22 Dartmouth Medicine—online at dartmed.dartmouth.edu Spring 2010

LETTERS

the holidays, Thomas spent a lotof time with his grandfather,communicat ing wi th himthrough music. In one of themost moving experiences of mylife, I watched my father’s facechange from worry and confu-sion to complete serenity asThomas touched his essentialself with the piano, playingpieces by Haydn and Brahms.

I am very grateful to Jon Sta-bleford for telling his story sobeautifully. It has allowed me togain a measure of perspective onmy father’s situation. And I willshare it widely with my traineesand colleagues—so we don’t for-get to care for our patients’ es-sential selves, while we also treattheir illnesses.

Susan K. Parsons, M.D.Boston, Mass.

E-ager for e-mailable versionI see that the Winter 2009 issueof Dartmouth Medicine is notyet online. I would like to e-mailthe article “The Longest Run” tomy son, a 1986 graduate of Dart-mouth College and a 1982 grad-uate of Phillips Academy. I thinkhe probably knew Jonathan Sta-bleford, the author of the story.In any event, I know he will beinterested to read the article. Itwas excellent.

James W. Ryan, M.D., Ph.D.Dartmouth College ’57

Augusta, Ga.

It usually takes between two andthree weeks after our paper editiongoes in the mail before our onlineedition can be posted. We hopeeventually to have both editionscome out simultaneously; in the

Running commentaryMy daughter, who is a freshmanat Dartmouth College, sent methe article “The Longest Run”(see dartmed.dartmouth.edu/w09/f03). Itis one of the best articles I haveever read from a patient’s pointof view about what it’s like to bein that situation.

I am a nurse, and I really ap-preciate the fact that JonathanStableford was willing to sharehis experiences; he did a thor-ough and heartfelt job.

Thanks for such a great story,so well done!

Elna Narula, B.S.N.Gaithersburg, Md.

Essential insightsThank you for sharing JonathanStableford’s story about his battlewith and recovery from acuterespiratory distress syndrome. Iabsolutely marveled at the ex-tent of his recovery. My son,Thomas, is a student at PhillipsAcademy (PA), where Jon Sta-bleford teaches English, and I re-call listening to him speak at avisiting day in April 2007. I was

inspired by his approach toteaching and delighted that ourson would have the opportunityto learn from him and others likehim at PA. It is hard for me tohold these two very different im-ages of him in my mind.

I am a pediatric oncologistand bone marrow transplant spe-cialist. I care for children who of-ten are fighting for their lives. Isuspect that they find the expe-rience as jarring as Jon Stable-ford did his own experience, butthey lack his eloquent words,considerable intellect, and emo-tional strength.

I was especially moved by his

description of the “essential self,the real me.” He wrote: “It iswhat remains when an illnesssuddenly strips away good healthand personal history. But it’s in-visible to those treating the ill-ness unless they look carefully,and it’s often obscured even fromthe patient himself.”

In late October, we movedmy father, now 88 years old, toan assisted living facility for pa-tients with Alzheimer’s. Thisdreadful disease strips people ofthe ability to articulate or makesense of their personal story, butI have to believe that it cannotstrip away the essential self. Over

W e’re always glad to hear fromread ers—whether it’s some-

one weighing in about an articlein a past issue or someone ask-ing to be on our mailing list for fu-ture issues. We are happy to send Dart-mouth Medicine—on a complimentary ba-sis, to addresses in the U.S.—to anyone interested inthe subjects we cover. Both subscription requests and letters tothe editor may be sent to: Editor, Dartmouth Medicine, 1 Med-ical Center Drive (HB 7070), Lebanon, NH 03756 or DartMed@Dartmouth.edu. Letters for publication may be edited for clarity,length, or the appropriateness of the subject matter.

A ll three of the features in ourWinter issue appear to havetouched a chord with our au-

dience. We heard from readers whotold us they’d shared articles withfamily members or colleagues, whomentioned that they’d like to seemore articles on historical subjects,and who asked permission to useimages from the magazine in coursematerials. We always appreciateknowing what resonates with read-ers. Let us know if an article movesyou or fascinates you. Or puzzlesyou or intrigues you. The only thingwe hope not to do is bore you!

44 Dartmouth Medicine—online at dartmed.dartmouth.edu online at dartmed.dartmouth.edu—Dartmouth Medicine 45Winter 2009

Top, the group nears the end oftheir trek; the village where thebus will meet them is in sight.

Winter 2009

When a fit-as-a-

fiddle marathoner

collides with a

near-fatal bout of

pneumonia, he finds

that getting back on

his feet takes far

longer than he had

imagined. In fact,

his recovery calls

for more fortitude,

emotionally and

physically, than a

grueling road race.

Jonathan Stableford has taught English at Phillips Academy inAndover, Mass., for 34 years and was chair of the English depart-ment for eight years—including during the period described here,when he was ill. He is also the head coach of the Andover boys’cross-country team, as well as a longtime runner himself.

The Longest Run

T hey removed my breathing tube just oneday after I woke up from an induced comathat had lasted two weeks. I understood

vaguely what was about to happen. My room in theICU suddenly swarmed with doctors and nurses.One of them asked my wife and daughter to leavefor a few minutes, saying, “This might not work. Ifwe have to reinsert the tube, it’s not something youwould want to watch.”

I had emerged the previous morning from a fort-night of unconsciousness feeling utterly confused. Iawoke to the sound of a nurse sweeping open thecurtains at the door of my room. As I looked outthrough the doorway onto the ICU’s central nurs-ing station, I heard my nurse greeting the other pa-tients in turn. I had no idea where I was. I felt likea child in some strange summer camp.

Some time later that day I awoke again. Thistime, I slowly gathered I was in a hospital, as thepeople leaning over my bed explained that I need-ed to undergo a breathing test. All I really under-stood was that they would leave me alone and mon-itor how I did from afar. A test? I wanted to performwell, of course. But how could I do that simply bybreathing? I couldn’t actually ask any of these ques-tions, however, because the breathing tube prohib-ited me from talking.

So I lay alone for what seemed like a long time.In the distance, I could hear voices making plans forlunch, and these voices worked their way into areverie. I became convinced there were several ofus taking the test simultaneously and that we’d allbeen involved in a fire and inhaled smoke. If wepassed the test, we’d be allowed to go out for lunch.My stomach felt empty, and a sandwich soundedwonderful. So I tried to inhale deeply, but eachbreath felt like I was drawing cold sand into mylungs. My gut churned. I had to go to the bathroom.Then there was a long silence. I was sure everyoneelse had left for lunch without me.

Disappointed and lonely, I slipped back intosleep and then awoke once more to see my wife,Cindy, and son, Jason, at my bedside. They ex-plained that I had been asleep for two weeks whilethey anxiously watched and waited. As they talked,I began to dimly recall feeling very sick, coming tothe hospital, and being told that I would be put tosleep so they could intubate me. Years seemed tohave passed since then. But at that moment, whatI wanted to do more than anything was to tellCindy and Jason about the breathing test—about

By Jonathan A. Stableford

Jon Stableford, rounding the last curve hereon the way back from a recent run near hisVermont hilltop home, is back in full stridethree years after nearly dying of pneumonia.

MAPLE LEA

F PHOTOS

This Winter feature, a first-person narrative by an English teacher (and runner),details his recovery from a life-threatening bout with pneumonia and sepsis. continued on page 60

60 Dartmouth Medicine—online at dartmed.dartmouth.edu Spring 2010

LETTERS

the Fall 2009 issue of the Bulletinof the History of Medicine. I’m very interested in early

medicine, especially its move-ment into rural areas and thefrontier, and am presenting a pa-per this summer on another19th-century medical controver-sy, calomel, at the Society forHistorians of the Early AmericanRepublic.

Dan AllossoKeene, N.H.

Issue was pro salute publicaAs I read the Winter 2009 issueof Dartmouth Medicine (fromcover to cover), I began to real-ize that this particular issue could

continued from page 22meantime, we appreciate readers’patience (and we are delighted toknow that readers are making useof the ability to e-mail articles).

Side suitsI receive Dartmouth Medicineregularly and want to commenton a recent article. “The mostunspeakable terror” (see dartmed.dartmouth.edu/w09/f02) suited me; mycongratulations to the authors. Please include more articles

like this. They show another sideof medicine—one that otherreaders, I think, will also value.

Virginia L. CloseNorwich, Vt.

Knowledge of KnowltonI just read “The most unspeak-able terror” in the Winter Dart-mouth Medicine—good article!Congratulations to the authors.

Charles Knowlton, who ismentioned in the article, is in-deed a fascinating character. Healso found his way into print inan article by Michael Sappol in

The journeyhome...

begins here.

On The GreenLyme, NH 03768

603-795-4816

Allen StreetHanover, NH 03755603-643-4200

www.marthadiebold.com

“The most unspeakable terror”

online at dartmed.dartmouth.edu—Dartmouth Medicine 37Winter 200936 Dartmouth Medicine—online at dartmed.dartmouth.edu Winter 2009

In the 1800s, childbirth

was often fraught with

fear and death rather

than joy. But growing

knowledge about the

cause of puerperal fever

—also known as childbed

fever—eventually

brought the epidemic

of maternal and infant

mortality under control.

How that knowledge was

gained can be tracked in

19th-century documents.

By Emily Baumrin, William Corbett, Amita Kulkarni, and Lee A. Witters, M.D.

n November 30, 1843, tragedy struck atthe brick home of Harvey Benton, a car-riage painter of “unusual skill.” Benton

and his 31-year-old wife, Orilla Greely Benton,lived at 6 South College Street in Hanover, N.H.,the current site of Dartmouth’s Hood Museum giftshop. Orilla Benton had given birth a few days ear-lier to their first child but died of postpartum com-plications on the 30th. Their infant daughter,named Orilla G., died on December 5. These facts were duly recorded in a list of deaths

“in the vicinity of Dartmouth College from 1777-1861” kept by William Worthington Dewey, a tav-ern keeper and chronicler of Hanover history.Dewey recorded the cause of death as “childbederysipelas,” but then crossed out the latter term andreplaced it with “puerperal fever”—a disease calledby Dr. Charles Meigs, a leading 19th-century ob-stetrician, “the most unspeakable terror.”As it happens, three days earlier—on November

27—Dewey had also recorded, and then amended,the deaths of Mary Baker and her infant as due to“childbed erysipelas puerperal fever.” A later entry

by Dewey noted that out of 23 deaths in Hanoverduring 1843, “Mrs. Baker and Benton both died ofpuerperal fever.” Dewey appears to have been struck by this coin-

cidence; indeed, they were the only deaths due tothe condition that he recorded over the course of84 years. Could the deaths have been related, andif so how? And what was the relationship seeming-ly identified by Dewey between puerperal (pro-nounced PWER-per-ul) fever and erysipelas (air-uh-SIP-uh-liss), a skin disease? Had he learnedsomething by living across North Main Street fromthe institution now known as Dartmouth MedicalSchool but then called New Hampshire MedicalCollege? What was being taught about the two dis-eases to 19th-century medical students? Answers to many of these questions can be

found in medical reports and textbooks of that day;classroom notes and theses by Dartmouth medicalstudents; local and national census data; and infor-mation gleaned from visits to local cemeteries, mu-seums, and town clerks’ offices.The DMS student theses are especially revealing

This 1635 painting by John Souch depicts an all-too-common occurrence in centuries past—death in childbirth. Titled Sir Thomas Aston at theDeathbed of His Wife, it was commissioned by Aston, a wealthy merchant in Chester, England, after his wife died giving birth to their fourth child.

These entries from 1843, in a record kept by a tavern keeper of all deaths in the vicinity of Hanover, showthe suspicion even then that there was a relationship between childbed fever and the skin disease erysipelas.

For several with furtherbackground on this subject, seedartmed.dartmouth.edu/w09/we01.

WEB EXTRAS

PAGE 36: MANCHESTER (ENGLAND) CITY GALLERIES, PAGE 37: DARTMOUTH COLLEGE ARCHIVES

O

A member of the DMS faculty collaborated with three undergraduates on this fea-ture about the eventual elucidation of a terrifying disease of the 19th century.

online at dartmed.dartmouth.edu—Dartmouth Medicine 61Spring 2010

We didn’t set out to give our Win-ter issue a public health theme; infact, it’s sometimes only in retro-spect that such threads become ap-parent. But more and more expertsare making the case for a closer in-tegration of medicine’s focus on thesingle patient and public health’spopulation-wide focus, so neither isit an accident that there is a grow-ing emphasis on public health with-in medicine—and within the pagesof Dartmouth Medicine.

Gold standardIt was with great interest that Iread the article in your Winterissue about gold amalgamation

LETTERS

have been given the theme of“Dartmouth medicine and pub-lic health.” The feature “An Uphill Bat-

tle” (see dartmed.dartmouth.edu/w09/f01) was about hearing loss inNicaragua due to the neurotoxiceffects of mercury as well as topervasive exposure to loud nois-es there. Both of these interna-tional health problems are cov-ered in public health journals. Another feature, “The most

unspeakable terror,” discussedpuerperal fever in the 19th cen-tury and the resulting epidemicof maternal and infant mortali-ty—another subset of the field ofpublic health and epidemiology.

The concepts of “contagion” and“hygiene” were mentioned oftenthroughout this wonderful andcomprehensive article on a historical public health issue.

I wish you continued successwith Dartmouth Medicine.

Daniel M. Anzel, Dr.P.H.Dartmouth College ’55

Los Angeles, Calif.

Uphill

online at dartmed.dartmouth.edu—Dartmouth Medicine 27Winter 200926 Dartmouth Medicine—online at dartmed.dartmouth.edu Winter 2009

enjamin Jastrzembski is searching thestreets and shops of Bonanza, a gold-min-ing town in northeastern Nicaragua, for the

perfect piece of scrap metal. He spots a stainlesssteel bowl on a blanket laid out in front of a smallshop. “That might work,” he muses as he pays forthe bowl.

Jastrzembski, a 2008 graduate of Dartmouth Col-lege, sometimes wonders what local residents thinkhe’s up to when they see him carrying around potsor pans or random bits of metal. Sometimes even hewonders what, exactly, he’s doing. But then he’ll bereminded of the difference that a few dollars’ worthof materials can make in this impoverished ruralcommunity.

In Bonanza, as well as many other towns in thispart of Nicaragua, thousands of people make theirliving from small-scale, or artisanal, mining. Thework is difficult, to say the least. Miners use picksand shovels, and sometimes dynamite, to extractore from the hillsides above the town.

Then they load the ore into bags and bring it tolocal processors, where the ore is ground into acoarse mixture. That mixture is combined withmercury, which binds to gold, creating a mercury-gold amalgam that is much easier to collect thantiny flakes of gold alone. The miners take thatamalgam and heat it—often over an open flame ora blowtorch—releasing the mercury as vapor andleaving behind the gold.

Sometimes, Jastrzembski says, the process is car-

Toxic pollution from

small-scale gold-mining.

Indiscriminate use of an

antibiotic that can lead to

hearing loss. Scarce or

nonexistent health-care

resources. Those are a few

of the problems that are

drawing more and more

people with Dartmouth

ties down to Nicaragua.

Amos Esty is the managing editor of Dartmouth Medicine.Thanks to financial support from Dartmouth’s Dickey Center forInternational Understanding, he was able to travel to Nicaraguain July 2009 to do on-site reporting and photography for this arti-cle (he took all the photos, unless they are credited otherwise).

Bonanza, Nicaragua, is scenic but remoteand impoverished. Most residents areinvolved in some way with artisanal gold-mining—difficult and dangerous work.

B

An

BattleBy Amos Esty

For a with more photos ofNicaragua, plus several short videos, see dartmed. dartmouth.edu/w09/we08.

WEB EXTRA

A number of people with Dartmouth connections are helping forge long-term so-lutions to several interrelated health (and public health) problems in Nicaragua.

continued on page 62

62 Dartmouth Medicine—online at dartmed.dartmouth.edu Spring 2010

in Nicaragua and the efforts to limit the re-lease of mercury into the environment. Iteach a course in industrial toxicology at theUniversity of Pennsylvania and gave a talkon “Industrial Mercurialism: Agricola, NewAlmaden, and the Danbury Shakes” at the2008 conference of the Society for Industri-al Archeology. Would you be willing to share your pho-

tographs of the homemade retort and theother mercury-related equipment? With yourpermission and appropriate attribution, Iwould like to incorporate them into mycourse materials.

Lloyd B. Tepper, M.D., Sc.D.Dartmouth College ’54, DMS ’55

Villanova, Pa.

The photographs for that particular article weretaken by a member of the magazine’s staff, sowe were able (and happy) to give Dr. Tepperpermission for their use in his course materials.When photographs in Dartmouth Medicinehave been taken by a freelance photographer,however, it is the freelancer, not the magazine,

who must give permission—but permission re-quests can always be directed to the magazine.

Paper trailI beg to differ with the conclusions of Dr. IanPaquette [see dartmed.dartmouth.edu/w09/d02 andscroll down to the item titled “Doctor dis-parities,” which reports on a study Paquetteled, showing that people who live in rural ar-eas are more likely to suffer a perforated ap-pendix than people who live in cities; onereason suggested in the paper for the region-al difference is that there are more generalsurgeons in urban than in rural areas.] What is needed in rural areas are more

general practitioners (diagnosticians) ratherthan more surgeons, to intervene at the acutestage of appendicitis rather than the endstage. Patients are more likely to consulttheir family physician for symptoms of abellyache, not a surgeon. An early diagnosisis the key to preventing the calamity of rup-ture. Teamwork is also important. For years,the diagnosis of acute appendicitis was madein my office and the cure was effected by myDMS classmate Jim Harshbarger—before the

availability of and without the need of an ex-pensive and duplicative spiral CAT scan.

Raymond E. Jankowich, M.D.Dartmouth College ’52, DMS ’53

Stratford, Conn.

Dr. Paquette and his collaborator, Dr. SamuelFinlayson, responded as follows: “We agree withDr. Jankovich that the low supply of primary-care physicians in rural areas likely contributes tobarriers to timely evaluation and treatment ofpatients with appendicitis. However, the pro-gression of a patient from initial symptoms tocure follows a chain of events within a health-care system in which surgical care is clearly anintegral part. We believe that both components—primary care and surgical care—are necessaryto provide good, timely care for rural patientswho fall ill with appendicitis.”

Vive la (médecine de) FranceRecently I came across your excellent maga-zine and want to congratulate you on a pub-lication of fine quality.I am American but now live in France—

a beautiful, interesting country with a fine

DartmouthCENTER FOR CONTINUING EDUCATION IN THE HEALTH SCIENCES Educational Opportunities: Spring 2010

The Dartmouth-Hitchcock Medical Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Dartmouth-Hitchcock Medical Center’s Nursing Continuing Education Council is accredited as a provider of continuing nursing education by the

American Nurses Credentialing Center’s Commission on Accreditation.

For more information and to register online visit: h t t p : / / c c e h s . d a r t m o u t h - h i t c h c o c k . o r g

Accreditation available for conferences marked (M) for Medicine and (N) for Nursing

MARCHMarch 1, 2, 22, 23, 29, 30, 2010

Hematology Oncology Mini-Course (N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

March 5 - 7, 2010Dartmouth Radiology Third Annual Symposium:

Role of PET-CT in Cancer Management (M)The Mount Washington Resort, Bretton Woods, NH

March 10 - 12, 2010An IV Therapy Course for LPNs

Dartmouth-Hitchcock Medical Center, Lebanon, NH

March 22, 2010Surgery for Diabetes: Who’s the Right Candidate,

What’s the Right Procedure? (M & N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

March 29, 2010Fun at WORK?: Cultivating Workplace Wellness with

Humor, Optimism and Creativity (Holistic Series) (N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

APRILApril 5, 2010

Updates on the Prevention, Diagnosis and Management of Patients with Vascular Disease: 2010 (M & N)

The Center of New Hampshire, Radisson Hotel, Manchester, NH

April 6, 13, 20, 27 & May 4, 11, 18, 2010Dartmouth Community Medical School:

Bionic Man and Super WomanKellogg Auditorium, Dartmouth College, Hanover, NH

April 9 - 10, 2010Geriatric Update 2010 (M & N)

The Woodstock Inn, Woodstock, VT

April 14, 2010Tumors of the Anterior and Posterior Skull Base:

Anatomy, Diagnosis, and Management (M)The Common Man Restaurant, Concord, NH

April 19, 2010The 31st Meeting of the New Hampshire-Vermont

Hospital Ethics Committee Network (M & N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

April 23 - 24, 2010Northeastern Genitourinary Oncology Symposium 2010:

Observation vs. Intervention (M & N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

MAY

May 3, 2010Managing Medical Emergencies: For Physicians

Working in Emergency Departments (M)Dartmouth-Hitchcock Medical Center, Lebanon, NH

May 3 - 4, 2010The Third Annual DHMC Conference on Nursing Excellence: Preparing Nurses for Success in Today’s

Complex Clinical Environments (N)The Woodstock Inn, Woodstock, VT

May 10, 20102nd Annual Otolaryngology Updates for the Primary Care: Office Management of Common Ear, Nose, and Throat

Diseases (M)Dartmouth-Hitchcock Medical Center, Lebanon, NH

May 14, 2010Pediatric Issues: Yours, Mine and Ours 2010 (N)

Dartmouth-Hitchcock Medical Center, Lebanon, NH

May 18, 2010Ambulatory Care Nursing Update: Diversity in the New Decade (N)Colby-Sawyer College, New London, NH

May 20 -21, 2010Ultrasound for Emergency Providers:

Basic and Advanced (M)Dartmouth-Hitchcock Medical Center, Lebanon, NH

May 21, 2010Tumors of the Anterior and Posterior Skull Base:

Anatomy, Diagnosis, and Management (M)Location TBD, Portland, Maine

May 24, 2010The 6th Annual Dartmouth Conference on Advances in

Heart Failure: “Special Topics 2010” (M & N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

JUNE June 3, 2010

Fundamental Disaster Management (M & N)Dartmouth-Hitchcock Medical Center, Lebanon, NH

June 4 - 5, 2010Fundamental Critical Care Support (M & N)

Dartmouth-Hitchcock Medical Center, Lebanon, NH

June 18 - 19, 2010Northern New England Neuroimmunology

Symposium 2010 (M & N)Mountain View Grand Resort and Spa, Whitefield, NH

JULYJuly 17, 2010

Center for Liver Disease Patient and Family Awareness Day

Dartmouth-Hitchcock Medical Center, Lebanon, NH

continued from page 61

online at dartmed.dartmouth.edu—Dartmouth Medicine 63Spring 2010

medical system. So I follow with interesthealth-care developments in the U.S. Hav-ing lived either in France or Canada sincemy marriage, I am used to being able to seedoctors or obtain care without having toworry about the costs. The costs are admit-tedly high; we pay through our tax system tounderwrite medical coverage for all. But the system is efficient. Everyone is

covered, we may consult doctors or use hos-pitals and clinics of our own choice, our rateof death in childbirth is very low, and ourlongevity is high. It would seem that such asystem provides many benefits. The Frenchrefuse to contemplate any other.It seems high time the United States got

around to providing universal coverage. Jane Triaureau

Cergy, France

Additive requestI would very much like to be added to themailing list to receive Dartmouth Medi-cine on a regular basis. My interest inDHMC stems from having a second home atEastman, being the father of a staff member,and having recently been a patient (in theER and orthopaedics). Thank you.

John W. Brackett, Jr.,M.D.Oxford, Conn.

Close encountersI was introduced to your magazine during myhusband’s recent stay in the hospital. I foundit intriguing and informative. I would like tobe placed on your mailing list.We’ve been very pleased with the spe-

cialty care my husband has received over thepast two years and are glad we live so close toa top-notch hospital like Dartmouth!

Belinda DeckerCharlestown, N.H.

Receiving endMy wife and I are interested in receivingDartmouth Medicine. I just completed theDartmouth Community Medical School inManchester, and every time I visit theLebanon campus for an appointment I enjoyreading your publication. Many thanks.

Jonathan KippLondonderry, N.H.

We are delighted to add to our mailing list any-one who is interested in the subjects that we cov-er. See the box on page 22 for details.

WillowBrook Prosthetics & Orthotics

Robert Diebold, C.O., Orthotist • David Loney, C.P., Prosthetist

190 Hanover Street • Lebanon, NH • 603/448-0070