On a Few Things…

“Monday Musings” for Monday September 17, 2018
Volume VIII. No. 38/402

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Moses Maimonides

 YOM KIPPUR AND MOSES MAIMONIDES OF CORDOBA

By Assad Meymandi, MD, PhD, DLFAPA, ScD (Hon)*

Rosh Hashanah, the Jewish New Year, 5779, began on Sundown Sunday  September 9, leading to Yom Kippur which begins at Sundown September 18, 2018. These ten days of reflection, introspection and atonement are the holiest days of the Jewish calendar. Yom Kippur (Yom means day and Kippur means great–the great day) which is focused solely on prayer, fasting and redemption bears much mystery,.

One of my favorite Jewish Theologians, Martin Buber, whose thinking and writings were influenced by Sigmund Freud and Fredrick Nietzsche describes these ten Holy Days as a drama that unfolds. Rabbi (Lord) Jonathan Sacks, the former Chief Rabbi of UK and Commonwealth, in a seminal essay wrote “These days constitute a courtroom drama like no other.  The judge is God himself, and we are on trial for our lives.  The drama begins with Rosh Hashanah with the sounding of the shofar, the ram’s horn, accounting that the court is in session.  The book of life is written on Rosh Hashanah; and on Yom Kippur, when the atmosphere reaches a peak of intensity atonement and prayer, the book is sealed…”  In Christianity there is Lent and in Islam there’s Ramadan and Eid-e-Fetr which parallel the intensity and concentration of prayer and the  fascinating drama of the personal relationship between God and humans.

As promised in the last week’s “MM” to honor the Holy Day of Yom Kippur, we present a review of colleagues Fred Rosner and Samuel Kottek biography of Moses Maimonides of Cordoba.

Moses Maimonides of  Cordoba

REVIEW OF BOOKS
by Assad Meymandi, MD, PhD, DLFAPA

Moses Maimonides
Edited by Fred Rosner, MD and Samuel S. Kottek, MD
229 pages of text, 41 pages of reference notes and 10 pages of index
Jason Aronson, INC., Publisher

There is a sweet anecdote at the beginning of Sherwin Nuland’s biography of Moses Maimonides which has to do with Jewish mothers insisting their sons to become doctors, the “My Son, the Doctor” paradigm.  It goes something like this: “Imprisoned in a tower in Madrid, disabled by syphilis and further weakened by abscess in his scalp, The French King Francis asked of his captor, the Holy Roman Emperor Charles V, to send the finest Jewish physician to attempt a cure.” Frances discovered that the doctor sent to him was not Jewish but a baptized Christian. Irate, Francis dismissed the doctor and insisted to be treated by a genuine Jew. That physician may have been Moses Maimonides, brought all the way from Cordoba.

Not only was Moses Maimonides of Cordoba was a good Jewish doctor, he was a Rabbi, a philosopher and a prolific writer.  During his life time he wrote 5.3 million words, most of which have been preserved. He wrote on all aspects of medicine, infectious disease, nutrition, spirituality and internal medicine. But he also made inroad into the world of psychiatry.

You would think that cognitive behavioral therapy (CBT), an effective methods of treating w aide range of psychiatric problems, including obsessive compulsive disorder (OCD), anxiety disorder, depression, borderline personality disorder and many other neuroses including phobia and panic disorder, is thought to be one of the contributions of the twentieth century medicine, until you read about the life and work of the polymath, “super-genius” physician, theologian, philosopher and astronomer, Rabbi Moses Maimonides of Cordoba  (MM of C) .

The Rabbi, a major author of Helakhic authorities, the collective corpus of Jewish religious, rabbinical and later Talmudic laws wrote about CBT way back in 1170. Fred Rosner, a respected hematologist and medical ethicist, a professor of medicine at Mount Saini School of Medicine in NY, and his colleague Samuel Kotteck, professor of the history of medicine at the Hebrew University-Hadassah Medical School, Jerusalem, have collected papers and articles by no fewer than 20 scholars offering this  remarkable edited volume. It is a slender   and compact 229 pages chock full of historical jewels. In essence it is a biography of Dr. Maimonides, along with a description of his writings and work.

Fred Rosner’s erudite discussion in this  well researched  and meticulously referenced book shows the reader that Moses Maimonides, in his famous trilogy, The Commentary on Mishnah (means ‘repetition’), is the major source of rabbinic Judaism, the Mishneh Torah, and the Guide for the Perplexed traces much of what we know today about effective nutrition, methods of practicing CBT and biofeedback, guided imagery and self-awareness, a discipline he learned from the  work of the Persian physician, Abu Ali Sina, Ibn Sina  or Avicenna  (980-1130) and Saint Augustine of Hippo  (345-420).

In a chapter that asymptotically approaches brilliance and virtuosity, Gad Fruenden that explains how Maimonides, a citizen of the medieval age of superstition and primitive thinking, opposed astrology radically. He was quick to give credit for his enlightened thinking to Omar Khayyam, the Persian poet and astronomer, born 1085, died 1123, only eight years before the birth of Maimonides. So for all practical purposes, Avicenna, Khayyam and Maimonides were contemporaries. Although Omar Khayyam is known for his poetry and The Rubayats, he was a scientist and an avid astronomer to whose work Galileo Galilei (1564-1642) has made numerous references. Like Aristotle, Maimonides insisted on scientific objective and not speculative findings. In his book, the Guide collection of his personal letters referring to practice of medicine he wrote: “Medicine is not knitting and weaving and the labor of the hands, but it must be inspired with soul and be filled with understanding…”

Reading Moses Maimonides of Cordoba make us fall in love with our holy profession all over again, and take refuge from the oppression and intrusions of the government and bureaucrats.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association; Life Member, American Medical Association; Life Member, Southern Medical Association; and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He is a Raleigh, North Carolina writer and dramaturge and the 2016 winner of NC Award in Fine Arts.
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A Few Events…

“Monday Musings” for Monday September 10, 2018
Volume V!!I. No. 37/401

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Rosh Hashanah, Jewish Year 5779

By Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

This is a very busy week for calendars of faiths. Besides Rosh Hashanah,  the beginning of Jewish New Year, Yom Kippur, the most solemn Holy Day which this year takes place on September 18; Tishrei and Sukkot the most joyous day in the Jewish calendar are all crowded in the span of 10 days. Also, there is the Constitution Day on September 17 which most purists, like my household, consider and celebrate as a Holy day in itself. In addition, our beloved North Carolina Symphony starts its 83nd season on September 20 featuring virtuoso violinist Joshua Bell. Here ae some reflection on each occasion.

Constitution Day

The US Constitution is 231 years old.  We wish it a Happy birthday, its 231th.  On September 17, 1787, the delegates to the Constitutional Convention met for the last time to sign the document they had created. We encourage all Americans to observe this important day in our nation’s history by attending local events in your area. Celebrate Constitution Day through activities, learning, parades and demonstrations of our Love for the United State of America and the Blessings of Freedom Our Founding Fathers secured for us. If you forgot to celebrate the Constitution Day yesterday, it is not too late.  You and your family can do it today.

Rosh Hashanah, Jewish year 5779

Sundown, day after tomorrow, September 20, 2017 will mark the beginning of Rosh Hashanah. The etymology of the word Rosh Hashanah is RAAS (HEAD OR BEGINNING) AL (OF) SENNEH (YEAR or DATE), THUS ROSH HASHANAH, the beginning of calendar.  The Jewish year is 5779 (1st ofTishrei, a joyous occasion for all Jews). Some reflections:

Moses was born 1590 BC, and reportedly lived 120 years until 1470 BC. Scholarship about the birth of Moses, 3608 years ago and Rosh Hashanah, the start of the Jewish calendar 5779 years ago is very interesting. The relationship between the two dates has gone through many twists and turns. The struggles very much remind me of the struggle of C-major and C-minor in Beethoven’s Fifth Symphony, battling back and forth for attention and primacy. The final note is the celebratory C-major coming through triumphantly. The currently perceived resolution of these two competing dates is simply that it was approximately 6,000 years ago when the world’s oldest religions simultaneously began to emerge. Abram of Ur, renamed Abraham by the Lord (Genesis 17), had much to do with this remarkable emergence. We could say that this year marks 5779th year of the dawning of the human awareness of God…and the dawn of monotheism. It sends a chill down one’s spine to get in touch with human connectedness and human history. It is regrettable to neglect the fact that all of us Jews, Christians and Moslems are children of Abraham and as such should love one another like brothers and sisters.

 

Occasions like Rosh Hashanah, Yom Kippur, Islam’s Eid-Al Fetr, celebrating completion of Ramadan, the Muslim month of fasting, worship, and purgation of the soul (was observed on June 14, 2018), Easter Sunday and Purim, the Jewish Holiday that marks liberation of the Jews by Cyrus the Great (Book of Esther), collectively elevate our awareness that we are children of God and regardless of labels that separate us, we are inextricably inter-connected.  We wish everyone not only a joyful 5779 but a fruitful and consequential life. The other holy occasion is Yom Kippur which will begin at sundown on September 18, 2018.

Next week’s “MM” will be devoted to Yom Kippur and a book review on Moses Maimonides of Cordoba, the Rabbi, the formidable physician/clinician, the awe-inspiring medical researcher and discoverer, the superb medical ethicist, and the remarkable writer. Shana tova.

 Music: Mankind’s Savior

Seeing Mozart’s masterpiece, Idomeneo, in any venue, any city, and at anytime is a good reminder that Mozart was an ordinary man with all the flaws and scars of alcoholism, syphilis (from Pamena of Magic Flute), kidney failure and periodic bankruptcy, with an extraordinary and truly God-like mind to produce and write music of such complexity, architectural soundness of structure, yet immense sublimity and transcendence, that is beyond any mortal’s comprehension. The gift of Mozart is available to all lovers of music.  The memorable production of Idomeneo by the Metropolitan Opera is super special.  The unusual assembly of the international cast involved countries of Australia, England, Canada, South Africa, India, New Zeeland, and France. Our own Maestro James Levine, veteran Met Opera Music Director (now, emeritus), and now conductor of the Boston Symphony, born and raised in Cincinnati, Ohio,  who conducted the feast, was America’s contribution. The virtuous performance of the star-studded cast and Levine’s skillful directing once again proved that music is the universal language of peace, understanding and love.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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On Gun Violence

Monday Musings for Monday September 3, 2018
Volume VIII, No. 36 /401

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Gun Violence Control, Where is the Wisdom?

By Assad Meymandi, MD PhD, ScD (Hon), DLFAPA*

The former President Obama called the massacre of 20 innocent children and six adults on Dec 27, 2013, in Sandy Hook Elementary school in Newton, Connecticut, the worse day of his presidency.  History tells us that every president since GW has had a/the worse day.  For George W Bush it was September 11, 2011, for FDR it was Pearl Harbor, December 7, 1941.  All our 44 presidents have had the worse day in their presidencies.     It would be a meritorious project for some PhD candidate in history to compile a volume on every US Presidents’ worst day in the office.

We thought and hoped  that the December 27 occurrence was a turning point in the debate over guns in America.  But it was not. Last month’s deadly shooting at Marjory Stoneman Douglas High School in Parkland, Florida, was just the latest example of gun-related violence targeted at students, often by individuals not much older than themselves.  The statistics are staggering:  The first four Months of 2018 (real-time data, May 1st): -4,685 gun deaths -8,301 gun injuries -196 children shot/killed -819 teenagers shot/killed.  The numbers are logarithmically increasing and the dynamics of these violent acts are becoming more complex.

A brief review of  the history of gun violence, especially since the 1960s, might be helpful. We remember the University of Texas clock tower in Austin Texas, then in the 70s Kent State University Massacre, in the 80s. Cleveland School mass killing and the 90s several schools, including Columbine High School, mass shooting at Virginia Tech, not counting mass murders in other facilities including Sikh Temple, army bases and others, the numbers are staggering. But none was as gruesome as the Sandy Hook massacre.  Everyone seems to agree that these tragedies must end.

After the December 27, 2013 shooting, the then Vice President Joe Biden chaired a task force to examine the issue by holding extensive public hearings in which expert testimony was given by representative of American Psychiatric Association (APA), American Medical Association (AMA), American Bar Association (ABA), and forensic authorities were collected. A report was compiled but no action took place. The matter became politicized, National Rifle Association (NRA), Democrats, Republicans, Second Amendment to the Constitution all began spinning in the media. Gun control advocates brought in an extensive agenda, namely tougher penalties for ill gun sales, increased school safety programs, expanded background check for gun buyers and mandate to keep guns out of the hands of criminals and folks with history of mental illness.  Republicans and NRA saw this as unnecessary interference by government.  So a compromise was generated by Senators Joe Manchin, a Democrat from West Virginia and Patrick Toomey a Republican from Pennsylvania, focusing attention on background check. It failed.

Issues like gun violence control, abortion, and cloning carry within their constitutional DNA a huge dose of controversy. My focus in this essay is a dispassionate and analytic examination by separating the hype and hysteria from reality and data.It  is hoped that cool heads and wisdom will prevail.

In the debate of gun violence mental illness has gotten a bad rap. The alleged connection between mental illness and mass violence is not supported by objective data and science:  “substantial research shows that the vast majority of people with serious mental illness never act violently, and the vast majority of violent crimes -96 % by the best available data-is not perpetrated by persons with mental disorder” said Paul Appelbaum, Past President of APA, Professor of Psychiatry, Medicine and Law at Columbia College of Physicians and Surgeons. What we need to do is to face and design program of mental health care instead of warehousing the mentally ill in jails and prisons.

The APA position which I am advocating is to appoint a presidential commission to develop a vision for a system of mental health care, creating a mechanism for facilitating responses to key mental health issues such as designating a White House point person, improving early identification of youth with mental health problems and developing sensible, nondiscriminatory approaches to ensuring that dangerous individual cannot gain access to guns.  In his report and testimony Dr Appelbaum stated that people with mental illness who are engaged in regular treatment are considerably less likely to commit violent acts than those who need but do not receive appropriate mental health treatment.

Another expert testimony at the Vice President Task Force was Dr. Thomas Insel, the then Director of National Institute of Mental Health stated that “Suicide, not homicide, is the most urgent public health problem associated with gun violence. About 90% of suicides involved individuals with mental illness. Dr. Insel reported that “the popular association of homicidal violence and mental illness is tenuous at best..” Despite common public perceptions, there is little connection between gun violence and mental illness.  Only 6 percent of violent crimes are committed by someone with a diagnosed mental illness, as opposed to 96 percent suicides that are associated with mental illness.

What to Do?

For more than 55 years, I have been involved in various capacities with the North Carolina mental health system. At no time the services to and for our patients have been as chaotic, sparse, and erratic as they are today. Fifty years ago, in North Carolina, we had a system in place that was truly superb. At Dorothea Dix Hospital, where I received my psychiatric training, in the late 50’s and early 60’s, patients had predictable, excellent, and academically cutting edge treatment available to them with ready access. No patients had to wait for days and in some instances for weeks in emergency departments of general hospital waiting for a bed. And no patients were put in jail and prisons because of lack of mental health treatment and shortage of psychiatric beds.  We have certainly devolved and regressed.  Taking care of patient with mental illness–and really it is brain disease—is a moral responsibility about which Thomas Jefferson and our country’s other founding fathers expounded.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He is a dramaturge. Received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

 

 

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On Washington’s Ancestral Home

Monday Musings” for August 27, 2018
Volume VIII. No. 35/399

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Sulgrave Manor, a Source of Pride or Shame

By Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

Around my household, we are purists. We celebrate and observe Lincoln’s birthday on February 12, and pay homage to the father of our country, George Washington, on his natal anniversary on February 22. Today’s “Monday Musings” was written for July 4.  But it was crowded out by other topics. Apologies for being late. If a trip to England is in your future plans, please an effort to take a side trip to Sulgrave.  I visited Sulgrave on a July 4th, an eerie experience.

Sulgrave, a hamlet, population 58, houses one of the most significant pieces of American and British history, unbeknownst to many Americans and certainly British. Sulgrave Manor, the ancestral home of George Washington, the father of America, lies 14 miles southwest Northampton, a busy city of 120,000. No, you won’t find it in the Northampton city directory, nor does it appear on the county or “Shire” map. The Chamber of Commerce of Northampton politely said “We do not know, Sir” to my telephone inquiry as to the whereabouts of Sulgrave Manor. No place in London, including the eager to please Bureau of Tourism, acknowledged its existence. Like an in- house secret shrouded in mystery, it eluded my persuasive curiosity.

My host, Dr. Michael O’Brooke, a consultant psychiatrist at Saint Andrews Hospital in Northampton, almost changed the subject when I asked about Sulgrave. Somehow we ended up talking about the newly discovered oil off the Britain’s coast. Finally I pinpointed him, and demanded an answer. With his genuine English wit he snapped “Oh, yes, I will have my driver to take you there…” He made it clear in his elegant old Anglo-Saxon, non-verbal but piercing way, that he did not wish to discuss the matter any further.

I rode through the bustling streets of Northampton. It belied that it was July 4th. No picnic, no American flags and no Happy Birthday! Total oblivion of the importance of America’s birthday enveloped this industrial city which lies 70 miles southwest of London.

Finally we arrived at Sulgrave. It was a bright and sunny afternoon. A fairly short, thin gentleman whose bushy eyebrow literally covered his eyes, with graying full head of hair combed straight back giving ample space for a high forehead, looking like a character just stepped out of one of F. Scott Fitzgerald’s novels, greeted me with a simple but eloquent Churchillian deep voice: “Good afternoon! I am Mr. David Robbins, your guide.” We talked a bit. I felt like he was genuinely happy to see me breaking his loneliness, somehow reminding me of the British version of the Maytag repairman commercial.

The layout of Sulgrave Manor was elegant. Eight courtyards, a vegetable garden, and immaculately kept manicured yards and shrubs took me back 350 years. Foxglove of several colors graced all sidewalks. A British and an American flag were flying on the sides of the building. Mr. Robbins gave me a quizzical look upon finding that I might write up the Sulgrave experience for my fellow Americans. He briefly disappeared, soon to reappear with brilliantly printed brochure. He wanted to be sure that the facts were accurately reported…As Mr. Robbins and the brochure have it: the main part of the house was built of stone and he made sure I understood that it was the original structure, and not like the wooden colonial houses which were burnt and re-constructed—a mere replica—this house was built by Lawrence Washington in 1560. General George Washington was the 7th descendant of Lawrence Washington, who incidentally, was the mayor of Northampton in 1539 and again in 1545. Mr. Robbins took me around the building with utmost care, explaining that the perpetual Board of Trustees of the manor consists of the British Ambassador to US and the American Ambassador to England. The manor and the grounds belong to both countries. The cost of maintenance, conservation and purchase of pieces of land are bourn directly by both countries.

There was an air of ambivalence inundated by moments of awkwardness as Mr. Robbins’ basic loyalty to his own country and crown saw George Washington as a rebellious rash soldier with poor manners who committed an act of treason by fathering America, along with the pride that he finally acknowledged for the American experience, offered twinges of cultural/patriotic schizophrenia. Here I stood, on a 4th of July, my country’s birthday, proud to be an American and concerned about my host’s mixed feelings. I empathically told him that if I were in his place I, too, would be most uncomfortable. There was a sudden glitter in Mr. Robbins’s eyes. After so many years of working there, he had found a person who looked at and talked with him as a person with feelings. He looked me in the eyes and invited me to the afternoon tea. As we were sipping the tea he asked me about my work. “Psychiatrist” I said. “Oh Lord, I should have known not to ask…” he said in reply.

I saw not only the most proudly and secretly kept historical monument in England, but also had made a good friend in Mr. Robbins, the official host/guide of Sulgrave Manor.

Mr. Robbins and I kept in touch. He was scheduled to come to US for a visit but died of a sudden heart attack in the mid-eighties. He was 80 years old.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He is a dramaturge. Received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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My Favorite Classical Music

Monday Musings” for August 20, 2018
Volume VIII. No. 34/398

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The Joy of Classical Music

By: Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

 We are privileged to receive many letters from our faithful readers, a source of much learning and stimulation. Several readers have written to ask our opinion about our favorite top ten pieces of classical music. I found the task of picking favorites very daunting and complicated. I felt like being asked which of my children would I pick and favor. After much thought and listening with both my physical ears and the ears of my soul—metaphysical ears—here is my conclusion: Talking and writing about music and the arts is a delight to me. Thank you all who wrote and asked.

My number 1 pick is Beethoven’s 9th Symphony. It is an elegant piece of not only music, but theology, humanity and spirituality.

Number 2 is Mozart’s Jupiter Symphony in C Major.

Number 3 is Brahms’s Violin Concerto.

Number 4 is Rachmaninoff’s Piano Concerto No. 2. This amazing, technically complex with over 30,000 notes is an exercise in exploring the soul.

Number 5 is Henryk Gorecki’s Symphony No. 3  with soprano Dawn Upshaw.

Number 6 is Mendelssohn’s Violin Concerto.

Number 7 is Tchaikovsky’s Symphony Pathetique (his No.6). This was my late mother’s favorite. A word of explanation: This work is imbued with passages reminiscent of “Marsyeh”, cantorial rendition of a “joyful” mourning and grieving. What a delicious Nietzschean oxymoron! It is the closest thing to Biblical polyglossia. The music speaks in thousands of languages used by children of God from all walks of life, and all religions, all over the planet.

Number 8, Tchaikovsky’s Violin Concerto in D Major, opus 35.

Number 9: Carl Orff’s Carmina Burana and Olivier Messiaen’s Turangalila and his opera Saint Francis D’Assi  (I have had lectures and seminars by Maestro Messiaen in Paris). Robert Chapman played the opera on Classical station, WCPE, one Thursday before Easter Sunday.

Number 10: the music of Wagner’s Tristan and Isolde and Dvorak’s Cello Concerto.

Number 11: Brandenburg Concerti Nos. 1-6

Number 12: Samuel Barber’s Adagio for Strings.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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On Epigenetics…and More

“Monday Musings” for Monday August 13, 2018
Volume V
III. No. 33/397
DNA

Epigenetics, Depression Gene, Book of Genesis and Pauline Theology of Faith, Hope, Love and Redemption

by Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

Faithful readers of this space recall the article on epigenetics that defies Darwinian Theory of Evolution. Darwin asserted that it takes millennia to evolve changes in an organism. The studies of the families in northern Sweden, sparsely populated Norbotten, just six people per square mile, reveal that it takes only a couple of generations to effect evolution. The ancient biblical story in Genesis chapters 41 through 47, which describes the Egyptian Pharaoh’s dream of “seven years of plenty and seven years of famine,” prove to be relevant to the science of epigenetics and the rapid two-generation-evolution-cycle instead of two millennia. Epigenetics, a 21st century science, is the study of changes in gene activities that does not involve alteration to the genetic code but is passed down to successive generations. Many scientists including British colleague, neurologist/polymath, Raymond Tallis, the 2010 Fall Meymandi Fellow, National Humanities Center, call this phenomenon as “Darwinits.” Here is a summary of research described previously.

In the 19th century, a province in northern Sweden called Norrbotten literally experienced seven years of famine followed by good harvest and abundance of food. The feast and famine period that occurred in this sparsely populated province (only six people per square mile) has offered astonishing epidemiologic and scientific data that have given birth to the science of epigenetics. The years 1800, 1812, 1821, 1836, and 1856 (the year of potato famine in Ireland) were years of total crop failure and famine for the people of Norrbotten. But in 1801, 1822, 1828, 1844, and 1863, there was excellent harvest and an abundance of food. Scientists of the renowned Karolinska Institute, Stockholm, Sweden, have undertaken the painstaking work of evaluating this history of famine and feast to see how it affected the lives of the children born then.

They have found that “life conditions could affect your health not only when you were a fetus, but also well into adulthood,” concluding that parents’ experiences early in their own lives change the traits they pass on to their offspring. The result of the study shows that the years the children were well fed, their own subsequent offspring grew up to be healthier and physically bigger. Epigenetics makes it possible to enhance the activities of the good genes and silence and discourage the activities of the bad genes. The task is not very difficult. To chemically flip the “good” switch on, one must introduce a methyl group (CH3) to the side chain of DNA—a very simple procedure; or vice versa, to flip it off, introduce a demethylate compound to suppress the activities of the bad genes. The exciting science of epigenetics is very much like a switch on the outside of the genetic circuits and genome that influences the behaviors of a gene. The very prefix epi, which means to lie outside of the root structure, helps explains that, while not an integral part of an organism’s genetic code, epigenetics can influence the gene’s activities from the outside. Flipping the switch enhances (turns a gene on) or inhibits (turns a gene off) DNA activity.

Now we are learning that genetic configuration and longevity of a cell is very much related to telomeres. In 2009, Elizabeth Blackburn, Jack Szostak, and Carol Greider, won the Nobel Prize in Physiology or Medicine for their elucidation of the structure and maintenance of telomeres (the tips of chromosomes). These investigators discovered that telomeres are DNA sequences with a structure that protects chromosomes from erosion and that a specific enzyme, telomerase, is involved in their repair after mitosis. In daily psychiatric practice one wonders why the incidence of suicide is so high in so many families irrespective of socioeconomic and religious orientation. Here is an examination of depression.

Is there a depression gene?

Suicide of Ali Reza Pahlavi, 44 year old son of the late Shah of Iran (Jan. 4, 2011) which followed by the suicide of his sister, Leila Pahlavi in 2001, has stirred many questions regarding the genetic aspect of depression. We have known depression as a distinct clinical illness since the days of Hippocrates (460 BC-370 BC) and Galen (129 BC-217 BC). It was called melancholia with the fascinating etymology of melon, black; cholia, colon, or black bowel. The ancient clinicians thought the origin of depression was in the intestines.

It was not until the Persian physician-polymath, Abu Ali Sina (Avicenna 980-1037 AD) and Abū I-Walīd Muḥammad bin Aḥmad bin Rušhd (Averroes 1126 – December 10, 1198), and contemporary colleague, the Jewish physician, Rabbi, theologian and philosopher, Moses Maimonides of Cordoba (Rambam 1135-1204) who stirred up academic kerfuffle and forwarded the basic thesis that depression had to do with the brain and not the gut.

Rambam in 1150, not yet 25, a physician to the Muslim Caliph, described depression, obsessive compulsive disorder (Vasvas), and designed methods of treatment that we today continue to use, namely cognitive behavioral treatment (CBT). Of course, they used many herbs and botanical products. Their pharmacopeia is replete with plants, herbs and roots. Edinburgh University in Scotland, around 350 years ago, created the famous Edinburgh Botanic Garden with nearly 400 acres of plants with the single purpose of copying Avicenna’s pharmacopeia. Avicenna’s medical textbook Canon of Medicine was taught in all European medical schools well into the nineteenth century.

Sir William Osler’s writings have many references to these giants of medicine. Three learned colleagues interested in history of medicine, Mohammad M. Sajadi, MD; Davood Mansouri, MD; and Mohamad-Reza M. Sajadi, MD, of Baltimore, Maryland, have written a comprehensive article in Ann Intern Med. 2009;150:640-643. Visit www.annals.org for further details about the genius of Avicenna as a clinician, teacher, author and polymath. Avicenna’s brilliance continues to shine and give guidance to the teachers of medicine even a millennium after his death. Fast forward to present the clock of medical science and technology.

We now know that DNA provides powerful clues to understanding disease. Data from the National Institute of Mental Health strongly suggest a particular gene may increase the risk of depression. The scientists have found that people with one form of a protein that transports serotonin, one of the many mood-related neurotransmitters, are especially prone to depression when faced with traumatic events, such as alienation, loss of power, country and princely positions. The displacement is especially consequential for members of disposed royalties. In exile, these privileged children often forget their native tongue and do not learn the language of their adopted country which exacerbates the sense of alienation and social isolation. The version of the particular depression gene prevents the neurons (brain cells) from re-absorbing serotonin, which leads to feelings of sadness and negative mood and may make it harder for them to recover emotionally from a crisis. Depletion of the good juices of the brain such as dopamine, indoleamine, serotonin and catecholamine, epinephrine and nor epinephrine leads to depression.

Untreated depression often leads to poor quality of life, addiction to, abuse of, substance and other forms of self-destructive behavior including suicide. Just as there are families predisposed to paucity of brain dopamine and familial suicide, I know of many families genetically predisposed to an abundance of brain dopamine, especially in the Locus Coeruleus and the Limbic system, particularly hippocampus, the seat of memory in the brain. This is the biochemical and neuroendocrinological equivalence of Pauline theology of hope, love, faith and redemption. Fortunate folks with well-endowed dopamine circuitry face adversities and vicissitudes of life with optimism and possibilities.

Science has accumulated enough knowledge about the mechanisms of cognition, mentation and perception and their molecular underpinnings at the synaptic junctions that we can make bold advancement in the area of understanding the nature of depression gene. We reviewed the book by the learned science journalist Sharon Begly, Train Your Mind, Change Your Brain, in which she cited her work with Dalai Lama and the interest His Holiness, has exhibited in neuroplasticity. One of the strongest findings in neuroplasticity, the science of how the brain changes its structure and function in response to input, is that “it is almost magical to observe the ability to physically alter the brain and enlarge functional circuits…” We may have depression genes. But we also have a plastic brain, and chromosomes that have flexible telomere length, even making us live longer. We now are learning the molecular biochemistry and endocrinology of joy, a constant running brook of dopamine, producing Straussian symphonic poem of life.

Let it be known that joy is not the same as happiness. Happiness is the uncorking of a bottle of wine and celebrating an evanescent moment. Joy, on the other hand, is steady, permanent, and life giving. Like a running brook, it is constant and it refreshes. Joy changes the morphology and molecular structure by our brain. And these changes may be brought about by a simple change in our attitude and approach to life. Scientists have shown that by just showing purpose and determination, and by merely uttering positive words and intentions, the level of brain dopamine is raised. Think joy. Read Saint Paul’s writings and replenish your brain’s dopamine.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association; Life Member, American Medical Association; Life Member, Southern Medical Association; and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He is a Raleigh, North Carolina writer and dramaturge.

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On a Few Things…

“Monday Musings” for Monday August 6, 2018
Volume VIII, No. 32/396

Martin-Luther-Here-I-Stand3423px-Holbein-erasmus

On Magic, Memory, Wrong Diagnosis, Origin of Inoculation, and What to do for Depression

By Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

Luther and Erasmus

Recently, we observed the 90th birthday of a good friend at a luncheon. The toast was the story of Luther (Nov 10, 1481-Feb 18, 1546) and Erasmus (Oct 27, 1466 to July 12, 1536), two fierce competitors (but good friends). Erasmus who was quite a few years older than Luther was debating the existence of ‘Miracle” and “Magic” with Luther. After many exchanges of letters, with a sense of exhaustion, Erasmus tersely wrote to Luther, ”Boy, Of course there is magic and miracle. You get magic and miracle when you combine intellect and industry ” Yes, “smarts” and “hard work” produce magic and miracle…. I think Erasmus was thinking of our honoree. Happy birthday to our nonagenarian friend!

Digital Learning

Promulgation and promotion of digital learning, and creation DigiLearn as reported in news media including New York Times and the Wall Street journal are all meritorious. But idealizing DigiLearn as a powerful instrument that nurtures imagination as opposed to memorization that discourages imagination is a disservice. This view is scientifically flawed and untenable. In neuroscience and neurobiology, we know that those areas of the brain, including the limbic system, association cortex and nucleus coeruleus that are responsible for memory and storing of information are strengthened by memorizing facts. The same centers are also responsible for strengthening the power of imagination, creativity and innovation. These centers work together to enhance both memory and imagination. Memorization complements and enhances imagination. Please do not malign memorization and do not deprive our children from receiving the gift of knowledge through activating the memory centers of their brain. All the computers and artificial intelligence floating around will never replace memorizing epic poems of Homer, Dante, Faust and Milton.

Homage to the late Dr. Charles Krauthammer

I usually agree with the opinions of my respected colleague turned journalist, the late Dr. Charles Krauthammer. His style shaped by his training as a physician, to cut through symptoms and look for the correct diagnosis(es) and cause(s) of America’s ills, is most gratifying. But his recent syndicated column in Washington Post and other papers “An Action Plan to Stop Putin”, while making recommendations to cure our current ills do not go deeply enough to make the correct diagnosis before offering suggestions and remedies.

The basic problem with America’s repeated failures in foreign affairs is that our European and Middle Eastern allies no longer respect the office of American Presidency or the current person who occupies the post. I hear derogation, mockery and condescension from ordinary citizens of foreign nations about US presidency. We should address that basic malady before offering remedies.

The Origins of Inoculation and Vaccination

For the readers who are contemplating to travel to Turkey, here is a historical aside: It is about Turkish women of many centuries ago. It explains the character and intellectual capacity, with Baconian and Lockian power of inductive reasoning and empirical observation of Turkish women of the middle ages. These women were most likely illiterate. The story has to do with inoculation against smallpox. These women observed that they can sell their daughters into slavery for a higher price if they were unmarked by the scars of smallpox. They noted that mild cases of smallpox provided lifelong immunity to the disease and limited the scarring. So they exposed their young daughters to benign cases of smallpox. This practice was carried out hundreds of years before Louis Pasteur (1822-1895) and Robert Koch (1843-1910) introduced inoculation and vaccination to modern medicine. Voltaire while exiled to England in Les Lettres philosophiques has written extensively about powers of observation, inductive reasoning and empirical knowledge.

Treating Depression with Good Thoughts

Worth reading. I will be writing about how empirical data are showing that good thoughts, good words and good deeds Zarathustra’s Motto) not only elevate mood and restore dopamine levels of the brain, but actually changes the morphology of the brain. This is the essence of Eshgh, the Sufi love. Thinking good thoughts suffuses brain with good hormones like dopamine and indoleamine…Exciting stuff to think about and write about….POSITIVE PSYCHOLOGY.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He is a dramaturge. Received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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Monday Musings” for Monday August 6, 2018
Volume VIII, No. 32/396

dr-michio-kaku

Michio Kaku

 

Book Review: Michio Kaku’s “The Future of the Mind”

By: Assad Meymandi, MD, PhD, Sc D (Hon), DLFAPA*

The Future of The Mind

342 pages of text
10 pages of meticulously indexed notes relevant to each discussion
61 pages of index
Doubleday Publishing Company, Inc.
New York, London, Toronto, Sydney, Auckland

Review of Science Books Series

When a publisher sends a book for review, I routinely cast an editorial “screening” glance to separate substance from fluff by noting the book’s proportion of text to notes, bibliography, and index. A scholarly and substantial book usually carries an extensive set of notes and references for documentation of almost every line of the book. A high volume of notes and an extensive bibliography assure the reader that the book is not fluff. Such is the book “”The Future of The Mind” by Dr. Michio Kaku, Professor of Theoretical Physics at the City University of New York (CUNY). The book’s subtitle is “The Scientific Quest to Understand, Enhance, and Empower the Mind”. The book does all that and more. Faithful readers of this space recall our review of books by psychiatrist Eric Kandel, 2000 Nobel Laureate in Physiology or Medicine, “The Emergence of the New Science of Mind”, Stephen Hawking’s book “Standing on the Shoulders of Giants”, 1989 Nobel Laureate in Medicine or Physiology “Retroviral Oncogenes”, by Harold Eliot Vamus, and many others. This book is a continuation of the series on science.

First, a word about the author:

As you see in the picture, Michio Kaku is of Tibetan descent. His grandfather immigrated to the United States to work in the cleanup efforts following the devastating 1906 earthquake in San Francisco. Dr. Kaku was born on January 24, 1947, in San Jose, California. He first became attracted to science as a young child, and while a student at Cubberly High School in Palo Alto, he famously built an atom smasher in his parents’ garage. He eventually landed at Harvard University, where he graduated first in his physics class in 1968. From there it was on to the University of California at Berkeley, where he worked at the Berkeley Radiation Lab and earned his Ph.D. in 1972. The following year Kaku lectured at Princeton, but not long after, the Army drafted him. He was trained as an infantryman but was spared combat when the Vietnam War ended shortly before he was scheduled for deployment.

“The Future of the Mind” is Kaku’s ninth book. In my view he is a symphonist like Beethoven, Shubert, Mahler, and others, with nine symphonies. I think this, his latest book, is very much like Beethoven’s Ninth. It is not just plain physics, raw science and equations, but an intellectual celebration of possibilities. The book carries with it spiritual and artistic messages. For example, in the chapter about Einstein’s brain, the author speaks of plasticity of the brain, refuting the past notion that brain does not grow. He brings in subliminally Pauline theology of redemption, possibilities and hope. Brain grows…brain matures…brain gets bigger…brain gets “smarter”…

The volume consists of an acknowledgment listing the names of 11 Nobel Laureates, followed by six and a half pages that contain the names of luminaries in science, technology, nano-technology and journalism. They include Ann Druyan, widow of Carl Sagan of Cosmos Studio and John Donoghue, creator of Braingate (see below). Physicians acknowledged include Francis Collins, Director of the National Institutes of Health (University of North Carolina Medical School alumnus) and many bioethicists and environmentalists. The acknowledgment clearly reflects the author’s vast contacts. It also presents his humility and humaneness. The acknowledgment is followed by an introduction and three books.

Book I:

The Mind and Consciousness, and his viewpoint of consciousness;

 Book II:

Mind over Matter deals with mental telepathy, and telekinesis, and moving objects by will through thoughts and memories. It offers explanation about  Einstein’s brain with the promise that we can be smarter, and our brain can grow. He gives the example of a 2011 study that analyzed the brains of “London’s famous taxicab drivers who have to laboriously memorize 25 thousand streets in the dizzying maze that makes up modern London. It takes three to four years to prepare for this arduous test, and only half of the trainees pass. The brains of the cab drivers who successfully passed the test were studied several years after the test, and it was found that the brains of the taxi drivers who passed the test successfully “were bigger and grown in volume.” He proposes while geniuses are born, brain’s capacity to grow and become “smarter” is undeniable. The evidence of plasticity of the brain and its capacity to grow, presented in Book II, are most exciting. This is where I make the connection between Kaku’s science and Pauline theology of hope, redemption, and possibilities. This is where I hear Beethoven Ninth’s message of joy belonging to human race…

Book III:

Altered Consciousness elaborates on a most attractive and comprehensive tour de force of artificial intelligence, mind as pure energy, and finally, the future of the mind. The protean nature of the topics discussed in Book III reflects the author’s vast interests and penetrating curiosity. It has meritorious discussion on the diagnosis and treatment of depression. He cites the work of Dr Helen Mayberg and colleagues at Washington Medical School. Using brain scans, they identified an area of the brain, called Brodmann area 25 (also called the subcallosal cingulate region) in the cerebral cortex that is continuously hypoactive in depressed individuals. Deep brain stimulation (DBS) has astonishing results in relieving depression. Of course, clinically, we reserve this approach for those patients who are treatment resistant and do not respond to pharmacotherapy and psychotherapy.

The chapter on telekinesis illustrates cosmologist Stephen Hawking, a victim of Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig disease) whose many books we have reviewed in this space (the latest was “Standing on the Shoulders of Giants”) wore a neuroprosthetic device attached to his glasses with a special feature. Like an Electroencephalogram (EEG or brain wave test machine), it could connect his thoughts to a computer to maintain some contact with the outside world.

These neuroporostheses have profound effect on improving the quality of life of ALS patients, and of those who are quadriplegics, such as stroke victims. He cites the heart rendering story of Cathy Hutchinson who was “trapped” in her body, quadriplegic, for 14 years as the result of a massive stroke. Brown University scientist John Donoghue and colleagues placed a tiny chip on the top of her brain called Braingate (see above reference to John Donoghue) which is connected by wires to a computer. By simply thinking, she gradually learned to control the motion of her arm so to grasp objects.  Her thoughts or intentions are translated into action. This is the nearest thing to a modern day miracle.

The book looks into the future of artificial intelligence (AI) and its possibilities. The work of futurist Ray Kurzweil who received his PhD at MIT under Marvin Minsky, one of the founders of artificial intelligence, is cited. Dr. Kurzweil has predicted that by 2019, a $1000 PC will have the computing power of the human brain—twenty million billion calculations per second. He proposes that this number was not grabbed out of thin air. It is obtained by taking the one hundred billion neurons of the brain, multiplying one thousand connections per neuron, and two hundred calculations per second per connection.

As an aside, it might be useful to say a few words about the new age of connectomics.  We have had genomics, proteomics, and now we have entered connectomics which is the field of study of connectomes, and production of comprehensive maps of connections within an organism‘s nervous system, typically of the brain. These maps are being developed and studied with enormous speed. Harvard biologist Jeff Lichtman has devised a contraption, connecting a giant electron microscope to Magnetic Resonant Imaging (MRI) and functional MRI (fMRI) taking pictures of the connections of the neurons in the brain. The number of connections is astounding. It is in the trillions. Now back to the prediction of futurist Ray Kurzweil:

By 2029, a $1000 PC will be a thousand times more powerful than the human brain and the work of futurist Kurzweil;

By 2055, $1000 of computing power will equal the processing power of all human brains on the planet.

What is most impressive, this book, Kaku’s ninth which I call his Ninth Symphony, just like Beethoven’s Ninth, gives the reader a sense of transcendence and elevation. Like Beethoven’s Ninth, listening to the celestial voices of the Chorales singing “Freude, Tochter of Elyzium, deine Zauber binden weider was die Mode stren geteilt; alle mencchen werden Bruder who dein sanfter weilt.” “Joy, daughter of Elysium, your magic again units all that custom harshly torn apart, all men become brothers beneath your gentle hovering wing”, in Kaku’s latest book, I felt like I was floating among myriads of angels of hope, comfort, promise and beauty. Who knows, Kaku might be related to Beethoven or maybe Dali Lama. Reading Kaku elevates Augustinian awareness of the gift of our brain, this 2.5 pounds of mystery given to us for free, a sheer act of grace. We must enjoy discovering our brains by learning more and more, the highest form of joy. The latest work of Michio Kaku The Future of The Mind is all music and no noise. I highly recommend it to readers of all ages.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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“Monday Musings” for Monday July 23, 2018
Volume VIII No. 30/394

siredwarddownesandwife

Sir Edward Downs and Lady Joan

THINKING THINGS THROUGH:
Assisted Suicide

By Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

(Editor’s Note: Jerry Brown, California Governor, a former Jesuit seminary student, finally got around to singing legislation approving and legalizing physician assisted suicide in his state of California. This calls for celebration. Celebration ought to come after cerebration and awareness of what is at stake. For that reason we are reprinting a ‘Monday Musings’ to further think about and advocate the cause. Other states that have this law on their books are Oregon and Washington. Since writing of this article Vermont has joined the ranks. We hope that by domino all the rest of US will emulate these progressive states and adopt laws to offer physician assisted suicide and death with dignity. Will NC be next? We hope so.)

I know this is the quadrennial issue of “Monday Musings”. I know we should break out the champagne and give cheers. However, important medico-social issues beckoning the practice of medicine prevent us from that luxury. A few years ago, an event took place that has profoundly affected me personally. The passage of time has helped to calm the emotions which now are transformed into an intellectual challenge. The event was the death of a friend I most admired and loved. He was the gifted, knighted, and holder of the rank of Commander of British Empire (CBE), conductor Sir Edward Downes. He was 85. The lives of both his and his wife, Lady Joan, were shortened by design. Here is the story:

Sir Edward was partially deaf and completely blind, suffering from terminal illnesses and failure of multiple organs including heart and kidneys. His wife Joan, 74, had terminal cancer and was in a great deal of pain requiring enormous quantities of narcotics and opiates. They wanted to take their lives, but the British law does not provide for such plans. Therefore, they travelled to Switzerland where the law on assisted suicide is the world’s most liberal. Their son and daughter watched them as they drank a lethal dose of barbiturates and died while holding hands.

In most of the Western world, suicide is not a crime but helping another to commit suicide is a crime. Not all the incapacitated, terminally ill, or permanently disabled patients are willing to wait for a natural death. Nor are they willing to take the messy and uncertain measures to kill themselves without medical help. Increasingly they travel to Switzerland, often with members of their families, to seek assistance in terminating their lives. In Switzerland, assisted suicide is a crime only if it is done for gain. However, there are strict rules and guidelines as to who qualifies. Belgium, the Netherlands, Luxemburg, and the American states of Oregon and Washington are a few places in the world where assisted suicide is allowed. People who go to Switzerland to receive assistance for suicide are often called suicide tourists.

The history of assisted suicide in England is interesting. In every case of assisted suicide police investigate the suicide thoroughly. Over one hundred cases, including Sir Edward and Joan, there have been no prosecutions of those who accompanied the seeker of suicides. In the case of Sir Edward, Joan, their son, and daughter, no slippery slopes of misdeed and no conspiracy have ever been uncovered. Nonetheless in England, July 2009, a law to guarantee exemption from prosecution of those persons who accompany suicide tourists was defeated. Likewise, it is the case in the United States. The laws are strictly against assisted suicide. Our readers recall the case of pathologist Jack Kevorkian who was sentenced to 25 years of imprisonment and but was freed on parole (he died in 2011). He defied the law and assisted terminally ill with lethal doses of drugs.

It is not suggested to do away with the existing laws without thoughtful debate. The laws are designed to protect the elderly against avaricious shuffling and coercing older relatives off to die before they wasted their assets on nursing home fees and depleting their inheritance. In addition, granted, many terminally ill suffer reversible depression. In my own daily practice of geriatric psychiatry, I see many elderly who suffer from reversible depression. They need to be treated and returned to enjoyable life. However, we have adequate diagnostic skills to separate those who are depressed from those who are terminal and close to death. We should allow the patients of this category to die quickly and peacefully. We also have enough linguistic skills to frame a law that clearly offers guideline to achieve these goals. Studying the laws of Netherlands, Switzerland and Belgium could be helpful (I have copies of these laws and would be happy to share with readers.) A law of this sort would have allowed the esteemed, honored, honorable, the famed composer and conductor, Sir Edward Downes and his wife, Lady Joan, to die as they wished in their own country and in their own home. Physicians and organized medicine, such as American Medical Association (AMA) and American Psychiatric Association (APA) should bring this matter to the forefront of public consciousness.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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On Parkinson’s Disease

Monday Musings” for Monday July 16, 2018
Volume VIII. No. 29/393

Science Series
No. 87

j_parkinson

          James Parkinson

Parkinson’s Disease

By Assad Meymandi, MD, PhD, ScD (Hon), DLFAPA*

(Editor’s Note:  The response to the last week’s column on Alzheimer’s disease was unprecedented. We thought it appropriate to offer a follow up on another debilitating brain disease, namely Parkinson’s disease. This conludes our six part sries on Brain and Behavior,  First a brief history:

Parkinson’s disease (PD) was originally diagnosed by James Parkinson, a British neurologist in 1817. We do have evidence that as early as 12 century BC, Egyptians knew about the disease and wrote on papyrus about a king drooling with age. Also the Bible contains a number of references to tremor. An Ayurveda medical treatise from the 10th century B.C. describes a disease that evolves with tremor, lack of movement, drooling and other symptoms of PD. Moreover, this disease was treated with remedies derived from the mucuna family, which is rich in L-DOPA. Galen wrote about a disease that almost certainly was PD, describing tremors that occur only at rest, involving postural changes and paralysis.

In 1817 James Parkinson published his essay reporting 6 cases of paralysis agitans, An Essay on the Shaking Palsy, that described the characteristic resting tremor, abnormal posture and gait, paralysis and diminished muscle strength, and the way that the disease progresses over time. He also acknowledged the contributions of many of the previously mentioned authors to the understanding of PD. Although the article was later considered the seminal work on the disease, it received little attention over the forty years that followed. Nevertheless, early neurologists who made further additions to the knowledge of the disease include Trousseau, Gowers, Kinnier, Wilson and Erb.

Of all these early diagnosticians the most important was Jean-Martin Charcot whose studies between 1868 and 1881 were a landmark in the understanding of the disease. Among other advances he made the distinction between rigidity, weakness and bradykinesia. It was Charcot who championed the renaming of the disease in honor of James Parkinson. In America, there are more than four million patients afflicted with this dreaded and deliberating disease.

James Parkinson (1755-1826) was a polymath. He had vast academic interest in all branches of science, including, geology, environment, medicine specializing in neurology and diagnostics  He held several doctoral degrees. He held strong views of social issues as an activist, and argued with the then British Prime Minister, William Pitt, in support of universal suffrage. His 1817 seminal paper on the topic of paralysis agitans continues to be used to describe Parkinson’s Disease, the clinical features of which are intention tremor, and others listed below.

Diagnosing Parkinson’s s disease is through observation.  It really does not require a million dollar workup to make the diagnosis.  Here are some of the signs and symptoms:

Tremor or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson’s disease is a tremor of your hand when it is relaxed (at rest).

Slowed movement (bradykinesia). Over time, Parkinson’s disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move.

Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can limit your range of motion and cause you pain. Exercise both aerobic and anaerobic is important to fight rigidity.

Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson’s disease.

Loss of automatic movements. In Parkinson’s disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.

Speech changes. You may have speech problems as a result of Parkinson’s disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than with the usual inflections.

Writing changes. It may become hard to write, and your writing may appear small (micrographia)

 Brain Lesions

The research neuroscientists who work on the brain talk a lot about neurological diseases such as Alzheimer’s Disease (A-D) and Parkinson’s Disease (PD) as the proteins in the brain become misfolded. This misfolding phenomenon occurs with tau protein and “goo”/amyloid junk-like stuff by misfolding the amyloid cluster into larger plaques. The plaques kill the brain cells. In (PD) the protein called alpha-synuclein clumps in similar fashion. Other protiens called prions clump in conditions like mad cow disease which is a form of animal PD.

Basic Facts of Brain Structure and Function

Way back (and down) approaching the spinal column sits the brain stem. It is an important part of the brain that produces neurohormonals and chemicals that are responsible for sleep. Much research is concentrated on brain stem to find a safe sleeping aid for billions of people who have sleep disorder. Another part of the brain which is responsible for being awake and alert is the thalamus. A third important structure that plays a majorrole in PD are the basal ganglia (plural for ganglion). In PD, the structure of the basal ganglia is attacked and erosion takes place. Again, the destruction is by misfolding of alpha-synuclein protein.

Treatment is basically by use of anticholinergic drugs, L-dopa or L-dopa like chemicals and dopamine agonist (re-enforcers). Physical exercise is very important in the management of PD. More recently electrical stimulation of the brain has gained ground. If you do have PD, please devote yourself to exercising.  Neurology literature recommends boxing–yes boxing–the abhorred pugilistic sport, as a very helpful treatment for Parkinson’s Disease. And if you do not have PD devote yourself to exercising, anyway.

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*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He received Raleigh Medal of Art in 2001, inducted to Raleigh Hall of Fame 2013, elected Lifetime Trustee, North Carolina Symphony in 2015, and 2016 recipient of NC Award, Fine Arts.

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