice in what care we receive and from whom we receive it. No longer should we let them refuse to take care of us once we are sick. Of what use is health insurance that only insures the healthy? We the public need to make informed decisions about what happens to us when we are sick, such choice a welcome change from the current model in which we are kept in the dark as to the motives, workings, and impact of those taking care of us.

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