Portrait from Asclepiad 1987 (University of Arizona College of Medicine yearbook).
By Dale D. Dalenberg MD
June 17, 2014
There have been four great mentors in my professional life. They are: Leonard Peltier MD PhD, Marc Asher MD, Edward H. Simmons MD, and William H. Pickett JD. As a group I owe them my career in orthopedics, any modicum of respect and credibility I have as a practicing physician and as a medico-legal consultant, and the inspiration to be what pale shadow of a Renaissance man that I can hope to be. Today, I exist professionally on the crossroads between the arts & the humanities, clinical medicine, and that zone of overlap between medicine and the law. Without the inspiration of these four great men, I would never have had the notion to try to combine all that in one life.
I owe a great debt to Dr. Peltier, who is quite simply the main reason that I am an orthopedic surgeon today. I met him when I was a third-year medical student (1985-86) at the University of Arizona doing a rotation in orthopedic surgery at the Tucson VA Medical Center. Peltier was at that time the elder faculty member in orthopaedics at Arizona, having recently stepped down from the chairmanship of orthopaedics and handed that job to his former resident Bob Volz. He was shortly to be saddled with the designation of Acting Head of Surgery, which is a job I don’t think he sought out but which was thrust upon him. In that brief window of time when he wasn’t head of anything, he found time for teaching students, and part of that was weekly teaching rounds at the VA. I remember that a commotion ran through the orthopedic ranks of residents and students as the hour approached for Peltier’s visit. It was as if a visiting dignitary were coming. We were admonished to be on our best behavior, to pay rapt attention, and to speak only when spoken to. I was immediately enthralled by him. He was erudite, impeccably bow-tied, and seemed like one of the medical gods that I had worshipped in all my reading about famous doctors up to the time I entered medical school, which included names like Jenner and Lister and Pasteur. It’s actually a good thing I’d done all that reading, because that’s how Dr. Peltier got to know me, how I stood out of the crowd to him, and why he wrote me that all-important letter of recommendation to the program (University of Kansas) that enrolled me as an orthopedic surgery resident.
My medical school classmates clearly got the message that I was an immediate convert to the Leonard Peltier, MD, PhD, fan club. I was definitely a Peltier follower after those VA rounds. In my medical school year-book, Asclepiad (1987), my classmates wrote the following caption under my senior portrait: “A disciple of the Leonard Peltier school of charm, Dale would give anything to inherit Dr. Peltier’s bow tie collection. His serious demeanor suggested to many ill-fitting underwear, when in fact he long suffered from an overdose of Ingmar Bergman films. Having fathered a son, and thus rediscovered the Wonderful World of Disney, a full recovery is expected prior to beginning Ortho at Kansas.” My classmates were perceptive about my attachment to Peltier, my study of the arts along with medicine, and they predicted the day when I would be co-authoring this arts blog with that same son referenced in the yearbook, Alexander David Dalenberg. Due to my middle-aged spread, the underwear is still ill-fitting, but I am much less serious these days than the yearbook entry would suggest.
Anyway, about Dr. Peltier, and how he noticed me enough to recommend me for a residency:
Peltier’s Big Thing was the history of medicine. Granted, he wrote a lot of original scientific papers, some 200 of them, most notably about fat embolism syndrome, but his great passion was history.
When we students were all standing at the scrub sinks washing our hands (at his behest) before entering a VA ward, he asked the group why we were doing what we were doing (namely, handwashing.) After an unpleasant silence by the group at large, I could not contain myself any longer, so I blurted out the answer: Ignaz Semmelweiss. And I proceeded to relate the story about how Semmelweiss, without knowing anything in those days (circa 1847) about bacteria or infectious organisms, figured out by sheer epidemiological reasoning that women on the obstetrics ward at his Vienna hospital were dying from exposure to “cadaver particles” that were being taken to the maternity ward by the medical trainees doing autopsies, whereas the women on the midwives’ ward were only rarely getting “childbed fever” because the midwives’ didn’t go to the morgue to do autopsies. Semmelweis also noticed that women who gave birth in the street also rarely died. Semmelweiss instituted a policy of handwashing and slashed the death rate (unfortunately, the medical establishment didn’t believe his research, and Semmelweiss spent the rest of his life railing against the ignoramuses and murderers who were allowing the women to die for want of proper handwashing; Semmelweiss died in an insane asylum and his research wasn’t resurrected until decades later after Pasteur and Lister had popularized the “germ theory” of infectious disease).
When I related this story on the orthopedic ward at the VA, Dr. Peltier was silently impressed. Peltier was rather lofty from the students’ perspective and seemed very un-approachable, so his silence was widely mis-interpreted. I remember that Bradley Brainard (a resident at the time) assumed Peltier’s intent had been to stump us all, and he whispered in my ear that Peltier was pissed off that I knew the answer. However, the fact is that Dr. Peltier never forgot who I was after that. When I asked him later for a recommendation letter for my orthopedic residency applications, he was eager to help. Thus Dr. Peltier kick-started my orthopedic education and career, and I am forever grateful to him for that. I used to hesitate to say hello to him at the American Academy of Orthopaedic Surgeons annual meetings, where I would run into him even after he was fully retired and Dr. Volz had started replacing his joints. I always thought he would have forgotten who I was, but he always remembered.
The thing I loved most about Peltier was his Renaissance quality. He was never focused on the picky little details of orthopedic surgery, but rather he conveyed a sense of the over-arching place of modern orthopedics as it existed in the context of historical medicine. And on the clinical side of things, he propagated the message that orthopedics did not exist in a vacuum, but that the orthopedic problems of a patient existed in the context of a greater world of general surgery and an even greater world of the whole organism. Peltier was one of those giants who used to populate the orthopedic world, but have since become a vanished breed, who were trained as general surgeons and only later specialized as orthopedists. I loved going to the orthopedic radiology conference with Peltier presiding. A typical Peltier tactic was to get an unsuspecting student in front of the crowd and show him a pelvis radiograph and ask, “What systemic disease does this patient have?” You were supposed to scrutinize the radiograph and notice the vascular clips in the lower corner of the film from saphenous vein harvest for coronary artery bypass, and you were supposed to say something like “atherosclerosis” or “coronary artery disease.” Peltier didn’t want to hear about the pelvis—he wanted you to glean from the pelvis radiograph something more general and more important about the whole patient.
About the time I was finishing my orthopedic surgery residency, Peltier came out with his two fine, illustrated books, one on the history of fractures, and the other one on the history of orthopedics. I couldn’t afford them at the time, but I have since made up for that with the financially successful career that Dr. Peltier made possible for me. A small corner of the Dalenberg Library today is devoted to historically important medical books, and Peltier’s two volumes (that I have since acquired) are a fine addition to the Library, right alongside the books Peltier himself would have wanted me to read–like Mercer Rang’s pediatric fracture book and Henry’s Extensile Exposure, to name just a couple from Dr. Peltier’s era.
A couple of things impress me as I read back through Fractures: A History and Iconography of Their Treatment (1990) and Orthopedics: A History and Iconography (1993). Nowadays, the orthopedic literature is preoccupied with economics. We read about the economic impact of total knee arthroplasty and lumbar discectomy. We read about the lack of efficacy of non-operative spine care and spine surgery as related to the public policy burden of paying for it. But historically, the quest was more directed at defining disease and the solutions to disease. One senses that expensive, but not always efficacious, technologies (and—perhaps–expensive doctors commanding six-, bordering on seven-, figure incomes) have changed the dialogue and buried good science. In Dr. Peltier’s books, we can experience a refreshing return to a more innocent time when there were problems to be solved, like tuberculosis of the bones and joints, like infantile paralysis. The other thing that impresses me about Dr. Peltier’s books is the vast expanse of orthopedics that existed BEFORE arthroscopy and arthroplasty. These days, entire careers are spent doing only arthroscopy or only arthroplasty (in many sub-specialty practices), but those two disciplines merit barely a chapter out of the two books, and only the infancy of each are touched upon. It is humbling to realize what a vast and varied field is orthopedics, and how little of it any one of us modern orthopedists really has a grasp upon.