The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
There's a saying in poker circles: never play against someone with lots more money than you have. The American Revolutionary War can be thought of as just that sort of poker game. The British could afford to lose what they lost, while somewhat smaller debts were quite enough to overwhelm the French. The cost of any war is a guess because it cannot account for death and destruction it provokes. But after a few years, it could be observed the British were holding the British Empire, while the French were left with the desolation of their own revolution. The Americans held most of a continent, free and clear, in return for their sacrifices, although their physical sacrifice was the greatest of the three main war participants.
Pierre Augustin Caron de Beaumarchais,
Leaving the British aside, much of the money paid for the war passed through the hands of Robert Morris and Pierre Beaumarchais, so in one sense they paid for at least the munitions part of the war. At the time, Beaumarchais was penniless from a lawsuit, so he was a judgment proof manager of a dummy corporation, Rodriguez Hortales et Cie. The real payors were the French Government of 1 million livres, the Spanish Government of 1 million, and 1 million from several adventurous individuals. On the American side, Robert Morris was often personally responsible for defaults, as a result of the Continental currency made worthless from printing-press inflation. In a dramatic moment, Morris stepped forward and announced he and a few friends would stand behind the debts. Not only was Morris a wealthy man, but he was largely running the United States government. Among other considerations, he had a fairly good chance of inducing the government to raise taxes to pay its own debts before he would have to assume them. Many people doubted that ability, however. Even Morris' wealth would have been insufficient to carry the whole burden, so the guarantee he made must be seen as a form of default insurance or credit default swap, containing a high degree of risk. Regardless of details, if Great Britain won the war, both Morris and Beaumarchais would have been impoverished, and probably imprisoned. The main difference was that Beaumarchais was already broke.
Morris never forgot the message, that the real security backing the loans was the wealth of the North American continent. That's what America gained by winning, and that's what it would have lost if England won. If you win a war, buy real estate.
Although they seem to have the same design, employer groups don't fit the ACA plan very well. You will notice in current reports of 20% boosts in the individual health insurance contracts because of the Affordable Care Act, there was scant mention of employer groups. Their rates are negotiated privately, and usually at lower rates. They usually pay a different share of subsidies, too. In fact, it can be easier to deal with a plan with no subsidy at all, than with one which requires fitting several partial pieces together. Employer groups are often further subsidized by state and federal income tax deductions, with puzzling circular dependence. Employers make young employees subsidize older ones, while the ACA emphasizes rich ones subsidizing poor ones. (Young employees are seldom richer than older ones, so there's a mismatch, somewhere.) Young employees think of buying protection against unexpected illness, while older employees think of buying necessities at what they hope is a discount.
Some employed subscribers then find they are better off switching to Medicaid, which has historically been quite substandard. Others conclude their health risks cost less than the penalties for having no insurance at all. Some genius may be able to reconcile these issues, but at some point, it seems better to start over. An important fact to remember: many poor persons are eligible for Medicaid, but haven't applied for it. That's a job the hospital social worker usually supplied in the Accident Room as they were being admitted. When it was decided to give ACA insurance to poor people, this awkwardness suddenly surfaced, in the form of implicit subscribers who were sicker than was planned for.
Mixing the subsidy with the service package usually causes trouble, lumping too many sick people with too few well ones.
In the case of the Affordable Care Act, a fear is raised, a migration away of either subsidized or low-cost clients would raise the premiums of those who remain. The suggested compromise emerges that if government subsidies are resorted to, they should be unwrapped from the service delivery package, and funded independently. So long as the subsidy is distributed by the same criteria for everybody, it might pass muster. To emphasize: mixing the subsidy with the service package usually causes trouble; confusing too many sick people with too few well ones, has often proved to be a disaster.
Since Health Savings Accounts were begun independently of subsidies, they sometimes face the unjustified taunt they "do nothing for the poor man." If equal subsidies were distributed, the subsidy issue could become independent of the type of health care someone happens to have. It's too bad this wasn't examined from the beginning since it definitely hampers the Affordable Care Act more than it helps it. Competition paradoxically does the opposite, no matter how hard that is to accept.
If you want to extend the same health subsidy to the HSA as is extended to ACA, go ahead, but stop using the addition of subsidy as a reason to prefer one payment system to the other, or one proposal to another.
Our culture is reluctant to subsidize poverty, for fear of encouraging it. We are somewhat more willing to subsidize poverty caused by addiction, but prefer to subsidize it less than poverty caused by other diseases, like blindness -- once again, because we are afraid we might encourage self-inflicted conditions. But hierarchy doesn't always stop with different diseases; we might prefer to subsidize one race, one region, or a whole host of other conflicting preferences. Nevertheless, it seems definitely better to subsidize individual poverty -- as such -- than to get into quarrels about the relative shamefulness of causes for health poverty, or the politics of their funding. My present conclusion is: if you want to extend the same health subsidy to the HSA as is extended to ACA, go ahead, but stop using the addition of subsidy as a reason to prefer one payment system to the other, or one political party's proposal to another. Hidden in that preference is the delusion it is easier to control politics than the marketplace.
Perhaps, poverty should be treated as economists treat unemployment -- a net absence of affluence, imitating unemployment as a net absence of employment. That says it might be temporary, which is not implied by saying it's a class of people or a particular form of thinking. The Biblical description once implied both unemployment and poverty were two classes of society, quite likely permanent ones. But that was hundreds of years ago and in a foreign land. A small demonstration program in several states might clarify whether this difference of viewpoint might actually lead to an improved subsidy approach. For a long while, I thought eliminating poverty would eliminate the sense of being poor. But it doesn't. Somehow we must get over the idea that the way we were born is the way we must remain, overlooking the plain fact that just about everybody is going to live thirty years longer, and that's generally a good thing. In fact, it's hard to think of anything most people would rather spend money on, than longevity.
Superstition" is defined by the dictionary as "a notion maintained in spite of evidence to the contrary." This might be paraphrased as "an obstinate belief in something that is probably not so." It is quite impossible to define the words "health" and medicine" in any compact compass, but I think that we can reasonably well understand each other in their use. Please keep in mind though all my talk that definition of superstition "a notion maintained in spite of evidence to the contrary," I hope that you will not carry away with you the idea that I am a sadistic iconoclast, that I delight in destruction for the sake of destroying. I have great respect for ancient faiths and popular beliefs, for they often contain a golden kernel of precious truth. I could give you many examples.
I saw a most interesting one in a textbook on obstetrics published about one hundred years ago. In a footnote about the care of the navel in the newborn, the writer says-- "some midwives believe that if the sheers used to cut the cord is first heated before the fire, and if the cord is then covered with a piece of scorched linen, it (the cord) will heal kindlier. He then adds, "I can see no reason for such belief." We know now that the doctor was wrong, and the midwives right, for by these procedures the sheers and dressing were partially sterilized. They had properly observed cause an effect but had not thought the matter through. I once witnessed an amusing and potentially tragic survival of this ancient practice. I saw an old lady scorch a piece of linen and start to place it on an unhealed cord. When I called her attention to the fact that she had dropped the cloth on the floor and then picked it up again on the way from the kitchen to the nursery, she could not understand what difference that made for had she not followed the formula was it not linen and was it not scorched?
I am not going far afield today. I shall speak of superstitions remember the definition that is more or less current in any community and more or less familiar to you all. Some have their origin in the dim and pagan past. In general, however, they are examples of and result from three curious ways of false and sloppy thinking.
The "post hoe ergo proper home" type of reasoning. The Latin may be translated "after this, therefore because of this." Since B follows A, B is caused by A. For example, I am sick, I take a pill, I get well; therefore, the pill cured me. Not necessarily true at all. Closely linked with this is.
The drawing of conclusions from insufficiencies endorse a very common error. The same crude example of illness may be elaborated to illustrate this also. Ten persons with the same disease take a given pill and get well. Such a report is of little or no worth. If out of a hundred persons with the disease and given the same pill, ninety get well, we begin to have some evidence of the value of that pill in a given condition. I out of a thousand such cases so treated 900 recovers, the evidence is much stronger than the medicine had something to do with their cure provided that the recovery rate of a like number of controls was much lower. In all the cases we are assuming the presence of only one factor must be considered, the drawing of a correct conclusion may be a terribly complicated and difficult problem.
Blind acceptance of statements, hallowed by age or authority, without critical examination and analysis.
No one is immune to the contagion of these three methods of reasoning, for they are the easiest way. Herd, consecutive, antically, constructive thought is one of the hardest tasks that anyone can undertake. Dr. Vincent used to say that when most of us fondly imagine that we are thinking, we are only rearranging our prejudices.
Let us now examine a number of superstitions about health and medicine that are right among us believe by an astonishing number of people who should know better and whose ignorance can be laid directly at the door of our faulty educational system.
It is entirely true that one man's food is another man's poison, but a mass of superstition has grown up about articles of food and drink. This r that food is frequently said to be "especially good" or especially bad" for us; careful examination seldom addresses evidence to support such statements. Milk is certainly not perfect food at least for adults because it is over 90% water. Coffee is claimed to be bad children and cocoa good for then, but both have about the same content of similarly acting drugs. Of course, as usually prepared, cocoa contains more nourishment. In spite of advertising, cereals are not rich in body-building proteins and are not in general "all around" foods. There is no such thing as skin food, and it is not true that fish is brain food. There is no essential difference in food value, digestibility or other quality between light and dark meats. It is very easy to say that something is "hard to digest," but to prove that and to make clear just what is meant is quite difficult. Broths have practically no food value. I have never heard a completely satisfactory explanation of why oysters should be eaten only in those months that contain the letter "R".
Probably one of the most commonly held ideas, even by physicians, is that meat is "bead for", even if not a cause of, high blood pressure and kidney trouble. There is no good evidence that this is true. Vegetarians may suffer from high blood pressure as well as anybody else, and surely Eskimos, who eat meat exclusively, do not all die of kidney trouble. This story is told of Stephenson, the famous Arctic explorer. He was telling some skeptical friends of the harmlessness of a meat diet. His friends said that it might be all right in the frozen north but could not be done with impunity in this climate. Stephenson wagered that h and a companion could and would live exclusively on meat end its products in this country for two years. This they did remain well and in good health and medical examination of them at the end of that period revealed nothing abnormal. The greatest objections to a total meat diet are the bulk required and the cost.
The study of religious food taboos is of great interest, but there is no time. There is no reason why only those fruits should be eaten that grow in the climate of the consumer. An apple a day keeps the doctor away no better than many another wholesome fruit. Incidentally, there is no reason to believe that eating green apples causes colic. Fruit juices make the body less acid, NOT more acid. The advertisement that advises you to "get over on the alkaline side" is rarely scientific. Many advertisements play upon and up to the reader's superstitions. How often have you not known diabetic to reject a small amount of sugar while eating starchy foods in my quantities desired, and gorging on rye, gluten or bran bread which does not differ much from white bread in their carbohydrates content? Americans drink more water than any other people and European think us crazy in this respect. We claim that it is "good for us, but I never have seen it proved. A lot of nonsense has been written and believe about the effect of alcohol on health. Not for one moment do I belittle or underestimate the bad social and economic effects of drinking, but there exists no proof that alcohol in moderation causes any disease. Dr. Osler used to say that bad teeth and oral sepsis have caused more harm to the human race than alcohol. Many alcoholics develop curious ideas and defense mechanisms about their drinking habits. Many still believe that whiskey is an antidote for snake bits.
There are many fads in foods and diets. The strict vegetarian is in error, for the human intestinal tract is geared for a mixed diet. Many fears to eat lobster and milk at the same meal. A short time ago a popular fad was not to mix certain foods, for example, acids and starches. I know nothing to support such fancies. Reducing diets are frequently quite indefensible. The value of fresh against stale foods is large, if not entirely, esthetic. The advertisers of raisins used to ask, "Have you had your iron today?" At present, molasse is highly praised for its iron content. It is true that it is comparatively rich in that metal but not more so than oatmeal. If you need considerable iron and unless you are crazy about molasses, an iron pill is easier to take and cheaper. Vitamins are of real importance. Much is known about them, but a great deal yet remains to be discovered. They are of great interest in many ways one is that we can watch superstitions about them in the making.
It is fallacy that savage man is noteworthily healthy. I doubt that it can be proved that good health protects against diseases, or that exercise is conducive to health. It is not true that the Chinese pay their physicians only while they remain well. The early church was responsible for a hideous superstition when it taught that the human body was sinful and low, something to be scourged and mortified. That idea has permeated our whole life and thought; its eradication her just began, a slow and painful process. All sorts of things are introduced into school curricula, but rarely anything really valuable about a personal, community or general hygiene, using the word "hygiene" in the broadest sense. A man's body is his most precious material possession, the temple of his mind and soul, but he is practically never taught anything true and worth-while about its structure, functions, and care. In this respect, at least our educational system is appallingly stupid.
Germs come in for their share of superstitions. They are usually pictured in many bizarre shapes; actually, their forms are usually extremely simple. A citizen will object most strenuously to the establishment of a contagious hospital in his neighborhood, although the chance of contracting diseases from its presence is exceedingly small in comparison with the danger from common eating and drinking utensils, or from our sputum strewn streets. Fumigation was once held in high esteem but, as you know, has been practically abandoned, for as usually carried out, is without value. Bore acid and peroxide are very feeble antiseptics, and the efficiency of iodine far exceeds that of ordinary mercurochrome. A thing is sterile or not sterile there really is no middle ground, and the briefest and slightest touch of something else spoils its sterility. The possible value of external applications is rarely due to the absorbing power of the skin which is very slight. An iceberg over a threatened appendicitis is no better and no worse than a hot water bag, neither are of probably much value and may be the cause of fatal delay. A rusty nail is dangerous not because it is rusty, but its rust is evidence that it may have been whore tetanus germs abound. All say that frostbite should be rubbed with snow, but probably both friction and cold are bad advice in this condition. Normal blood pressure is NOT one hundred plus your age. A person cannot get warts by taking oil. Night air used to be "bad" when malaria-carrying mosquitos because active with nightfall. The word malaria comes from the Italian "malaria" which means bed air, and chat is its origin. The advice contained in the adage "Feeds a cold and starve a fever" should best be reversed. "Colds" are catching and are usually gotten from someone who has a cold like any other contagious disease.
Intestinal conditions rarely cause fever in adults, and laxatives do not reduce the temperature. Acute indigestion, if there is such an entity, is not associated with severe pain, and is never a cause of death. Grinding of teeth by children in their sleep is not a sign of worms. Worms do not come from candy or other food, but from a person or animal or meat that is infected with or harbors the parasite. Colic, teething, and worms are dangerous diagnoses to make in children, for they are rarely the cause of acute illness. Mothers feel obligated to take their babies out for the sun and air. They could save themselves much effort for their infants could get just as much air if wrapped up and placed in a room with opened windows; as ordinarily wheeled about, the amount, the amount of sun they get is legible with only their faces exposed and these often covered with a veil. While bad orders are objectionable, they do not cause disease. Grape seeds do not cause appendicitis, mad dogs do not cause it to grow thicker, and there are no such things as "growing pains".
Of all the fields of medicine, obstetrics offers the most outstanding example of superstition. The reason for this is a long story. You are probably familiar with some of them that it is dangerous to have the teeth pulled during pregnancy; that a seven months baby is more apt to live than one of eight months; that a raisin is good to put on the cord stump; that it is unwise to out the hair or fingernails of the newborn. Very possibly your attitude toward them is like that of a famous Englishman who said that he did not believe in ghosts but was scared to death of them. It is unnecessary to dwell on the darker of these beliefs. Probably no person here believes that a cat can kill an infant by sucking its breath. Today few believe in possibly some in this room have never even heard of the evil eye. But the old Irish lady who, after praising a baby, says "God bless him", unwittingly adds a saving formula to ward off the influences of evil that ever menace, especially the newborn. The ritual of the christening gives, among other advantages, the child the protection of a name. Probably one of the commonest superstitions is that a mother can, some experience or activity, affect her unborn child, in other words, "mark her baby". The origins of this belief, widespread through the world in all ages and cultures, is obscure but very interesting. Probably the best guess is that it contains the idea of the scapegoat. In savagery true today in our civilization through superfine sensitivity refuses to recognize it a deformed baby was a definite liability, and its mother was a natural scapegoat. In self. protection and as an alibi the idea of "marking" was evolved, by which the mother absolved herself from responsibility for such a birth. But someone will ask, "if that is not the case, how do you explain it?" This, of course, propounds a new question, and inability to answer it does not in the slightest prove the truth of the first. If I could answer all the question, and inability to answer it does not in the slightest prove the truth of the first. If I could answer all the questions that might be asked me about the human body and its working I should be God. If I could tell you exactly what happens in my brain and body when I thus crook my finger, my niche in the Hall of Fame would be assured. There exists no proof that any women have ever "marked" her baby. The cause of the deformities has never been explained.
A common superstition is that the suppression of menstruation will "throw" (just how, is quite obscure) women into tuberculosis. There are many erroneous ideas prevalent about the dangerous effects of cold and water on the menses. Some mothers will not allow their daughters. to even put their hands into cold water during their periods, and the number of women who fear to take a bath during that time is legion. False beliefs about the menopause or change of life are far too common and have led many women to their death. Really very few symptoms are directly attributable to a change of life itself, though almost everything is ascribed to it. It is unfortunate that bleeding is associated with a normal female function for about thirty years of every women's life. Abnormal bleeding from any other body cavity would drive her to seek the doctor early. Be it enough to say that in a normal change of life the bleeding is always less in amount, shorter in duration and farther apart. Anything else is ALWAYS abnormal, it matters not any statement by any person to the contrary, notwithstanding.
Superstitions about "Tumors"
Incorrect medical terminology "tumors" means swelling whether caused by inflammation, blood clot, collection of fluid, new growth or what not. When your wife hits you on the head with the rolling pin and thereby produces a lump, that lump s, strictly speaking, a tumor. When the average women speak of a "tumor", she usually means either a fibroid of the womb or a cyst of the ovary. The proper word of all such as neoplasm or new growth. To new growths disappear spontaneously? Warts certainly do, and many persons have charms to get rid of them if they are not wart charmers themselves? Occasionally, smell cysts of the ovary do. At times, multiple small cystic tumors of the breast. PLEASE note carefully, I said MULTIPLE, not SINGLE tumors of the breast. To the best of my knowledge and for immensely practical and all safe purpose no other new growths ever do. There are two prevalent beliefs about cancer that are false. One, that cancer is always painful; the truth is that pain is never a sign of cancer except in the late and hopeless stage. The other, that cancer cannot be cured; the truth is that many cancers have been and can be cured by early discovery and proper treatment. We know little or nothing about the world the real cause of any tumor will have a place among the immortals of all time.
Superstitions about Healers and Schools of Healing.
Dr. Locke of Canada is a good and recent example of such healers. He has had and still has, many sincere advocates, and he may believe wholeheartedly in himself, his mission and his ability, it has always been thus. But no doctor who has seen his action could by the greatest stretch of charitable imagination understand how the manipulations he performs can have the slightest permanent effort on crippled joints. With his enormous material, he has added nothing to our knowledge about orthopedics. Homeopathy has almost run its course. Some of you have probably been helped by spinal adjustments, and some may even be followers of Mrs. Mary Parker Eddy. It would be foolish to deny that some sufferers have been helped by such men and such methods. It would be strange it if were not so. Most of these schools of healing have taken one small, often neglected, item or branch of the great domain of medicines, and tried, sometimes in well-intentioned ignorance end sometimes in the spirit of pure charlatanism, to build it up into an independent science, though science is not the word. They exceedingly rarely contribute anything that is new or valuable. One of the best answers to all this lunatic fringe of medicine is that it will be a long dark day when trainloads of chiropractors will be rushed to a railroad wreck or the battlefield, or shiploads of Christian Scientists to stamp out a scholar's epidemic. The history of medicine abounds in such individuals and such movements'. They will continue to appear, to have their day, and pass into oblivion. Wishful thinking is no pleasant. It is much easier to say and believe that a thing is so than to prove its worth. Scientific medicine will still march on.
Superstitions about Regaining Lost Health.
Energy, once expended, can never be restored. Once gone, it is gone forever; nothing can ever bring it back. Nature always exacts her penalty for folly. Man has always been willing to suffer agonies and torture, to do anything, to pay any price to recover lost health. We break or disregard the laws of health which are usually so plain that he who runs may read. Then we hopefully, frantically, often too late, strive to undo the evil by the magic of some cure: the waters of some reputedly healing spring; the restoring power of some system of mental therapy (remember the errant nonsense of Dr. Coue's "every day in every way I am getting better and better"); penance or prayerful petition to some anthropomorphic god; the exhibition of some holy relic, or a visit to some sacred shrine; the administration of some medicine of magic potency. Many patent medicines illustrate the last-named superstition and are still sold in large quantities. Someone has said that all patent medicines contain a bitter, an aromatic, a laxative and alcohol. Incidentally, many people are seen to judge the strength of medicine by its nauseating or near strangling power. The fountain of youth ever beckons us on. The elixir of life has yet to be found. We still believe in magic.
Superstitions about State Medicine
Health is not something that can be bought, bestowed, given away or insured. In all the drive and propaganda for socialized medicine formerly called "health insurance" and as seam but now dropped as an impossible concept, not a word is said about the MEANS of health, and nothing about individual instruction in and for health. Health is largely an educational and individual thing. The government fosters and attempts to foist upon the people of this country some miserable superstitions that illness is the greatest cause of poverty; that organized medicine has failed, and medical men are remiss and lack social consciousness; that socialized medicine can and will solve all the unsolved problems; that we shall, almost overnight and at relatively small cost, banish illness, disease, almost death itself. They are all cruel untruths.
In no please where socialized medicine has been put into effect has the incidence of illness been lessened, disease been prevented or the death rate lowered, the only honest criteria by which its efficiency can be judged. Mass production, assembly line tactics and political control do not work well in the domain of medicine. This country has the lowest disease and death rate in the whole world, and the finest hospital system in existence. The medical profession has made it so. No one knows better or is more genuinely interested in the medical needs and shortcomings of this country than the doctors. The medical profession takes strenuous exception to the false assumption that socialized medicine is the only method capable of solving the health and medical problems of the United States. The superstition of the benevolence, all-wisdom, and all-powerfulness of government is freighted with tragic disappointment for us all.
Superstitions about Doctors.
In some mysterious way the physician has been credited with possessing the powers of life and death. Such a mystery has always been feared; such power must be curbed. Accordingly, society has always wished to make the medical man either a slave or a god and still does. In many ways, it is unfortunate that the old family physician has been idealized into a see-all, know-all type of being because it is not a true picture. He is usually represented as follows he came, took the patient's temperature, counted the pulse, asked a few questions, mumbled a bit and doled out some medicine. If the patient recovered, the doctor got the credit, frequently deserved; if he died, it was God's will to be bowed to in resignation.
The attitude toward the physician has profoundly changed in recent time. There are several reasons for this. ONE the physician no longer lays claim to the omniscience which was freely ascribed to the stereotyped old practitioner,TWO the laity, I.e. the non-medical part of the population knows more about doctors and medicine, even though they know so many things that are (speaking ungrammatically) "just isn't so." THREE the present generation is impatient and wants things done in a hurry, a procedure that is rarely compatible with good modern practice. FOUR this generation is also unwilling to bow to God's or anybody's will. The reason that illness and death ought to be prevented, which all grant is desirable but by no means always possible. Since they are not prevented, they further reason that someone is to blame, which is some is to blame, which is sometimes true. However, they Seldom blame themselves, their own acts or their own ignorance, or the failure or shortcomings of the social order; nor are they over willing as the negro aid, to cooperate with the inevitable. They have been taught to shrink from the stark realities of life. They do not like to hear that we all must die. Instead, they frequently turn upon the doctor who is conveniently and helplessly near from birth through life to death. I have heard a person state to a group that Dr. So and so "killed Mrs. Jones, or Smith or Brown," a statement for which she had little evidence to any nothing about proof, and against which the doctor is powerless to defend himself.
Many harsh things have been said about my profession. I think it was Voltaire who said that doctors our medicine of which they know little into bodies of which they know less for diseases of which they know nothing at all. at the other end of the scale is Robert Louis Stevenson's Tribute to the Physicians. Doctors are sometimes foolish, sometimes ignorant, sometimes dishonest, occasionally knives. They make mistakes, which because of nature their work is sometimes tragic in their results. In other words, they are frail human beings like yourselves. There is no superior, all-wise being who chooses and decides who shall become your physicians. The modern doctor is better trained in his profession than in any period of the past. In general, he is the best-educated man in the community, as to being almost always has been. He is deeply religious, general impression to the contrary notwithstanding. he is humble for he deals with the intricate complexity of living things and is in content daily and intimately with the great mystery of life. The human body has been compared with an automobile. The comparison would be more valid if the automobile could repair itself with materials of its own production. While the physicians today possess a real specific cure for many diseased conditions, he still recognized the limitations of even modern medicine. He sincerely subscribes to the great truth in that sentence of Ambroise Pere, a famous harbor surgeon o the 16th century who said, "I treated him and God cured him." Individually and in groups he contributes a great deal to his community, and none deserves better at the hands of his fellow citizens. He exemplifies that "greater love hath no man this, that a man lay down his life for his friend."
I have reviewed (this afternoon) a few superstitions about health and medicine. I hope that I have interested you and have given you something to think about. If I have cleared away some of the notions that you have held about these things in spite of evidence to the contrary, I am satisfied. It has been a great pleasure for me.
I am going to take chance in this essay that I can hold the attention of the reader through a preamble of theory, before addressing the consequences for the practice of medicine. That seems necessary because I believe that the consequences are different from what most readers would intuitively expect and persuasion lies in first convincing the reader of the theory.
CLOSED AND OPEN SYSTEMS
There is a growing body of endeavor known as the Theory of System, which acknowledge that all events are consequences of pre-existing conditions (like the consequences of adding acid to bicarbonate in a beaker), and are thus “closed†systems. However, most events in biology and sociology are so complex that it is only possible to deal with them as “open†system, for which we substitute wisdom for scientific certainty. “Wisdom†is a set of traditions, maxims, opinions, and strategies which allow you to make predictions about the inevitable outcome of events within an open system. The teleological nature of human events was once referred to as Manifest Destiny, and realists like Talleyrand spoke of diplomacy as the art of manipulating the inevitable.
Example:
Wisdom has it that in your choice of a practice location, you should remember that “you can’t make money where it ain’t.â€
And now a conclusion about the computer revolution: Since computers increase the capacity to store and manipulate detail, the computer revolution increases the number of closed systems, and shifts the scope of wisdom in decision-making from traditional areas to new subject which was formerly incomprehensible.
HIERARCHIES
In dealing with open systems, managers and executives have evolved a basic strategy; they organize manageable subunits into hierarchies. Units are organized within departments, then organized within divisions, reporting to a policy-making body. Further, because the purpose of the organizational structure is to simplify management, each level of the hierarchy is oblivious to the techniques of the level below, and is only interested in the output of the level below.
Example:
The patient paying his bill is interested in the total amount that he has to write on the “bottom line,†which in his case is the dollar amount of the check he must write
The director of the x-ray department is concerned with a subtotal related to the x-ray department. The chief technician is concerned with individual studies. The dark-room attendant is only interested in pieces of film.
COMPUTER CONCLUSION:Primitive Computer Systems merely duplicate the pre-existing manual system. Their real power lies in the next step, which is to reorganize the reporting system. That is, they cause a reorganization of the hierarchy.
TRANSMISSION
The prediction is made that management system will be forced in the direction of a hierarchy of three: Those who are able to make decisions, those who cannot make decisions but are necessary for some task, and the computer. One function often seen in non-computer systems is simply to pass the information unchanged up to the line. There is little doubt this activity will vanish.
Example:
Robert McNamara (from Princeton via Ford Motors) was a computer expert who became Secretary of Defense under John Kennedy. By installing computers, McNamara was able to jump the Army reporting system (Sergeant to Captain to Secretary of Defense) and confront the generals with discoveries before the generals had received the news. We are told that the generals didn’t like it a bit. But can anyone doubt that Robert McNamara carefully filtered the data before h presented it to President Kennedy? The system of hierarchical reporting condenses the data to the next step up.
COMPUTER CONCLUSION:Many systems of management by delegation will soon be swept away by the computer revolution, and middle management will be the most threatened region. It will resist but it will lose.
MODIFICATION
Another function of delegated systems is to take raw information and reduce it to condensed form for the benefit of the next level upward. They do so by a process which is often a mystery to the next higher level, and hence a certain power is conferred on the lower subunit to modify the conclusion by modifying the system of manipulation. The method for controlling such activity is to produce a procedure manual which the next higher level must approve, but the inherent complexity which forced a delegated process to be created also obscures the power of the delegated subunit to modify the system.
COMPUTER CONCLUSION:Computer technology strictly defines and inflexibly follows defined procedures for steps in hierarchy. It thereby confers much stricter control power to the higher levels of hierarchy.
THE NEED TO KNOW
If for no better reason than to reduce programming costs, the computer process confers a new power to the lower levels of hierarchy. The higher level must now strictly define its reasons for asking for certain information. If it cannot demonstrate a need to know, it cannot justify the cost of knowing.
Example:
The PSRO, acting on behalf of the physician community, violently resists the inclusion of data elements in the reported tape sent to the Bureau of Quality Assurance. At the same time, it is anxious to acquire as much data as possible from units lower in the hierarchy, who in turn resist the process. It can be expected that this process will eventually settle out at roughly the best equilibrium for the community at large, although differing aggressiveness among the participants may cause temporary inequities. The weapons in the battle, which are at the disposal of the physicians are:
(1) Superior Claims on the decision-making process.
(2) The faith of the public in physicians as the most trustworthy custodians of their health privacy.
(3) A superior pool of talent, determination, and independent means committed to a vital issue.
COMPUTER CONCLUSION:If you have a good chance of being the winner in the reorganization of a hierarchy, it is better to participate to your utmost rather than hold back out of fear that someone else will be the winner, because only participants are winner.
NETWORK
We have spoken thus far of hierarchy as the only manageable approach to the complexity of open systems. A more general description would be “modularity†since modules can interact in a lateral direction as well as vertically. When they do, the result is a network of modules in three dimensions. Since computers increase the ability to cope with complexity, they increase the ability to work in three dimensions. Hierarchy is the last resort of manual management; just as three-dimensional chess is beyond the ability of people who are not even very expert at two-dimensional chess. In this sense, the computer revolution provides some hope for the American System, which presents hierarchy and naturally prefers networks when feasible. This is to some extent a philosophical preference and does not seem to be true of the Japanese social system, or the German mentality, or the Communist method. The natural American instinct for lateral equality is thus an ally in Medicine’s conflict with Government, but a hindrance when it encourages Nurse independence or unrealistic consumerism.
Whether lateral or vertical, the interaction of modules in a complex open system is the same: delegation of a method, the output from one module as the sole input to other modules, and resistance to the need to know.
COMPUTER CONCLUSION:The organization of modules into vertical hierarchies or horizontal networks is largely a political process, with three-dimensional networks as the last resort of compromise, and with strict vertical hierarchies as the last resort of inadequacy.
CONFIDENTIALITY
Complexity is itself a major defense of confidentiality; since computers reduce complexity, they also destroy the smoke screen. Computer System which stumbles ahead or is manipulated into breaches of confidentiality is certain to raise a great uproar about the need to know and the right to conceal. In the PSRO system, the issues balance between the duty of accountability and the patient’s right to privacy. When reduced to these terms the physician community has a clear advantage in the mind of the public, if the advantage can be effectively exploited. The latter can, however, be overturned by speedy pre-emption of the turf. it can be predicted that special pleaders will insist on accountability when all they really want is power and satisfaction of envy; it can fairly be predicted that some will weaken their claim to privacy by overextending its bounds.
Example: The system of peer review on Medicaid prescriptions in Pennsylvania has turned up a number of instances of patients who obtained multiple prescriptions for “controlled†drugs from multiple doctors, filled at multiple drug stores, probably for resale on the streets. When the doctors and pharmacists were notified, they were universally grateful and took steps to curtail the problem. However, the computer vendor learned of the problem (regardless of the fact that all reports are shredded after review) and persuaded the state government to institute a system of restricting problem patients to a single physician. It may now be impossible to dislodge this meat-ax reaction, in spite of the fact that the computer peer-review system is probably able to cope with the problem without invoking hierarchical power.
A Second Example: The United States Navy recently developed a system of computer protection so elaborate that they boasted of it in the newspapers. Two computer scientists read of it, and in a month’s, the time had broken into the system via telephone. The Navy was then agitated to read of its disarmament in other newspaper articles.
COMPUTER CONCLUSION:There is no present foreseeable technical method of protecting the confidentiality of computerized data, except by physical ownership and physical protection of the machine itself and all of its activity.
CONCLUSIONS
The most significant event in the Twentieth Century is the Computer Revolution, just as the Industrial Revolution was the major event of the Nineteenth Century. By the greatest good luck for medicine, the computer revolution is capable of solving the four major problems which now threaten the American Medical System.
1. THE FAILURE OF THE PRE-PAYMENT INSURANCE MECHANISM. The removal of cost restraints on the patient (and thus the provider) has had a predictable upward effect on costs. The overwhelmed system has reacted in a typical hierarchical manner: try to convert insurance companies into regulatory bodies, and if that fails, into rationing systems. The computer revolution (if we are agile) has the potential of drastically reducing the information costs which are now 40% of hospital and insurance company costs. It also has the ability to control utilization abuses, and expose power abuse to public decision.
2. THE VAST INCREASE IN PARAMEDICAL PERSONNEL. Middle management is most vulnerable to computer replacement, and middle management now costs 20% of the hospital dollar. Physicians in complex medical centers are most alarmed about this problem, which they can easily identify by comparing the hospital parking problem with what it was, twenty years ago. Surgeons are typically least concerned since their role at the center of procedures is least threatened by aspirants. But surgeons are hearing of “unnecessary†surgery, and even the small-town solo practitioner has to hire girls to fill out forms. The complexity of our system must be reduced, and computers can do it. The best way to thwart the claims of aspirants to power is to eliminate jobs.
3. THE EXPLOSION OF SCIENTIFIC INFORMATION. No one would wish to reduce the output of the research community, but ways must be found to organize and transmit the information without resort to fragmentation by sub-sub specialists. The computer is ideally suited to the problem.
THE MALPRACTICE CRISIS. Physicians are uncomfortable with the idea that peer review may soon become entangled in the malpractice system, as indeed it inevitably will. The matter comes down to biting the bullet, armed with a statistic. Surely consent for an arteriogram is more threatening if it is couched as “you might lose your leg†than if you are told, “you have one chance in five thousand†of such an occurrence. Realistic insurance premiums can be set when the risks are defined. Juries can be provided with realistic statistics on normal risks and normal expectation of benefits.
Through all of these four problems runs a common theme: The cost of medical care. The PSRO seems to be the last best hope of curtailing the cost threat to medicine, and so the PSRO can be expected to be the vehicle for the computer revolution’s resolution of the issue. Senator Bennett probably had no idea of what he was doing, but he did it, and the problem is now our problem.
When I had finished writing the first volume of this quartet, I considered adding a bibliography. However, it sounded sort of Stodgy, so it wasn't included. That decision appears to have been a misjudgment since some reviewers criticized the lack of references. A bibliography is therefore found at the end of this volume.
But a bibliography does not satisfy me as a description of the intellectual influences which led to this book. If anyone really cares about the matter, some anecdotes are needed.
First of all, Benjamin Franklin
However, two hundred years after Franklin's death it is possible to see some other effects and to draw some other morals about "perpetual" fire insurance. For example, the effect of compound interest is such that the lump sum payments not only pay for the insurance premium, but it also draws a very handsome cash dividend in addition. As an investment, this fire insurance is so attractive that people have actually been heard to urge a higher assessment of the value of their house, in order to qualify for more insurance! What has developed in our olde towne is a very good illustration of the principle of "adverse selection of risk". Since subscribers with spare capital almost invariably live in more substantial and fireproof houses than average, are better able to afford fire alarms, and are more likely to live near responsible neighbors, they have fewer fires. That makes the insurance less costly, but it does not reduce the legal requirements for reserves. The insurance laws force the perpetual fire insurance into a position of "over-reserving" but since the company is a mutual company, owned by the subscribers, it all comes back as dividends and fancy directors' dinners. Would anyone like more Madeira?
The power of compound interest, and the frustrating inability of most citizens to appreciate it seems to have been an obsession of Franklin's. In his will, he left $500 to the cities of Philadelphia and Boston (he was born there) to be left at compound interest for two centuries. The Boston investors did rather better and generated $xxx million by xxxx, but even Philadelphia had generated $xxx million by XXXX. Poor Richard, of course, knew that the interest growth would seem astounding, and gave the bequest in order to promote self-interested thrift among his countrymen. The idea was simple and obvious enough; Poor Richard didn't need a Hewlett-Packard 12-C pocket calculator. Even more powerful was the insight that human nature would not likely change much in the next two hundred years. People do indeed still need the message about compound interest, and people who are young enough to profit from the concept still resist the arithmetic.
What's Needed to Create an Electronic Claims and Payment System.
1. A coordinated approach. Since everyone is giving up something to get something, there must be a global agreement before anyone will move.
2. The system must focus on one and two-doctor practices. At present, 14% of claims are submitted electronically, but this almost exhausts the market of large-volume provider groups. With a small-provider focus, it follows that packaged systems must be inexpensively provided and maintained by software houses; training and support must be provided by medical societies to their members in large groups. This approach requires universal standards negotiated by payors and organizations representing doctors. The small-volume provider cannot cope with or afford a multiplicity of payor protocols, nor can he cope with frequent changes of the rules.
3. The new systems must be paid for. HCFA could pay a surcharge for electronic submission ("but why should we pay people to send us a bill?"), one carrier could perform the service on behalf of all ("but why should we let a competitor see all of our business secrets?"), the doctors could pay all of the costs ("but why should we pay to do the key entry for the carriers when HCFA has rolled back our fees? "). Since possession of the interest float is a central part of the haggling, it seems easiest to capture a part of the float as the source of the needed transfer of costs within the system.
4. It is unsafe to make any national system changes without first trying a local demonstration project; therefore, negotiations should continue while a pilot program gets going rapidly. Many fears will prove to be unfounded, while many problems will have been unanticipated. The government has experience with this sort of venture and is fairly well equipped to deal with it.
5. Although everyone hates to see a new organizational layer in the system, the providers will probably have to create a new "provider intermediary" to aggregate their data for retransmission as well as negotiable at the interface with the present "payor intermediaries". This is true in part because of HCFA's insistence on the accounting principle that "the agency which prepares the bill should not also be the one to pay that bill." Since this intermediary acts on behalf of providers, will want to control it; the sticky thing is to get HCFA to pay for something which is controlled by others. The interest float seems ideal for this purpose since excessive costs would reduce the income of providers, causing them to raise questions and/or change agents. It also automatically adjusts itself to volume, so that the agency can more comfortably work with multiple payers and providers.
6. Although medical societies act on behalf of their members, their budgets are separate from the members' pocketbook. Furthermore, membership is voluntary and not universal. Therefore, what costs or benefits the members in aggregate is not necessarily the same as a cost or benefit to the societies. Any negotiating process must recognize the distinction between representing members and sharing in their finances.
7. While maximum competition between hardware and software vendors, timeshare computer companies, and long-distance carriers is desirable, there is one small computer software program to interface between provider and insurance company software, utilizing a single common protocol which will be subject to continuous revision while negotiations and the pilot program are underway.
Software developers on both sides of the interface need to know that someone will provide them with the interface so they can go ahead with their parts of the system. Since the specifications will be speculative at the beginning and subject to continuous revision, HCFA should be willing to absorb this cost of buffering, dealing with a designated vendor, in order to be able to assure the industry of stability. This piece of software should be strictly confined t the goal of permitting inputs and outputs to be untroubled by experimental variations in the interface mechanics; it should be mainly regarded as a research tool, although its final form would be operational. To repeat: anyone could develop it when the situation is stabilized, but no unsubsidized vendor could afford to develop it until then. And no one else can budge unless it exists.
Electronic Claims System From the Doctor's Point of View
The doctor would have one of several computer system choices in his office which cost about $2000, employing software which he purchased from one of many existing sources for about another $2000. He and/or his secretary learned to use it at courses provided at the County Medical Society.
When the office closes, the machine turns itself off, but turns itself on again at night and dials a number, redialing it if busy. After connection, it identifies itself and send all of the accumulated claims of the day to a file, then receiving accumulated payment bits of advice and EOB information. The machines then disconnect, but the office computer then reconciles accounts internally, producing revised balances and accounts and takes appropriate actions; it then turns itself off. Next morning, the first process after the start-up is to print out reports about the night's activity.
Back at the collection computer, the aggregated claims are sorted by carrier and transmitted. Carrier information is them received, and sorted by provider, awaiting the evening transmission.
Meanwhile, funds are electronically transmitted into an escrow account, and a money market operation invests the money for a specified period. After the expenses of the operation are deducted, the funds are either: 1) available at that bank for checking by the providers 2) electronically transferred to the providers' banks or 3) used to pay the credit card purchases of the providers on cards utilizing the account.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
