On Forgiveness

 

“Monday Musings” for Monday September 11, 2017
Volume VII.  No. 37/349

saadi

Saadi

ON FORGIVENESS

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

Today, September 11, 2017, coincides with the 16th anniversary of the brutal attacks on America.  The attacks were a series of four coordinated areal insurgence by the Islamic terrorist group al-Qaeda on the United States on the morning of Tuesday September 11, 2001. The attacks killed 2,997 people, injured over 6,000 others, and caused at least $10 billion in infrastructure and property damage.  It was a brutal attack on our beloved nation,  The attacks destroyed people and properties but they did not destroy the soul of America.  The National September 11 Museum and Monument are there as eloquent testimony of America’s resolve.  A few reflections on forgiveness:

About a year ago, a 77 year old man came to see me about gradual onset of a devastating depression. Harry (not his real name), always a positive, energetic and productive person, had lost his will to live. He told me that he was experiencing a gnawing sensation at the pit of his stomach. He could not sleep, had lost his appetite causing him to lose a considerable amount of weight. His wife confided in me that she was afraid that “Harry would end it all.” She had carefully removed all firearms from home. This, in itself, caused further escalation of Harry’s anger and irritation. We evaluated Harry and ran appropriate laboratory tests to rule out myriad of physical causes for his depression, including endocrinopathies such as hyperparathyroidism often caused by a parathyroid adenoma, a benign cancer of the parathyroid gland, and others. By the way, this was the cause of the  late US Senator from North Carolina, John East’s depression and suicide, a perfectly curable form of depression by surgery).

In the course psychotherapy, exploring his past and family history, we came across a demon. He casually mentioned that he has not seen eye to eye with one of his sons. As a matter of fact, he became angry that we were spending so much time on that unimportant lost relationship. In the course of therapy, the issue of forgiveness was bought up and explored. Harry took the matter seriously. He had 40 years worth of anger for his estranged son. Finally, as our work progressed, he chose to approach his son. The miraculous process of forgiveness rapidly assisted his total recovery. He became well and was terminated, and his medications were gradually discontinued. In the Christmas card I received from him and his wife, they were thankful to discover the powerful effect of forgiveness. Harry is back enjoying life, being positive, energetic and productive. This process prompted me to write the following essay on “Forgiveness.”

Some Thoughts and Reflections on Forgiveness:

In the ten thousand year annals of Neolithic man, the issue of forgiveness vs. revenge occupies considerable space.  Since Sumerians’ earliest recorded history, the contributions of three stars in the intellectual constellation guide us with their luminosity and brilliance. They are St. Augustin of Hippo, born in 354, the author of City of God and Confessions; Moses Maimonides of Cordoba, born in 1137, author of Talmudic Laws; and Ibn Khaldoun, who penned the definitive Islamic Cannons in 1363 (born 1332, died 1405).  Throughout their work, all three have spoken of grace, stoicism, altruism and forgiveness in the most compelling and persuasive manner. Some believe that the Lord’s Prayer, especially the passage: “Forgive us for our trespasses as we forgive those who trespass against us”, a staple of Christianity, and the only actual piece of literature ever authored by Jesus of Nazareth, is a hand me down from Zoroaster, the 500 BC Persian prophet and author of Avesta, and Abraham. It has been vastly copied by other major religions of the world, namely Judaism, Christianity and Islam. The celestial books of Torah, the Bible and the Holy Quran, each have hundreds of references to the issue of forgiveness and peace. A celebrated Persian poet and Sufi, Sheikh Mosleh-e-Din Saadi Shirazi, born 1210-1290, in his book, Gulestan-e-Saadi, refers to this subject with the most tender words:   “Forgiveness heals, comforts, transforms, preserves, remembers, promises, buries the dead and raises them once again.  Forgiveness refuses to be quiescent until all possibilities have been exhausted.”

Psychologically, forgiveness is altruistic and selfless. Forgiveness does not mix with self-centeredness and narcissism. It takes discipline and selfness to be able to forgive. God created us with the gift of forgiveness, compromise and peace. With recent stunning advances in biochemistry and neuroendocrinology, we have come to know that forgiveness plays a major role in preserving the function and the architecture of our brain, our hearts and our souls. Brain research, in the last half of the twentieth century, clearly demonstrates that feelings of enmity, adversity and anxiety produce undesirable and harmful hormones, specifically beta carbolines and the bad kind of catecholamines that increase blood pressure and heart rate; decreases immune response, and lowers the number of precious T-cells that fight infections. On the other hand, data driven seminal articles in peer reviewed medical magazines such as Archives of Internal Medicine, Lancet and New England Journal of Medicine demonstrate that forgiveness, peace and a sense of spirituality decrease blood pressure, sharpens body’s immune response and lengthens life span.

One of the most overworked words in English lexicon is the word “communication”. It has almost lost its meaning and effectiveness. The tools necessary for achieving the nirvana of forgiveness are understanding and empathy, both of which are achieved through communication, talking, sharing feelings and ideas. Forgiveness is not achieved through virtual reality. Two people must see each other, talk to each other, and possibly touch each other before forgiveness takes place. One must have not only a sense of sympathy for the other person’s pain and discomfort, but empathy, to feel the pain that the other person is experiencing. There are many alienated children, parents, and in laws who fall prey to this circuitous labyrinth of hatred, intolerance and “I will not say a word to that person as long as I live” diatribe. To hate, to resent, and to avoid wastes enormous emotional energy aimlessly directed at draining, depleting and destroying.

The evil acts of September 11, 2001 have posed an unprecedented ethical challenge. How do we, as a decent and civilized nation, respond?  These events have clearly demonstrated that the answer to world ills does not come solely through advanced technology and inflated stock market values. America is the most decent and generous nation on earth. The supremacy of the rule of law, and not of kings, Shahs and Ayatollahs, guaranteeing every American the dignity of individual human right, is unprecedented.

However, In the 1950s, with lingering cold war and the age of Sputnik, America accelerated programs of science, math, and technology. While these advances are essential, we are just beginning to learn that the ultimate answer to the world’s problems lies with better understanding of ourselves and those who hate us. In this terror driven world, we must resolve to learn more about ourselves through introspection, reflection and self- examination. As an act of thanksgiving, it might be a good idea to dedicate ourselves and a portion of our time to be more prayerful, more reflective, more knowledgeable, and more altruistic. Also, it is a good time to go see and call on those family members and friends whom we have long resented. Let’s replace the beta carbolines of our brain with endorphins and dopamines.

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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 Dreams and Mental Health

Monday Musings for Monday September 4, 2017
Volume VII.  No 36/348

on-the-couch

On Dreams, Psychoanalysis and Neuroscience

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

Interest in dreams goes back to Sumerian recordings some 8,000 years ago. There are abundant references to dreams in Torah, the Bible, the Holy Quran, and other celestial books, such as Avesta, the book of Zoroaster, written 500 BC. But it was not until early last century, when Freud published his work on understanding and interpreting dreams, that a firm connection between dream, memory, and “mental” history began to evolve.

Fast-forward the clock. Neuroscientific interest in dreams started in 1953 with the discovery of rapid eye movement (REM) sleep by Aserinsky and Klietman, taking psychophysiologic findings of dream into the realm of biology. There are many exciting discoveries in the area of psychoendocrinology of dream and memory coming out through many sources and laboratories both in the United States and abroad. In fact, an article by Mauro Mancia, the enormous sage of the Italian academia, neurobiologist, and psychoanalyst, was recently published in the American Journal of Psychiatry entitled, “The Role of the Interrelation Between Serotonin (5-HT), Muramyl Dipeptide, and Interleukin-1 (IL-1) in Sleep Regulation, Memory, and Brain Regulation.”

This brings me to a most interesting read: Psychoanalysis and Neuroscience, which was edited by Dr. Mancia. Dr. Mancia is Professor Emeritus of Neurophysiology, University of Milan, Italy, and Training Analyst of the Italian Psychoanalytical Society and has written extensively on the subjects of narcissism, dreams, sleep, memory, and the unconscious. This particular work by Mancia, Psychanalysis and Neuroscience [Springer, 436 pages, 2006] is organized into four parts that propose a link between neuroscientific knowledge and psychoanalytic theories of mind.

Overview

Part I—Memories and emotions. Part 1 of the book consists of eight chapters written by experts in their respective fields and examines one basic message: Memories stand out and last longer when they are accompanied and highlighted by emotional experience. The message conveys the importance of interconnection of memory with emotions. With scientific detail and elaboration, the authors demonstrate the proteins in the amygdala and hippocampus are responsible for retention of memories, which are parts of the limbic system that is, overall, responsible for housing emotions, denoting the common neuronic pathway for memory and emotions. It was Paul D. McLean in the 1940s, while mapping specific components of the limbic system, who invoked the romantic notion that the limbic system is “the anatomy of emotions.”

Part II—The shared emotions. The second part of the book examines the sensorimotor side of “empathy pain,” the role of the anterior cingulate cortex in affective pain, and social cognition and response to embodied stimulation.

Part III—The dream. The third part of the book, which is perhaps the most exciting, deals with the dream in the dialogue between psychoanalysis and neuroscience. One chapter dissects the neurobiological and psychoendocrinological anatomy of dreams and memory formation. In recalling events of the past as practiced in psychoanalysis, the brain’s physiology and even anatomy and morphology stands to be changed. This part of the book reminded me of another significant book recently published, Train your Mind, Change your Brain, in which author Sharon Begley, a Wall Street Journal neuroscience reporter, showed how thinking can change the brain functionally and anatomically.

Part IV—The fetus and the newborn. Part IV discusses fetal behavior. While the word embryology is seldom used, the authors of these two chapters examine in detail the onset of human fetal behavior and the neurophysiologic impact and influence of nursing on the early organization of the infant mind.

Discussion

With the knowledge that the basic instrument in the discipline of psychoanalysis is recall of memories, dreams, and transference, the 21 contributors to this book make a good case as to why there should be a robust and constant conversation between psychoanalysts and neurophysiologists. It is time for these disciplines to learn about and from each other. The book’s contributors invite readers, in the most scholarly and convincing manner, to consider that psychoanalysis is a powerful reservoir of volumes of memories and should integrate resources with neurophysiology and enjoy the mutual fertile and rich products. It is the expressed purpose of the book to further elaborate and understand the relationship between memory, dreams, and neurobiological changes occurring during the experience and the course of psychoanalysis. This holy partnership is encouraged, and the book’s contributors, like priests, are willing to bring about this holy matrimony to the world of science.

The downside of the book is that it is a rather difficult read, likely owing to the fact that it is a translated work. I do not know how much education on psychoanalysis and neurophysiology the translator, Mrs. Judy Baggott, has had. To a linguist, such as myself, who is conversant with a variety of Eastern and Romance languages, the slip of the translator shows fairly frequently. Her skirt should be longer! However, this minor flaw should not dissuade anyone from tackling this enormously informative and scholarly work.

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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 Obesity

Monday Musings” for Monday August 28, 2017
Volume VII. No. 35/347

General practitioner measuring waist of obese patient

General practitioner measuring waist of obese patient

THINKING THINGS THROUGH

The Moral Dimensions of Obesity, A Form of Severe Self-Abuse

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

 (Editors’ Note: Today’s ‘MM’ is a letter to an imaginary man of cloth or religious leader, giving us an opportunity to explore a very important social, religious, and health issue, namely obesity).

Dearest friend, man of cloth:

I consider you a combination of pastor, theologian, scholar-teacher-artist with the intellectual gift of balance and reason. So, from time to time, when I am exercised about some issue (the latest was the unacknowledged repeated errors of translation in the 1611 King James Bible) I bring it to you.

As a practicing physician and teacher with added interests in the arts, Christology/Christendom and theology, I have been thinking especially in the past couple of years “How Christian love influences and relates to our health?”.

I know that Christian love clearly teaches us not to be abusive to one’s self, to one’s fellow humans, and not allow others to be abusive to us. Yet we have this ominous epidemic of obesity that is rapidly deteriorating into a pandemic. We abuse ourselves by eating too much and not exercising. The cost of medical care is approaching 20% of America’s gross domestic product (GDP) most of which is spent on preventable disease stemming from obesity.

We go through excuses blaming obesity on various “glandular,” “metabolic,” “ovarian cyst,” as causes. And as of late, the biggest fraud perpetrated by my own medical profession is “genetics” is blamed to make us fat. Of course, genetics does have a place in illness, but it does not excuse gluttony. And we, the doctors and the medical profession, are not sanguine either. We have coined a new disorder, “Metabolic Syndrome” that seems to provide fat people with more excuses for laziness and lack of discipline. Blaming genes is an additional way of making excuses. Admittedly, science shows that genetics plays a role in obesity. Genes can directly cause obesity in disorders such as Bardet-Biedl syndrome and Prader-Willi syndrome. However, they are so rare that they do not register in epidemiologic radar screen. In some rare cases, multiple genes may increase one’s susceptibility to obesity but require outside factors; such as abundant food supply or little physical activity. Another emerging source of blame that I often hear in my practice is finger pointing a member or members of the family, sons, daughters, spouse, or parents. As the late comedian Flip Wilson used to say ”the devil made me do it…” There is no denying that people suffering from obesity need compassionate treatment, understanding, and love. But a serious national conversation should address the deadly epidemic of obesity. And perhaps it should be initiated in our religious institutions by our religious leaders. All said and done, the bottom line is very simple: taking in more calories than are expended accumulates fat. Keeping trim is a personal responsibility.

Traveling through Africa, Rwanda, Somalia, Ethiopia, Eretria, Ghana, Uganda and Sub-Saharan countries, one seldom sees a fat person except for the rulers and government officials, the members of the oligarchies. The new figures published by the US Health and Human Services are frightening. In the US, 80 million are pre-diabetic, with borderline elevated blood sugar and high basal metabolic rate (Basal Metabolic Rate—BMR–of 28 or above.) This figure is substantially more than previously estimated. Add this to the 51 million already diagnosed diabetics and you see that the population is floating in a sea of unused sugar. In the same report, HHS points to the alarming prediction of increase in future incidence of diabetes type II. The rate of increase is not linear, it is not logarithmic. It is exponential.

Type II diabetes has three causes 1) push button easy and sedentary life style. 2) abundance of food and 3) seductive ads on TV and other media. But the over-arching cause is lack of discipline.

The sad part of this life threatening, abominable and expensive illness that often leads to complications of hypertension, cardiovascular disease, blindness, kidney failure and early death, is that it is altogether preventable (except for Juvenile or type I diabetes, which constitutes a very small percentage of the cases.)

Diabetes is a behavioral disease. It may be prevented by controlling one’s weight and by daily rigorous exercise. Patients with type II diabetes are typically morbidly (twice normal weight) obese and have a scripted set of problems in common: bad back and musculoskeletal pain, irritability, slowness and depression, bad heart, high blood pressure and high incidence of addiction to either tobacco and/or alcohol. And they walk around with shopping bags full of medications given by their well-meaning physicians, a pill for each symptom.

Let me make one exception: Patients with psychiatric disorders including schizophrenia who are on psychotropic and antipsychotic medications, especially the third generation antipsychotics such as Risperdal and Zyprexa are vulnerable to pronounced side effect of obesity which they cannot control.  These unfortunate patients require more compassionate care, supervision and rigorous dietary consultation to prevent obesity and heart disease.

Now, my question: what are the church or organized religion’s responsibility, duty and obligation to eliminate this epidemic? And what are the Diocese, the State, the National Council of Churches and other religious organizations are doing to ensure that the clergy is not fat? Is it not un-Christian, unloving and blasphemous for the clergy, the role models for congregations and the moral and ethical leaders in our midst not to have the discipline of trimming down and staying slim? I am glad to report that organized medicine and the doctors have taken impressive strides in this area. You see very few fat physicians walking around!

I would really appreciate your reply.

Sincerely,
Assad Meymandi

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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 Music, and a Play

Monday Musings” for Monday August 21, 2017
Volume VII, No. 34/346

260px-Johann_Sebastian_Bach220px-AugustStrindberg

J.S. Bach, by Haussmann                       August Strindberg

Brief Reflection on Bach’s Music  and

Review of  “Miss Julie”, A Remarkable and Consequential Play

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

I.  Bach’s music: I have been asked frequently by friends, especially those friends in mourning for the loss of a loved one, why Bach’s music is so comforting. Here is a brief refection:

Dear Friends:

The evocative question exploring the magic–no, I should say the miracle of–Bach’s music, is joyful to contemplate.  I believe Back’s music is based on the fundamentals of conceptual and structural framework of fugue. In music, fugue is the well-defined contrapuntal compositional technique. A fugue subject is delicately balanced with musical agons that struggle to rhythmically produce not agony but friendship and love. The very formidable skill of producing harmony and love from agons, as Bach has achieved in his hundreds of compositions from, is a miracle.

To understand the mystical appeal of Johann Sabastian Bach’s fugue, one must consider and review the etymology and onomastics of the word fugue. The English term fugue originated in the 16th century is derived from the French word fugue, or the Italian, fuga. This in turn comes from Latin. Also fuga, which is itself related to both fugere (“to flee”) and fugare (“to chase”). The adjectival form is fugal. Variants include fughetta (literally, “a small fugue”) and fugato (a passage in fugal style within another work that is not a fugue).

So, the keyword is flee, and fleeing. Fleeing from what and to what? With his powerful spiritual mission, JSB composed his music suggesting that we flee from the mundane and to, the holy house of transcendence. As a matter of fact, in psychiatry and neurology we have ambulatory states of altered consciousness that is diagnostically called fugue. But medical fugue is a world apart from musical fugue. Yes, I magically flee from the mundane and enter the epistemic threshold of transcendence every time I listen to the music of Maestro JSB.  Thank you dear friends for sending me the pieces by Bach, especially his Matthauspassion, composed in 1727, forgotten but discovered by Mendelsohn in 1829.  We owe Mendelssohn much for this noble deed. My humble prayers are with all the mourners.

Love Joy and blessings,
AM

II.   Review of Miss Julie (Editor’s note: A Raleigh theater performed Miss Julie a dozen years ago.  We are told that it is returning to the stage. It is a remarkable play.  Here are the program notes I wrote for the playbill).

To appreciate and understand this sober and pedagogically significant play, Miss Julie, one must realize that it was written in 1888, in the then very conservative northern European country of Sweden. The country was imbued by the late 19th century Victorian mentality, morality, and social restrictions which permeated the entire of Europe. This was the age where tablecloths had to be long enough to cover the legs of the tables, lest sexuality and eroticism were inferred. It was also, the dawn of existentialism. Soren Kierkegaard, a Danish theologian, philosopher (1813-1855) had already laid the foundation of dealing with “here and now” of which human sexuality was an essential part. Then came Fredrick Nietzsche (1844-1900), who reinforced the notion of confronting the erotic issue head on. In Nietzsche’s biography there is a very passage relating his attending the opera Carmen 23 times, and proclaiming that every time he saw the opera he became a more informed person, a better philosopher and a more consumer of erotic mystic. Existential thinking and vigorous writings continued by Martin Heidegger (1889-1976), and later ushered into the 20th century by Albert Camu (1913-1960) and Jean-Paul Sartre (1905-1980). The roots of this play go even farther in history. It goes back to the “Axial Age”, roughly 200 to 900 BC when diverse philosophical thoughts such as Hinduism, Buddhism, Confucianism and Taoism formed the nucleus of humanities and theater as we know it today.

Miss Julie was a revolutionary play when it opened in 1888. It is in a way like Ricard Strauss’ Salome bringing out all the ugly but realistic side of erotic sex, class, murder and death and laying it on the table. Miss Julie remains one of the foremost naturalistic dramas of all time. It was a groundbreaking work that heralded a new era in modern theater, as Strindberg advocated a lack of intermissions, the use of real props and natural light. It culminated with all the elements of the era’s existentialism, eighteenth century theatre, and opera verismo, along with heightened revealing honesty and iconoclastic class barriers. Today, over 120 years later, the play still has major relevance and emotional impact. Critics believe that it is an amazing play that “still terrifies with its insoluble equation of sex, class and death.” The play offers a synopsis of human psychosexual development, examines the pedagogic succession of human affect, behavior and mental content of the landscape of unconscious.Some historians and dramaturges believe the play carries a good bit of the playwright’s own life and biography.

Born in Stockholm, August Strindberg (January 22, 1849- May 14, 1912) was born to a woman who was twelve years younger than his father. She is identified as a “servant woman” in the title of his autobiographical novel, Tjänstekvinnans Son (The Son of a Servant). The humble background heavily identifies him with Jean in the play.  This speculation is reinforced by the fact that his aunt Lisette was married to the English-born inventor and industrialist Samuel Owen. The entire family was socially ambitious. They wanted to break out of the social class restraint and enter higher rungs of the society. For example, August’s brother, Johan Ludvig Strindberg became a successful, wealthy businessman. It has been seen as the model for the main protagonist Arvid Falk’s wealthy and socially ambitious uncle in August Strindberg’s novel Röda Rummet (The Red Room). August became a very successful writer, wealthy by the late 19th century standards. Many argue that his autobiography should be taken with a grain of salt, because it is perhaps more a reflection of his ambitions of where and what he wanted to be, or what he wished for his readers and viewers  perceived him to be. And he had the talent and verbal skill as a writer and orator to succeed. He was a diluted Swedish version of our Samuel Clements. Many refer to him as the Mozart of the letter. He wrote over one hundred books, plays, essays, scholarly dissertations and poems. I remember seeing his portrait in Stockholm’s subway, and his statue by Carl Eldh, which graces one of the major squares of the city. He died from cancer, age 63, in Stockholm.

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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 Puccini

Monday Musings, August 14, 2027
Volume VII,  No. 33/

La Scalla

La Scala

Opera Season is Coming: Some Random Thoughts

Giacomo Puccini:  A Personal Glimpse

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

This is not a scholarly dramaturgical and psychoanalytical critique of the Western opera.  But I thought it would be fun to offer some random thoughts on several popular operas primarily those created by Puccini.  No, I am not an authority on Puccini and his compositions.  Many scholars and psychobiographers of Puccini,  including the renowned music critique Joseph T Kerman, while enjoying Puccini’s music, refer to it as cheap, vulgar and anti-intellectual.

Personal observation:

I love Puccini’s operas and his music. I grew up with vivid stories and memorabilia of giants, like Puccini, Rimsky-Korsakov, Rachmaninov, and Aram Khachaturian, etc., who had visited my hometown of Kerman.  We had hand-cranked phonographs playing the music of these giants which filled the halls and our living quarters with their music.  I remember, as a child, almost every night my mother read the stories of A Thousand and One Nights to me as Korsakov’s Scheherazade played in the background.  Often, my mother, a high palate amateur signer, herself, would belt out and sing along.  Growing up in a rich environ where music, words, languages and prayers were prominent, was most gratifying.  My mother, whom we all called Jambeebee, the “reigning lady of the world”, died in 1994 at the age of 101.

Brief biography of Puccini and Onomastics of Turandot:

Giacomo, ok, Giacomo Antonio Dominico Michele Secondo Maria, was born in Lucca, Italy, on Dec 22, 1858 to a well to do family.  He completed his studies at Milan Conservatory, 1880 to 1883.  He composed 12 operas.  His first, Le Willis in 1884, was a flop (so were Verdi’s firsr few operas including Oberto, conte di San Bonifacio and Un giorno di regno).  Puccini’s last, 12th opera was Turandot, a most brilliant work that to some surpasses the magic of Verdi’s Aida, by the way,

Onomastics of the word Turandot

Turan means China. Dot, short for dokht means daughter.  So Turandot means daughter of China or a Chinese young lady,  Puccini and his able librettist, Alfano, while researching material for Turandot, went to Persia after WWI, the purported birth place of the Unknown Prince Calaf, the hero in the opera.  Legends have Calaf born in and raised in Kerman, Persia, my hometown.  Finally, with collaboration of his faithful librettist, Pianist Franco Alfano, he started to produce the opera. Unfortunately, he died in 1924, leaving Turandot unfinished.  But the power of friendship and fidelity prevailed.  Alfano, completed the opera.  it was staged in 1926.

A brief history of Puccini’s 12 operas:

Tosca was Puccini’s seventh opera sandwiched between his other two enormously successful operas, La Boheme and Madama Butterfly. Tosca is in three acts. Puccini started composing it in 1895 and completed it by 1897. It is a story of love, despair, resolution, unselfishness, hope and redemption. Tosca has been in the repertoire of opera houses around the world, and continues to be a “work horse.”  I know that Palais Garnier, the Paris Opera House has performed it more than 300 times in its 305 years of existence. Sicily’s. The Palermo Opera House, Teatro Massimo is the best place to view Puccini and Rossini operas.  La Scala Di Seta, had Tosca in the repertory scheduled tis coming fall.

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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 the State of US Healthcare

“Monday Musings” for Monday August 7, 2017
Volume VII, No. 32/344

 240px-Duke_Chapel_4_16_05

Duke Chapel

America’s Health Care System is a Mess

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

There is one constant thread that runs in all of the Socratic dialogues and that is: Socrates always asked his interlocutors “what do you do? What are you selling? How are you making a living?  And above all, how are you measuring your success?”  I think the master’s method of 2300 years ago, is applicable to today’s American medicine.  We really do not know the value of our treatments to our patients.  We do not know how to measure health gain.  All this result in less focus on improving health and more on minimizing cost.

Medicaid expenses are bankrupting the county governments, especially small rural counties throughout NC and the nation.  Medicaid cost is eating into education and public health budgets.  Medicare rules conceived by what appears to be chaotic minds of a group of bureaucrats known as health policy makers, running around with no direction, are crippling to the practicing physicians who are taking care of patients. The focus is to contain and minimize cost.  No attention to improving health.  We are an illness-oriented system.  We need to become or be transformed to a health-oriented system.

In a book generated by Washington DC’s American Enterprise Institute, “The Diagnosis and Treatment of Medicare”, authors Andrew J Rettenmaier and Thomas R. Saving describe the ills of Medicare and seek solution to the problem.  In fairly intelligible and clear language, much of this 179 page book’s 14 chapters is spent on outlining the two basic problems with the Medicare system:

1)  Medicare simply can not afford to provide coverage for elderly health coverage, especially with the baby boomers approaching retirement age.

2)    There are no limits on payment of claims submitted to Medicare by health providers and clinicians.  The system lacks rigorous accountability and transparency.

3)    The system lacks means-testing.  A Mr. Rockefeller, if 65 and over, may not pay for his care out of his pocket.  He is obliged to go through the system and file papers for his treatment.  Means-testing is a very useful instrument to lighten the burden on Medicare.

At the end, the book does not offer any serious and systematic solution to the Medicare system that is universally known and agreed upon.  America’s health care system is like a patient in an Intensive Care Unit (ICU).

I submit that the ultimate solution is to focus on health and the turn the medical care system to a huge public health/prevention machine.  Prevention should be paramount in medical curriculum, medical practice and medical clinics.  Like Socrates, we need to constantly ask ourselves what is it that we do, how can the efficacy of what we do be measured, and how can we avoid the slippery slopes of medical profession becoming a commodity, business or industry?

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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

“Monday Musings” for Monday July 31, 2017
Volume VII. No. 31/343

Science Series
No. 87

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James Parkinson

Parkinson’s Disease

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

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. 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) the 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 excercising. And if you do not have DP 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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On Alzheimer’s…

“Monday Musings” for Monday July 24, 2017
Volume V, No. 30/342

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Alzheimer’s Disease, The Latest

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

Science Series
No. 86

Alzheimer’s Disease is a heart breaker. In spite of mountains of research we do not have any answer to this merciless killer.  Some reflections,  but first a bit of history:

Brief History:

Alzheimer’s disease is the most common form of dementia (forgetfulness/inability to recall) that afflicts more than 100 million worldwide, and five million in America. The dementia-causing brain disorder is named for its discoverer, German psychiatrist and neuropathologist Aloysius (Alois) Alzheimer (1864-1915). The first case of Alzheimer’s disease was, of course, presented in the form of a scientific paper to the Conference of Southwest German psychiatrists in Tubingen, Germany, on November 4, 1906.

Dr. Alzheimer discovered little bits of goo, starch-like substance, the chemical composition of which we now know to be amyloid, accumulated around the nerve cells (neurons) in the brain. These bits grow and coalesce into bigger pieces called plaques and later on neurofibrillary tangles, all of which disrupt the works of the brain which are primarily memory, intellectual functions, such as thinking, and communication. As the result, nerve cells die (are choked to death) and the brain literally shrinks in volume. The patient with Alzheimer’s disease experiences loss of memory, both for recent and distance events, as well as deficit in perception, mental processes, cognition and comprehension in a progressively worsening mode, until the patient dies. Alzheimer’s disease is a slow but major killer. In mid to later stages, the Alzheimer’s patients do not even remember or recognize their children and other close members of the family.

Clinical course:

Alzheimer’s disease is brutal. It robs the afflicted of experiencing joy, communication, and connection with life. The patient turns into a zombie. Most important loss is loss of dignity and nobility of the soul preceded by urinary and fecal incontinence. We now have five million Americans suffering from this disease (worldwide over 100 million). It is more prevalent in women because of female hormonal and body chemistry. There may be accompanying mood disorder, such as depression, or behavior disorder such as violence, and thought disorder, such as paranoia and delusions.

Interpersonal relationship, let’s say between a husband and wife, is based on ability to talk (communication). Talking is about communicating memories of the past, plan for the future and enjoyment of here and now. After attending a party, we chit chat about whom we saw at the party and who said what…And plan for the future, trips, vacations, grandchildren, etc.  With Alzheimer’s all this is taken away in a brutal and irreversible manner. Conversations are reduced to asking and answering the same questions limited in scope and variety, repeatedly, randomly and aimlessly. The “conversation”/exercise soon becomes exhausting. In Alzheimer’s disease, meaningful communication, the central alchemy of relation and love, is one of the first things to disappear.

Diagnosis and treatment:

Diagnosis is through neuropsychological testing, mental status examination and brain scans. Besides magnetic resonance imaging (MRI), we now have other radiological instruments such as positron emission tomography (PET scan) and functional MRI (fMRI) that not only visually demonstrate existence of the plagues and the amyloid bits, but can measure the physiological function of the brain. It is now well known that Alzheimer’s-related changes in the brain begin 10-15 years or more before people show signs of detectable memory loss. Scientists at University of Pittsburgh and the Johns Hopkins University have developed a BIOCARD, which study and predict onset of the disease in volunteers through long term monitoring and testing. Therefore, diagnosis leads to a treatment course primarily consisting of brain exercise by reading, memorizing, classical music, doing crossword puzzle, Sudoku puzzle, and through physical exercise and activities, staying socially active, interactive and engaged.

Chemical Treatment:

In the past few decades, we have had a number of chemicals, among them Aricept and Namenda. These drugs are designed to fight the progression of the disease and bring symptom relief. In essence they slow down the deterioration of the brain, but, unfortunately, not very successfully. More recently, a new group of drugs–the Zumab family of drugs—have been introduced with the promise that they attack the plaques directly by dissolving and removing them from the brain. They belong to a group of chemicals called monoclonal antibodies. Their expected function is to just like a chemical vacuum cleaner get in the brain and sweep away the goo, the plaques and the neurofibrillary tangles. The Zumabs (category of chemicals known as monoclonal antibodies) supposedly  are those chemical vacuum cleaners. The first one of these drugs Bapineuzumab which is still in trial has not shown glorious results. The fuss last week in Washington, DC was over another drug from the same family, Solanezumab, a drug made by Eli Lilly & Co. The first clinical trial of the drug is near completion, and the preliminary results offer some promise. More and bigger clinical trials are on the way. Now, critics, pharma pundits and stock market analysts alike, are awaiting with bated breath the results from Solanezumab- the second antibody-based vaccine drug marketed by Eli Lilly, currently in clinical trials. The hopes and dreams of a worldwide population of nearly 100 million (and growing) people with AD rides on these trials. A lot of money rides on these trials, too, given that the number of people with AD is steadily growing. The profits for any company that comes up with a reasonable drug for AD would be unimaginable. With all the hype in last week’s global conference on Alzheimer’s Disease, it remains unclear how Solanezumab will fare in subsequent clinical trials. Hot on the heels of the failed Bapineuzumab  trials, the Solanezumab trials carry the burden of possible failure and extra scrutiny.

Personal Thoughts, Not Only As A Practicing Psychiatrist, Teacher, But As A Care Giver: 

It was a distinct privilege to care for a beloved afflicted with Alzheimer’s (unfortunately, she died eight months ago). The opportunity to be exposed to deeper strata of love is unique and instructive. One learns patience, compassion, and care—feeling for—the victim with relentless constancy. There is nothing like experiential learning…However, personally, I believe that with the American ingenuity, and the vast resources of a mature capitalist society at our disposal, we will find a cure for Alzheimer’s.  Remember in 1981 when the first case of auto-immuno-deficiency syndrome  (AIDS) was diagnosed. In the 80s and 90s, tens of thousands died because of AIDS. Well, again this past week, at another scientific meeting re: AIDS, the speakers including our own Myron Cohen of UNC School of Medicine and Health, were talking about not only control of AIDS and minimizing mortality but curing AIDS. We are today with Alzheimer’s where we were with AIDS in the mid-1980s.

I am reminded of St Thomas Aquinas (1205-1275) view of science: “Believing is good. Knowing is better.” What a privilege to be alive today, especially in America, and enjoy the experience of explosion of knowledge.

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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 Medicine

Monday Musings”  for Monday July 17, 2017
Volume VII, No. 29/341

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Thinking Things Through: Health Related Issues

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

(Editor’s Note: we are sharing  a  few of our letters to mostly medical publications)  

I Journals of Consequence

For about the half of a centruy that I have dwelt in the holy house of science and medicine, I have been most intrigued, gratified, enchanted and awe stricken by three publications.  I read them faithfully, and keep them all over the house and in my office.  These publictaions print articles by future Nobel Prize winners.  You can bet on the next crop of Nobel Laureates in science, medicine, chemistry and physiology by carefully reading these journals.  No, they are NOT the New England Journal of Medicine, not Lancet, not JAMA, and none of the Archives or the Scandinavian Acta series…

Well, you are anxious to know their names.  They are ScienceNature and Cell.

More recently, a fourth journal has joined this elevated pantheon-like club.  It is the Journal of Stem Cells.  Articles such as “Generation of Insulin-producing Islet-like Clusters from Human Embryonic Stem Cells” bring the reader hope, awe and fascination. the authors report the use of  embryonic stem cells to form clusters like pancreatic islets that make insulin in measurable, if not abundant amounts.

Wow!  We are really getting there.  I would like to be alive in 2040 to see how medicine is practiced!

Assad Meymandi, MD, PhD, DLFAPA
Raleigh, N.C.

II Mental Exercises Counter Chemotherapy

I am writing with regard to the excellent article “Cognitive Damage May Appear After Treatment Ends” in the January 5 issue.

Being a survivor of colon cancer, stage III with 11 nodes, and having gone through the ritual of “cutting” (surgery), “burning” (radiation therapy), and “poisoning” (chemotherapy), I can attest to the danger of drastic decrease in cognitive functioning with standard cancer treatment. The chemotherapy agents “carpet bomb” all cells; they do not spare the very sensitive neurons. I wish research would accelerate on finding chemotherapeutic agents that target cancer cells only and not the rest of the body.

As a patient, it is imperative to be aware of this cognitive devastation and devise and implement measures to counter the poisoning of the brain and killing of brain cells. My strategy was to devote an hour or two each night before going to bed to memorize material of interest. I memorized many of Lorenzo Da Ponti’s rich repertoire of Latin poetry, Greek texts by Aristotle and Homer, and the epic poetry of Persian poets Ferdowsi and Rumi.

In my experience, memorizing is a very effective method of keeping neurons exercised and alive, and I felt I was successful inwarding off the ills and side effects of my treatment.

Assad Meymandi, M.D., PH.D., DLFAPA
Chapel Hill, N.C.

III Marketing Advice Article Desecrates The Proper Practice of Medicine
Regarding “Creating buzz: New approaches to Marketing”:

I disagree with the content, intent and suggested practice of “marketing” one’s practice reflected in your article. Medicine is not a commodity, it is not a business and it ought not to be regarded in mere secular terms. Medicine is a priesthood, and those of us privileged to enter its holy temple should take vows of service and altruism, above all. The idea of promoting business in medicine and having a business model of advertising one’s services is a desecration of what Sir William Osler taught.

In recent years, we have seen the lofty position of physicians eroded in American society. I believe if a physician is knowledgeable and skillful, and combines those earned attributes with compassion and a spirit of service, advertising is not needed. People will flock to your door without the slick and ethically challenged manners your article suggests.

Let us not desecrate the holy house of medicine with commercial and cheap schemes.

Assad Meymandi, MD, PhD, DLFAPA
Raleigh, N.C.

IV More On The Unwelcome And  Ugly Word of “Marketing” in Practice of Medicine

Dear Sir:

I am appalled by your article in the “Business” section of AM News.  Once again, with total disregard for the dignity of our profession of Medicine, the sanctity of its calling and priesthood of its mission, you have lowered the practice of medicine to the level of selling a commodity, dealing in a business, and reducing it to a common place “thing” that you pick up at a store on your way home…

Medicine has enough detractors and enemies that are dedicated to stripping it form the respect it deserves.  We do not need for AM News, a newspaper that is the official public face of American medicine, to further push us to the brink.

I believe we must do all we can to preserve and protect the dignity of our profession and discourage advertising.  It is an abomination and a literal prostitution of our profession when we join with a bunch of merchants who push their goods.  In practice of medicine, if we are knowledgeable and compassionate; if we follow the holy teachings of Sir William Osler and strive for excellence; patients will tear our door down and seek us out.  Soliciting, advertising and merchandising our skills and art are foolish and should not be tolerated by AMA, much less touted as you do in your Business articles in AM News.

Sincerely,
Assad Meymandi, MD, PhD, DLFAPA

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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 the Pride, or Shame, of Heritage

Monday Musings” for July 10 2017
Volume VII. No. 28/340

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Sulgrave Manor, a Source of Pride or Shame

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

Around my house, we are purists. We celebrate and observe Lincoln’s birthday on February 12, and pay homage to the father of our country on his natal anniversary on February 22. Today’s “Monday Musings” was written on July 4, 1973 after a visit to Sulgrave Manor in Northampton, England, and has been reprinted every year since.

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 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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