The Humpty Dumpty Syndrome: Fixing Broken Faces: Patient Stories of Maxillofacial Surgery

By Morton H. Goldberg

Early in his groundbreaking career as a maxillofacial surgeon, Dr. Morton Goldberg coined “The Humpty Dumpty Syndrome” to describe patients whose eggshell-thin facial bones had been damaged by trauma, disease, or malformation. The Humpty Dumpty Syndrome is his memoir of surgical adventures as he did what all the king

• Language: English
• Publisher: Morton H. Goldberg
• Release date: Sep 11, 2018
• ISBN: 9780692158555

Book preview

Five things are proper to the duties of a churgian:

To take away that which is superfluous,

To restore to those places, such things as are displaced,

To separate those things which are joyned together,

To joyn those which are separated,

To supply the defects of nature.

The Epistle Dedicatorie To Henry the Third, the most Christian King of France and Poland. 8 February, anno Domini 1579, Paris. Ambroise Paré, surgeon to the court of Catherine de Medici

Reflection and Revelation

July 2003, 2:00AM

The glaringly harsh, bright overhead lights reflected off the stainless steel retractors, clamps, scissors, needle holders, screwdrivers, high speed power-driven saws, and drills. The off-white walls absorbed some of that glare as well as that from the flickering cardiac and respiratory monitors. Damp, dark red blotches splattered the light blue gowns and white masks of the team as well as the draped sheets which covered the entire prone figure on the table, except for her face and neck, which were wet with copious amounts of antiseptic and irrigating solutions.

The odor of blood, both old and current surgical sanguination was familiar, as was that intimately well-known operating room pungency emanating from drilled bone and cauterized (burned) tissue.

Voices, the usual operating room banter, were soft, suppressed, fatigued. Clamp to me…cautery! Buzz that damn bleeding! How’s she doing? to the anesthesiologist. Have you heard the one about the malpractice lawyer who slipped on the ice…?

The steady dripping of intravenous fluid and blood transfusions could be seen but was neither pungent nor audible. Despite air conditioning, I was sweating beneath my scrubs and gown.

We had started close to 11:00pm and hoped to be finished by 4:00am. It was the second of two consecutive all-nighters. Both patients had been seriously injured from an MVA (motor vehicle accident). Both had sustained multiple limb and rib fractures as well as facial injuries. Neither of them had been wearing seat belts, in an old car without airbags.

Many years earlier, I had coined the term The Humpty Dumpty Syndrome to describe the effects of severe injuries to the multiple bones of the face and jaws, many of which are egg-shell thin. Poor Humpty Dumpty sat on a wall and took a great fall…now make that a car, motorcycle, farm vehicle, a police officer shot through the face, or a child mauled by a dog – all of them Humpty Dumptys. In the nineteenth century, all the king’s horses and men couldn’t put Humpty Dumpty back together again, but in the twenty-first it could be done! And we were doing it! If it is true that our face is our window on the world, our reflection in the lake of life, then shattered faces must be restored, both in form and function.

The fractured bones of both jaws, the palate, cheek bones, the nose and the orbits would be re-aligned into normal positions and stabilized with thin, narrow titanium plates and screws. Devitalized soft tissue would be removed, as would the roots of sheared off teeth. Deep lacerations of the tongue, lips, chin, cheeks, and forehead would be closed meticulously with almost a hundred deep and surface sutures. Much of it was carpentry – micro carpentry – but living bone which bleeds, feels pain, and can get infected must heal. Carpentry, if planned and performed well, can be an art form.

The face is an integral part of both the body and psyche. Would this patient recover a normal appearing face, the ability to smile, speak, chew, swallow, see, and smell? Would she regain her previous social or economic life and activities? Will she be elated by her recovery or depressed (post-traumatic stress) by her surgical and post-operative experiences?

Performing those procedures in that OR were long and fatiguing hours for me but less so for the residents who were decades younger. My feet were swelling inside my shoes, my previously operated lower back was responding to hours (two consecutive nights) of standing and bending and my bladder was full! And Phyllis was home, alone. What if she were suddenly to become acute or if she were to fall again and fracture more of her bones? Multiple Sclerosis is such a lousy disease!

I arrived home just past 4:30am and washed my hands and face – I would shower at six, when my clock alarm reminded me that I needed to make hospital rounds with the residents, and then I would spend a full day examining and treating patients in my office.

As my head nestled into my pillow in the dark bedroom, her voice asked, What are you doing? You’re seventy. Isn’t it time? She had been worrying about me! But, she was right – she usually was.

Later that day, I dictated a letter to the director of the Trauma Service at Hartford Hospital informing him that I was retiring from the trauma team. Henceforth, I would perform major surgery only on elective, selected daytime cases. It was over, after so many decades. All those Humpty Dumptys put back together again.

It had begun, many years earlier, in a dark and dusty Harvard basement...

Part 1

Harvard

Gordon Hall of Medicine, Harvard Medical School

Gordon Hall of Medicine, Harvard Medical School.

Veritas

Faces in the Dust

September 1956

The stairs were dark and narrow, a steep descent into an old Harvard basement. Just a few minutes in that cellar resulted in an epiphany that would alter the course of my life and career, and that of my profession.

Two years earlier (1954) while a senior biology major at UMass (Amherst), I had been recruited by a faculty member of Harvard’s School of Dental Medicine, America’s oldest (1867) and smallest (fifteen students per class) dental school. Why had I chosen dentistry? Perhaps it was an amalgam of social, educational, and family factors—my interest in applied biology, the lure of a profession, my parents’ encouragement, an oral surgeon as a role model, and the recommendation of my UMass faculty advisor.

I coined the term Humpty Dumpty Syndrome almost twenty years later to describe the problems of severe facial trauma, but my problems with Harvard began actually in the Middle Ages. After the fall of Rome, European medicine, primitive and unscientific as it was, survived in medieval monasteries and a few Italian universities, while surgery was practiced in the streets. Doctors of medicine, basically herbalists, refused to accept surgeons as their equals and preferred to rank them with barbers, hence the descriptive and derogatory term barber-surgeon. This was formalized by a papal edict in 1215, which divided physicians and surgeons into separate guilds. Later, during the reign of Henry VIII, English physicians created a professional association, a step up from the guild, known as the Royal College of Medicine, from which they excluded surgeons. Members were known as doctors, a title denied to surgeons. British surgeons, to this day, pridefully insist upon being addressed as Mister.

Barber-surgeons were considered by their contemporaries, the physicians, to be unlettered blood-splattered louts who wrought painful carnage with saws and knives. It is difficult to disagree with their low opinion of those itinerant hair-trimmers, cutters of abscesses and amputators of diseased limbs who performed their skills in village squares or in barns, without benefit of anesthesia, before gawking crowds of benighted peasants. One can only speculate on how much pain, misery, disease, and death they created, working with filthy hands covered with dried blood and pus. Their surgical instruments, depicted in many paintings and woodcuts of the era, appear to have been designed by someone who, perhaps later, might have become an employee of the Inquisition’s Grand Inquisitor, Torquemada. One of their most commonly performed procedures was the drawing out or removal of abscessed, painful, or broken teeth with gouges and sharp metal tongs. Hence the origins of dentistry.

Harvard had initiated the first university dental school, finally giving dentistry a genuine professional status and elevating its practitioners out of the chaotic and informal educational experience of apprenticeships and proprietary-for-profit schools. In the 1940s, Harvard attempted to drag a reluctant dental profession back under the loose cloak of Medicine and Surgery, but without smothering its uniqueness. An experimental six year combined degree program was initiated and actually graduated a small number of double-degree doctors who were granted both medical and dental degrees. It was anticipated that they would become educators and researchers and perhaps close the centuries old schism. However, within a few years, it became apparent that almost all of these graduates were abandoning their dental background and were limiting their careers to clinical medicine, or psychiatry, or surgery. Only two of forty-three remained in dentistry. The failed program was terminated by the university.

By the autumn of 1954 when I arrived in Boston, the pendulum had swung so far that Harvard officially and firmly discouraged its dental students from any attempts to obtain a medical degree. Perhaps the dental faculty feared for its future, inasmuch as there was no rationale for maintaining a dental school whose students were exploiting it as a back door into Harvard Medical School.

I was initially concerned neither with the ancient divergence of medicine and dentistry, nor the future employment opportunities of the faculty. My academic survival at Harvard was my only concern. The bucolic University of Massachusetts was then an unsung school of less than three thousand students and tuition of fifty dollars a semester. Suddenly I was one of a class of fifteen Harvard dental students, a small island in a sea of over one hundred Harvard medical students, many of whom sported Phi Beta Kappa keys dangling from their Ivy League ties. We were all to spend the next two years together in basic medical science classes and laboratories and taking tests, so many tests. I felt intimidated and a suddenly crushing sense of inferiority, until I discovered that a few of my new classmates had, like me, slipped through the hallowed Harvard portals from Brooklyn College and Boise State.

The medical faculty were the gods of this academic Olympus which occupied an architecturally impressive granite, ionic columned quadrangle at one end of Avenue Louis Pasteur in Boston. Many of them had already achieved fame for their research discoveries and their contributions to health science. All were busy publishing papers, obtaining research grants or scrambling up the academic ladder to tenure and professorships or department chairs, if not at Harvard Medical School (HMS) then at lesser institutions elsewhere. Their contempt for other North American medical schools was thinly disguised and some of them oozed envy for those members of the HMS faculty who had already achieved Nobel laureate status or those who were destined to do so. I soon developed an awe of this hallowed group, their achievements and their Harvard titles. I became overwhelmed by their aura of superiority. Although certainly worthy of praise for their career accomplishments, some were outrageously arrogant, their cups running over with the heady Harvard crimson wine of their own importance. Fortunately, a few did manage to exhibit that small measure of humility and humanity, which is so becoming and important in truly talented types.

On the very first day of introductory lectures, we were told that we were the best of the brightest, befitting our presence at HMS, a theme subsequently repeated so often that I almost began to believe it. Only those dangling PBK keys, and some disparaging put-down remarks about UMass kept the whole scene real for me; otherwise it would have been all too easy to succumb to the waves of elitism lapping at my tiny space on that little island. The weight of all those PBK keys pressed heavily on me and the Ivy ties blinded me to my own potential. Could I survive?

That academic struggle to survive consumed my first year. Competition was understated and in reality quite intense. Gamesmanship, that 1950s subtle and stealthy undermining of one’s opponents was played remarkably well by some members of the class who made a point of demonstrating their disdain for long hours of study by weekend sailing trips off the coast of Maine or by making a late entrance to breakfast the morning of an exam, with the previous night’s date on their arm. Perhaps they were just exceptionally quick studies. I wasn’t sure whether I should simply admire their one-upsmanship or sink into despair over my endless and often coffee-driven sleepless nights of study.

All these countless hours studying human anatomy, both gross and microscopic, as well as physiology, prepared me for sudden-death minutia quizzes and crunching exams. But fear of failure is a great stimulus to achievement and by the end of that first year I came to the gratifying realization that UMass had prepared me well enough so that I would indeed survive, probably somewhere in the middle of my super-achiever classmates. Also, although I had no PBK key, nor Ivy tie, nor blazer from Brooks Brothers, I began to feel comfortable with them and had formed a few friendships. No more thoughts of transferring elsewhere. I had made my peace with Harvard…or so I thought.

By the third year, the medical students went off to the Boston area Harvard teaching hospitals, and the surviving twelve dental students moved over to the little red brick Harvard School of Dental Medicine (HSDM) building which stood in the shadow of the Harvard Medical School quadrangle, both literally and figuratively. Having succeeded in the first two academic years in Harvard’s medical school, would I do as well in the next two clinical years in the dental school? It quickly became apparent to me that the only form of health care that would ever hold a lifetime interest for me was Oral Surgery, which like all forms of surgery can be intense and offers immediate and dramatically observable benefits to the patient. Every trip to the operating rooms of the Massachusetts General Hospital, the Boston City Hospital, or my home town hospital in Springfield, Massachusetts with an oral surgeon, Irving Meyer, who was both mentor and role model, strengthened my conviction that this specialty was to be my professional destiny. My chance discovery of Dr. Kazanjian’s faces in the dust also contributed to my early concepts of what I wanted to do with whatever knowledge and skills I could attain.

Phyllis and I were married in 1955 after agreeing to a year’s delay so that I might acclimate to the academic rigors of the Harvard Medical School curriculum, and then we moved into a small apartment. On the first day of class, September, 1956, I walked up Avenue Louis Pasteur from our apartment near the Fens, an area long inhabited by students. Passing Vanderbilt Hall, the Medical-Dental dormitory, I turned past the granite quadrangle of HMS to HSDM, where I was to spend my third and fourth years, finally, as a dental student treating patients. I had previously been in the building but twice, for brief faculty and student holiday parties. On that morning, after the usual desultory welcoming lectures by the dean and faculty, the students were given their laboratory, clinic, and locker assignments. The Dental School was minuscule in comparison to the medical quadrangle next door, and space was at a premium. I drew a locker in the basement, one of the last available.

Down those steep stairs I went, into the basement, along a dark corridor whose ceiling was coursed by a myriad of water, steam, and waste pipes of varying ages and diameters. The streaked gray walls were stacked with obsolete and discarded dental equipment whose forms cast grotesque shadows when illuminated by a few dim naked light bulbs hanging between the pipes. I found a row of old rickety metal lockers whose doors cried out, like Oz’s tin man, for a few drops of oil.

I deposited my laboratory coats and boxes of newly acquired dental instruments into the musty locker. For the next two years I descended into that nether region to retrieve or deposit clothing, books, or dental equipment. But on that early descent, I unburdened my arms by placing a few small boxes on what appeared to be a heavy wooden table covered by a thick layer of dust. When removing the boxes, some of the thick gray dust was swept away, revealing an old, sturdy, flat, rectangular glass-topped display case. A few sweeps of my hand and I was able to peer through the glass.

My own shadow stubbornly obscured the contents. When I maneuvered and forced my shadow to conform to my wishes, it took a few moments for me to comprehend what I was looking at through the dust and the thick glass. In the dim light (and also perhaps because of that dark, shadowed basement milieu) I was shocked and physically repelled by what I saw. I recoiled quickly backwards, momentarily stunned, and then I approached the glass again. The objects displayed within the case were rows of plaster-of-paris face masks, moulages that would startle even today’s most ardent horror film devotees. These masks had not been produced by artists in Hollywood, but were perfect representations of faces of horribly disfigured young men. Some had no eyes or lips, others were missing jaws, cheeks, and noses. Twisted faces, mutilated faces, broken faces. This was not art, not even macabre art. This was life—mutilated life.

My first impulse was to cover up that display case, but I left and returned the next day to stare at those faces, and then again and again. It became almost an obsession to look at all that horror, every time I approached my locker. One of the older members of the faculty finally answered my inquiries, about the origin of those faces.

Where? In the basement? Haven’t seen those for years. Sure…belonged to Kazanjian. You know… Dr. Kazanjian – he made those during the war. The War to which he referred had begun in 1914 with one fatal gunshot. Millions of young men then went off to meet the twentieth century and the mass produced killing machines of Messrs. Shrapnel, Gatling, Maxim, Colt, and Krupp.

Varazted H. Kazanjian was, in 1915, then thirty-five years old and was serving as Director of the Department of Prosthetic Dentistry at the Harvard Dental School. Born in Armenia, a subject of the Ottoman Empire, he understood the meaning of religious and ethnic intolerance, and during a period of political unrest he had fled to the United States as a teenager. Had he remained, the Turkish genocide of the Armenians in 1915 might well have claimed him. Settling in Worcester, Massachusetts within an established Armenian immigrant community, he had found menial work in a wire mill just before the turn of the century.

The young Kazanjian labored for seven years. Then, according to one of his biographers, he was encouraged to apply to dental school by one of his fellow workers because he had complained about the limitations and boredom of his life as a mill worker. By attending night school and participating in correspondence courses for a few more years, he finally finished high school and then was accepted to Harvard Dental School. Like the Biblical Jacob who had labored seven years and had acquired only Leah, then another seven for the achievement of his true love, Rachel, Kazanjian had finally found what he sought.

His manual, esthetic, and cognitive skills were recognized early as he became proficient and inventive in the treatment of fractured jaws, cleft palates, and congenital facial deformities. He devised dental-like appliances as well as innovative surgery in that era of risky anesthetics and lethal postoperative infections. By 1912 he had been appointed Director of the Department of Prosthetic Dentistry.

When Harvard Medical School organized a Faculty Hospital Unit to serve with the British in France, Kazanjian volunteered but was hesitantly accepted, because the role of a dentist in a military hospital was uncertain, at least in the minds of its medical doctors. The unit reached France in June, 1915 and was stationed at General Hospital No. 22 at Comiers.

The horrors of the Western Front, a trench war of attrition, have been well documented and names such as Ypres, the Somme, and the Argonne, as well as Vimy ridge and Verdun, are painted a bloody splash of red on the violent historical canvas of Europe and Western civilization. It was a vast human abattoir, unpredicted and unstoppable by the era’s generals and politicians. When mass formations of young flesh and young bone advance, unprotected, against such twentieth century innovations as long-range rapid firing artillery, ubiquitous machine guns, and mustard gas, it is the flesh and bone that almost invariably lose, even if a few yards of barbed wire or torn earth or trenches filled with rotting corpses had been re-gained.

That war created wounds never before seen, on a scale never before imagined. The magnitude and horror of the wounds created by high velocity gunfire and steel shrapnel was unprecedented and quickly abrogated many of the principals of the treatment of war causalities which had been taught to surgeons since the musketry and cannon balls of the American Civil War. The facial wounds created by modern warfare would require an innovative genius who would explore beyond the limited surgical dogma of the past and who could create new principia of therapy.

In France, in 1915, those victims of massive facial wounds who survived the initial hemorrhage and secondary infection of facial parts crushed or blown away, were shunted off to rear hospitals, hidden out of sight, doomed to jawless, joyless lives. Those were the real Andy Gumps, also frequently missing noses, cheeks, lips, or ears. Esthetic and functional cripples, they were condemned to social ostracism or self-imposed lives of solitude, phantoms not of the opera but of families, villages, and mirror-less veterans’ nursing homes.

Kazanjian found them, because no one else wanted them or knew how to care for them. Using his dental prosthetic techniques and developing previously untried surgical grafts and tissue flaps of muscle, bone, and skin, he filled in gaping wounds and rebuilt the broken mutilated faces. Performing innovative surgery and utilizing the early twentieth century prosthetic materials available to him, he rebuilt or replaced jaws, cheeks, noses, and lips, treating over three thousand of the wounded, mutilated leavings of The Great War. He restored many of them not only to functional ability, but to social acceptability as well, improving both their image and their self-esteem. British, French, and American surgeons heard of his successes and came to him to learn his new procedures and principles. He became renowned as a miracle surgeon, and at war’s end he was honored as Companion of St. Michael and St. George at Buckingham Palace by King George V.

In 1919, he returned to Boston as Professor of Oral Surgery at Harvard, but he knew all too well that despite his experience and accomplishments, he would be severely limited in the scope of surgical procedures permitted to him. His lack of a medical degree and sanctioned general surgical education as well as the generally low esteem for dentists held by physicians of that time would negate all that he had accomplished. He enrolled in the Harvard Medical School and graduated at the age of forty-two.

While a student at the medical school, two officers of the Royal Army Medical Corps were guests at a lecture also attended by the medical greats, neurosurgeon Harvey Cushing and physician Sir William Osler. One of the British officers, looking up, recognized Kazanjian in the back of the amphitheater and introduced the quiet, modest middle-aged student to his unknowing classmates as the Miracle Man of the Western Front.

Following graduation, Kazanjian pioneered the specialty of plastic surgery in America, holding the titles of Professor of Oral Surgery and Plastic Surgery at Harvard. His contributions in the form of new techniques, texts, and published papers expanded both fields for the next three decades as he remained true to the legend that had grown around his name. His text, the Surgical Treatment of Facial Injuries remains a classic in the field, though revised many times by his former students and in turn their students, who are perhaps his greatest legacy.

Regrettably, I never met Dr. Kazanjian, who had retired from Harvard before I arrived there, though I am familiar with his legend and his surgical publications. I will never be able to claim that I played in his ballpark, perhaps not even in his league, but that chance dusty brush with history in a shadowy basement corridor definitely sparked my desire to learn the game. Certainly his experiences stimulated me to press on to complete a medical education after dental school. Would I find what I was seeking?

Kazanjian was truly unique, but my home-town mentor and a few of the HSDM Oral Surgery faculty complained, privately, of the same frustrations – the ability to gain only limited OR surgical privileges because they had no M.D. degree and no formal training in general surgery. Why had they been locked-out? Was it centuries old tradition and prejudice, was it academic medical arrogance or was it simply the refusal of other surgical specialties to compromise their professional pride and professional pocketbooks? Surely, I thought, they must be able to comprehend that a dentist, with comprehensive knowledge of the human mouth, jaws, and teeth, would be an ideal surgeon of these anatomical areas. But history had proven repeatedly that the M.D, degree and the education it represented was the key to unlock the door to adequate surgical training and thus ultimately to improve patient care. I also reasoned that with an M.D. I could fill the gaps in the expertise of the non-dental surgeons who were treating broken and diseased jaws and faces. I believed that someone—and why not me?—could bridge the ancient chasm between dentistry and the other healing arts. Presumptuous, naive, egotistical—yes, but I was willing to try where others had failed. After dental school, I would finish those last two years of medical school, but I planned never to jump ship to some other type of endeavor.

I knew that choosing such a long and difficult course would not be easy, but to a twenty-five year old, anything seemed possible. The few classmates whom I confided in thought otherwise: You’ll be on a tightrope and they’ll cut it. You’re risking everything—do you know that? I knew that Harvard would not be pleased, but I was confident that any discouragement from that quarter could be overcome by the intensity of my dedication and by the basic decency and objectivity of the venerated Harvard faculty and administration.

Applications to medical schools, near and distant, were mailed, but not to HMS. I requested advanced standing, inasmuch as I had already successfully spent those two years of basic science study at HMS. Most of the schools responded negatively, stating that Harvard had refused to confirm my completion of those two years, indeed would not even send transcripts of my grades! However, Tufts University Medical School in Boston, being familiar with both HMS and HSDM sent me a letter of acceptance to their third year. It had been so easy after all. I immediately mailed the acceptance fee to seal the deal.

Harvard School of Dental Medicine Main Building

Main Building, Harvard School of Dental Medicine.

Le Miserable

In The Yard

April 1958

In the early spring of 1958, I was summoned by phone to the office of Dr. Heyman, the Dean at Tufts Medical School. He handed me a Tufts University check for the amount I had submitted. So much pressure is being applied from Harvard’s medical and dental deans, he stated. They insist that I reject you. Boston, he concluded, is a small town and I have to live in it… get out of town, son, if you really want to go to medical school.

The twenty minute ride back on the subway seemed endless—like Charley on the MTA. I felt trapped, ill, a blend of physical numbness and intense emotional pain. Two back-stabbing deans at Harvard and a spineless one at Tufts! By the time I exited near HSDM, my mood had changed from incredulity to anger. I was determined not to let my future be stolen away from me. I strode past the secretary into the Holy of Holies, the office of a Harvard dean. I knew little about him – only that the faculty considered him to be a competent administrator and that he was neither a dentist nor a physician, but was a well-respected research scientist.

Dr. Greep, I stuttered, how could you… how could you and Dr. Berry [the HMS Dean] do this to me?

He leaned back in his chair. The narrow lips and thin mustache moved slowly and deliberately. It’s done, Morton, and any further attempts on your part will be futile… go back to your patients in the clinic.

I stammered on, cold and sweaty, leaning toward the desk and then back to the door—a physiologic fight or flight situation, to be sure. What are you talking about? I applied to other medical schools, not Harvard—some of them over a thousand miles from here. You have no right… I can do whatever I please with my own life.

He stared and said nothing. I went on. I’ll never quit Oral Surgery… just give me a chance to try to change and improve things for us and for the people we can help. I was talking to a wall—a tall, thin, graying, patrician Harvard wall behind a Harvard desk in an imperial Harvard office. Despite my anger and outrage, both at him and the system he served, I resisted the almost overwhelming temptation to jump over the desk and throttle the son-of-a-bitch. I spoke with all the intensity of someone who has been grievously wronged by a conspiracy of the people he most trusted and admired. "This is wrong, very wrong. It’s just plain unethical for you to do this to me."

Yes, he finalized, without even a hint of emotion, it is, and that’s the way it’s going to be. I can still hear it – "Yes! It is, and that’s the way it’s going to be." That’s what the man said.

And so it was, for the remaining two months of that academic year. Suddenly my clinical work was not quite to standards, my attitude was incorrect, and some of the faculty were uncertain that I was fit for graduation. Some of my classmates, while not actually shunning me, did distance themselves—I had become a pariah. I asked a selected few of the faculty for advice and help. Most responded that they liked being at Harvard, and therefore could offer me no assistance.

I felt genuinely persecuted, trapped, and desperate. I had a wife and child and graduation was a must, and so I kept my mouth shut. Had this been the ’60s or ’70s perhaps I would have organized a sit-in or take-over of the dean’s office, with TV cameras present. In the ’80s or ’90s, or later I might have brought a civil rights suit and appeared on talk shows. But I was a child of the ‘50s, the silent generation, and I kept quiet and accepted my fate. I became resentful and at times aimless and listless. My days were slow and gray and my nights long and dark, staring at our bedroom ceiling. In retrospect, perhaps I was sliding toward depression. But I was saved by my wife’s unshakable optimism and realism and by my fantasies, which included starting all over in some medical school’s first year (too expensive) or waiting in the parking lot and pummeling the cold cruel bastard into a bloody pulp (too risky). I considered contacting the President. There, the term President signifies the President of Harvard, then Nathan Pusey, a distinguished educator. But what if he referred my pleas back to his deans? Would he be likely to challenge the power and decisions of two deans over the fate of one lousy little dental student? Would I graduate or even be denied that? What would become of my family? Perhaps I could try graduate school in biology or a job in a hospital lab or even work in my father’s furniture store. We discussed it over and over again, evening after evening seated at our small kitchenette table. I just can’t accept what these bastards have done to us. To hell with them. We’ll be ok. I know we will. I wish I could believe that.

They were powerful and unassailable while I was weak and totally vulnerable. They clearly understood the arbitrary and cavalier injustice they had wrought upon me and they didn’t give a rodent’s rear-end. These demi-gods of academia had felt threatened by the career aspirations of one trusting and defenseless neophyte. Mixing metaphors knowingly, I found those academic gods of Harvard to have feet of clay, which they put, one at a time, into their pants. Perhaps it was an overwhelming sense of disappointment and betrayal that I was experiencing, not depression. They were small men in high places, now worthy only of my contempt, rather than awe and respect. It was a shocking lesson in an otherwise trusting and reasonably tranquil life. I would recover, but never be quite the same. Why? Why had the deans crushed my dream? Was it fear for the future of Harvard’s dental school (and its faculty) if I were to become a role model for other students, especially if I were then to become yet another apostate from dentistry into medicine? Or was it simply that I had defied them, and from their lofty Olympian view that was intolerable?

It was now far too late in the academic year to find a first-rate residency in Oral Surgery to commence July 1, but a furious spate of phone calls resulted in a last-minute acceptance into a small Philadelphia hospital program, not fully accredited and unlikely to train me to perform the spectrum of surgery for which I had planned. We rationalized, Phyllis and I; we were young and our young baby was healthy and the move to Philadelphia was after all not a box car to Auschwitz or Dachau and maybe, just maybe, I could convince some better program to take