INTERVIEW: WHEN I GROW UP:
BECOMING A PATHOLOGIST.
DRAFT COPY ONLY.
G. William Moore, MD, PhD.
http://www.netautopsy.org/billgrow.htm
United States Government Work, uncopyrighted, public-domain,
DRAFT COPY ONLY. This document does not necessarily represent the views
or policies of any United States Government agency. This document is provided
"as is", without warranty of any kind, express or implied, including but not
limited to the warranties of merchantability, fitness for a particular
purpose and non-infringement. In no event shall the authors be liable
for any claim, damages or other liability, whether in an action of contract,
tort or otherwise, arising from, out of, or in connection with the document
or the use or other dealings made with the document.
The following discussion is adapted from an email correspondence
exchange between myself and the students of Johnston Middle School,
Johnston, Iowa, in February, 1999.
What is Pathology?
Pathology is the study of diseases
that occur in humans (human pathology)
or in non-human animals (veterinary pathology).
Many questions about pathology are
answered in more detail if you go to the
internet, and enter a few keywords, including
PATHOLOGY or HUMAN PATHOLOGY:
http://www.google.com/
What education is required to be a pathologist?
Human pathologists must have a bachelor's degee (four years of college)
a Doctor of Medicine (M.D.) or Doctor or Osteopathy (D.O.) (four years),
plus five years of additional training in a pathology residency program.
Veterinary pathologists must have a Doctor of Veterinary Medicine (D.V.M.)
and additional specialty training. Admission to U. S. medical schools
and veterinary schools is highly competitive, and requires
good undergraduate college preparation and grades.
How did I become interested in Pathology?
I became interested in biology and medicine research
when I was a middle school student. I participated in Science Fairs,
which were an opportunity for young scientists to show their work
to their peers (that is, among other young scientists), as well as
to adult judges.
I chose to go into medicine, because this is a practical area,
where you can immediately help other people. I chose pathology
because it is one of the most scientific branches of medicine,
and because it is one of the few branches of medicine, along with
general family practice and radiology, where you can work with diseases
of the entire body. Most other medical specialists work with
a particular area of the body, like the brain, the eyes, the skin,
the chest, the abdomen, etc.
What electronic tools are used in pathology?
At this moment in history, there are not many electronic tools
in the routine pathology laboratory, outside of computers
to perform ordinary office functions, like email and fax.
There has been a lot of discussion about an emerging area,
namely, TELEPATHOLOGY, in which a pathologist in one location
looks at specimens under a microscope which is physically located
hundreds of miles away. This has been suggested especially for remote,
sparsely populated areas, which do not have enough work to employ
a full-time pathologist. Right now, telepathology is still
very experimental, and many of the problems have not yet been worked out.
How important are autopsies?
Autopsies have always been very important
in societies with a sophisticated medical
culture, like the United States.
There are many medical questions that you can
determine from autopsy studies that
cannot be answered any other way.
There are two basic types of autopsy:
MEDICAL (asking why a patient died in a hospital);
and FORENSIC (asking why a patient died
under suspicious circumstances).
You might wish to enter FORENSIC PATHOLOGY
as a keyword on google.com.
In my job, I perform medical-type autopsies.
Medical-type autopsies are important
in studying the progress of diseases,
like heart-disease and cancer,
and determining whether certain
treatments have helped the patients.
There is a Latin saying that every
pathologist knows: Mortuí vivós docent.
The dead teach the living.
Most states have a MEDICAL EXAMINER,
a group of pathologists who have
additional training in forensic-type
autopsies, and who perform autopsies
on persons who died under suspicious circumstances.
Every pathologist, of course, has some
training in forensic pathology.
In my job, if I think that a crime
has been committed, I consult with
the medical examiner.
In recent years, the number of medical-type
autopsies performed in this country
has decreased greatly, but the number of
forensic-type autopsies has remained steady.
I think that the decrease in medical-type autopsies
is a mistake, but I am not allowed to decide whether
to request an autopsy.
Does it hurt the family to have and autopsy?
In my opinion, it never hurts the family
to have an autopsy, unless the family objects
to an autopsy for religious or other personal reasons,
or the family is informed of the autopsy results in an
insensitive way. For example, in Muslim
cultures, autopsies are almost never performed.
In my opinion, the doctor who has cared for
the patient during life should always
interpret the autopsy report for the family.
The autopsy report is written in very technical
language, and non-medical people might be
offended or confused by what they read
in an autopsy report.
How do I feel when I do an autopsy?
Pathologists are usually thinking about
the technical parts of an autopsy when
they perform an autopsy. Why did the patient die?
Was the disease controlled as well as possible
by the treatments? Will there be any unexpected findings?
Pathologists almost never know the patient
that they autopsy, and they become accustomed
to the gruesome parts of the autopsy.
If you can't get used to working with dead bodies,
then it doesn't make much sense to become a pathologist.
Still, even pathologists have feelings.
The autopsies that bother me the most
are the ones on young people about
your age who have suffered a great deal
before they died. We all have to die sometime,
but it seems to me that everyone should
have the chance to grow up first.
There is a joke among pathologists that we think about food
when we do autopsies. Many findings seen at autopsy are named
after food, probably because food is so familiar to everybody.
Examples: NUTMEG LIVER, CASEOUS NECROSIS,
BREAD AND BUTTER PERICARDITIS, SUGAR-CAKE SPLEEN, etc.
(These terms were invented by nineteenth century German
pathologists, and a lot of young people these days
don't even know what a nutmeg or sugar-cake look like.)
Put a few of these phrases into google.com on the internet,
and see what you get.
What do pathologists do, besides autopsies?
It might surprise you to learn that non-medical-examiner
pathologists do not spend much of their time
performing autopsies these days. Pathologists like myself
spend most of their time looking at specimens
that surgeons and other doctors remove from
a living patient. We prepare the specimens and look
at them under the microscope, so we can tell
the patient's doctor what is wrong with the patient.
Most working days for a pathologist are about
the same as for other professional people,
like lawyers, teachers, and businessmen.
It is a long, somewhat unpredictable work-week,
but most pathologists do not work at extremely odd hours,
like surgeons or emergency-room doctors.
There ARE emergencies in pathology, but
they don't happen very often. Usually,
a pathologist must be called to the hospital
if a patient needs emergency surgery,
and the surgeon needs to know the diagnosis
(that is, what disease) before he/she finishes
the operation. In these emergencies,
the pathologist quick-freezes the specimen
that the surgeon removes from the patient,
and makes a diagnosis, so the surgeon
knows what to do next. Most routine specimens
in pathology take several days to process,
sometimes longer if there are special tests.
Does the autopsy always give a conclusive answer?
Every honest pathologist will admit that
at least one in ten medical-type autopsies
does not tell us why the patient died.
I don't know what the percentage is
in forensic autopsies, but it is probably
a lot smaller. Still, there are some
things so wierd that a criminal can do,
that you couldn't figure it out in your
wildest imagination. A German-speaking
pathologist once told me a little rhyme
about forensic autopsies.
If you won't be offended by a slightly
off-color joke, then you can enter the
keywords UMSUNST BILL MOORE on google.com.
(Don't worry; the rhyme is translated.)
How important are findings at the crime scene?
The crime scene can be very important,
depending on the particular case.
The pathologist's findings are only
part of the puzzle, and the observations
obtained at the crime scene are necessary to put
together the whole picture, and make sense
out of the autopsy results.
ADDITIONAL NOTES:
1. Supporting material for this interview is posted on a private website,
at URL:
http://www.netautopsy.org/axsop/axsoptoc.htm
Procedures 202-227 are particularly relevant to autopsies.
Please note that the above, private website is only an approximate copy
of some sections in the Anatomic Pathology Procedure Manual of the
Baltimore Veterans Affairs Maryland Health Care System. The document
is uncopyrighted, public-domain, draft copy, and has
NO OFFICIAL STATUS. The document may be copied freely.
It is offered as a model electronic document, in a spirit of cooperation
with other pathology laboratories worldwide, who are considering
developing an electronic pathology manual at their medical institutions.
The authors assume no responsibility for any damages that might arise
from the use of the present document. See disclaimer:
http://www.netautopsy.org/axsop/axsopint.htm
2. In the State of Maryland, a Medical examiner's case
is defined as "any death which is the result, wholly or in part,
of a casualty or accident, homicide, poisoning, suicide, criminal abortion,
rape, therapeutic misadventure, drowning, or a death of a suspicious
or unusual nature, or of an apparently healthy individual,
or a case which is dead on arrival at the hospital."
The State of Pennsylvania has a similar law.
The website for the Office of Medical Examiner, State of Maryland, is:
http://www.dhmh.state.md.us/ocme/law.htm
3. Related interview:
http://www.netautopsy.org/billgrow.htm
4. Description of an autopsy:
http://www.deathreference.com/A-Bi/Autopsy.html
5. G. William Moore, MD, PhD. Curriculum Vitae.
http://www.gwmoore.org/gwmcv.htm
6. Association for Pathology Informatics.
Honorary Fellow Award. Recipients.
Sidney A. Goldblatt, MD. 2002.
Donald P. Connelly, MD, PhD. 2003.
William R. Dito, MD. 2004.
Raymond D. Aller, MD. 2005.
Bruce A. Friedman, MD. 2006.
G. William Moore, MD, PhD. 2007
http://www.pathologyinformatics.org/FellowAward.htm
Last tested: September 3, 2007.
7.
Definition: Pathology is the study of the etiology
and pathogenesis of disease. Our modern understanding begins with the
publication of
Giovanni Battista Morgagni's
De Sedibus et causis morborum per anatomem indagatis (1761)
(On the seats and causes of diseases, demonstrated by anatomy). In the
twentieth century, the work of
George N. Papanicolaou, MD, PhD,
saved more lives than any other single advance in pathology.
8.
Mortality statistics involves drawing inferences from large quantities
of mortality, data, collected systematically and repetitively.
The name derives from
mors (Latin: death), and
status (Latin: the state),
because
the first mortality statistics were the
Bills of Mortality,
collected by the British government
in 18th century London.
In European countries with inheritance taxes,
dead citizens and the causes of their demise
have always been a serious matter to the government.
See also: coroner (latin: corona=crown),
originally a British tax official who determined the cause-of-death,
and thus the disposition of the decedent's estate.
The 18th century British gentleman, John Graunt
was the first person to organize these statistics
(i.e., summary data on many persons),
and use them for descriptive and predictive purposes.
Graunt documented the XXXXX epidemic in London,
and was able to conclude that there was an outbreak of XXXXX
localized in the unsanitary conditions of the poorer districts of London,
leading to social reforms.
9. Sushruta. Indian anatomist.
Performed the first autopsy in 5000 BCE.
From Wikipedia:
http://en.wikipedia.org/wiki/Sushruta .
10. Hippocrates.
(`Iπποκρατης,
460-370 BCE)
Hippocrates. Volume I.
Jones WHS, transl. Loeb Classical Library.
Cambridge, MA: Harvard University Press. 1923.
ISBN 0-674-99162-1, 361 pages.
Hippocrates is the Father of Medicine.
The above book includes Hippocrates' Oath, with explanatory notes.
Every doctor swears a version of this oath upon becoming a physician.
"First, Do No Harm" is not in the Hippocratic Oath, but rather in
Epidemics, Bk. 1, Sect. 11. One translation reads: 'Declare the past,
diagnose the present, foretell the future; practice these acts.
As to diseases, make a habit of two things: to help, or at least
to do no harm.'
This note supplied by Harris G. Yfantis, MD.
Ancient Greek medicine was based upon the concept of four humors (blood,
bile, phlegm, and urine), as well as the location of the patient,
season of the year, and nearby epidemics. Many medical terms that we use
today, such as bronchitis, nephritis, hepatitis, carcinoma, etc.,
have their origins in the writings of Hippocrates, although we have a much
different view of pathogenesis that did these ancient physicians.
11. Galen Greco-Roman physician (129-200).
(Latin: Claudius Galenus) "of Pergamum was a prominent ancient
Greco-Roman physician, whose theories dominated Western medical science
for over a millennium."
"...Galen's writings on anatomy were the mainstay of the medieval physician's
university curriculum, but they had suffered greatly from stasis and
intellectual stagnation. In the 1530s, however, Belgian anatomist and
physician Andreas Vesalius took on a project to translate many of Galen's
Greek texts into Latin. Vesalius's most famous work, De humani corporis
fabrica, was greatly influenced by Galenic writing and form. Seeking
to revive Galen's methods and outlook, Vesalius turned to human cadaver
dissection as an evolution of Galen's natural philosophy. Galen's writings
enjoyed a revival at the hands of Vesalius, who promoted Galen and expounded
on him through books and hands-on demonstrations. Since most of Galen's
writings were also translated into Arabic, the Middle East knows and reveres
him." From Wikipedia:
http://en.wikipedia.org/wiki/Galen .
12. Avicenna (Ibn-Sina) (980-1037).
(Abu `Ali al-Husayn ibn `Abd Allah ibn Sina al-Balkhi;
Latinized as Avicenna). Persian Muslim physician, philosopher, and
polymath: physician, astronomer, alchemist, chemist, logician, mathematician,
metaphysician, philosopher, physicist, poet, scientist, theologian,
statesman, and soldier. Avicenna was born in Afshana near Bukhara
in Khorasan (now part of Uzbekistan), and died in Hamadan (now in Iran).
Avicenna authored some 450 books on a wide range of subjects, many of which
concentrated on philosophy and medicine. His most famous works are:
The Book of Healing and The Canon of Medicine, which was for almost five
centuries a standard medical text at many Islamic and European universities.
Avicenna's medical system was that of Islamic medicine, which was influenced
by the medical system of Galen, Aristotelian metaphysics, and early Persian
and Arabian medicine. Avicenna is regarded as the father of modern
medicine, and the father of the fundamental concept of momentum
in physics.
From Wikipedia:
http://en.wikipedia.org/wiki/Avicenna .
13. Andreas Vesalius (1514-1654), Belgian anatomist, author of
De Humani Corporis Fabrica (On the workings of the human body),
one of the most influential books of human anatomy.
From Wikipedia:
http://en.wikipedia.org/wiki/Andreas_Vesalius .
14. Giovanni Battista Morgagni (1682-1771). Italian anatomist,
born in Forlì, Italy. Father of modern anatomic pathology.
Morgagni published his "great work which, once for all, made pathological
anatomy a science, and diverted the course of medicine into new channels
of exactness or precision: De Sedibus et causis morborum per anatomem
indagatis (1761) (On the seats and causes of diseases, demonstrated
by anatomy) which during the succeeding ten years, notwithstanding its bulk,
was reprinted several times in its original Latin, and was translated
into French (1765), English (1769), and German (1771)."
From Wikipedia:
http://en.wikipedia.org/wiki/Giovanni_Battista_Morgagni .
For the younger readers, please note that this monumental
work was the product of Morgagni's mature years.
15. Karl Baron of Rokitansky. (1804-1878).
Czech-Austrian Pathologist. Father of modern autopsy pathology methods.
From Wikipedia:
http://en.wikipedia.org/wiki/Carl_Rokitansky
16. Rudolf Virchow (1821-1902).
German Pathologist. Father of modern cellular pathology.
From Wikipedia:
http://en.wikipedia.org/wiki/Rudolf_Virchow
17. Franklin P. Mall (1862-1917). Born "in Belle Plain, Iowa.
He received his MD from the University of Michigan, in 1883 and for the next
three years was involved in postgraduate study in embryology and physiology
in Germany. He came to Baltimore in 1886, as one of William H. Welch's first
fellows in pathology. Mall left Johns Hopkins in 1889 to become an adjunct
professor of vertebrate anatomy at Clark University, Worcester, MA.
From there he went to the University of Chicago, Chicago, IL, for a year
as professor of anatomy, before returning to Johns Hopkins in 1893
as the first professor of anatomy at the school of medicine. His research
included embryology and the relationship between structure and function
in adult organs, particularly the spleen, liver, and heart. Mall, together
with Welch, conceived the idea of a full-time faculty in medicine with salary
support sufficient to allow time for research." From
The Johns Hopkins archives.
18. William H. Welch (1850-1934), American pathologist
and microbiologist, for whom the bacterium Clostridium welchii
is named. "He was first dean of the Johns Hopkins University School
of Medicine. Born in Norfolk, Virginia, Welch was educated
at Norfolk Academy and the Winchester Institute. He entered Yale College
in 1866, where he studied Greek and classics. As an undergraduate,
he joined the Skull and Bones honorary fraternity. In 1912,
upon its creation, Welch was appointed to the Board of Scientific Directors
of the preexisting Eugenic Records Office. This organization attempted
to find the hereditary connection for "feebleminded" individuals between
generations; with the understanding they could eradicate these and other
undesirables through isolation, sterilization and euthanasia.
The ERO had contributers such as the Rockefeller Foundation
and the Harriman Family.
"From 1901 to 1933 he was founding president of the Board of Scientific
Directors at the Rockefeller Institute for Medical Research. He was
an instrumental reformer of medical education in the United States,
as well as a president of the National Academy of Sciences from 1913-1917.
He was also president of the American Medical Association in addition
to other prestigious associations. He was a founding editor
of the Journal of Experimental Medicine."
From Wikipedia:
http://en.wikipedia.org/wiki/William_H._Welch
.
19. Karl Albert Ludwig Aschoff (1866-1942),
German pathologist, for whom Aschoff bodies in the heart
(a morphologic finding in rheumatic heart disease) are named. Prof. Aschoff
"... was one of the most productive of the group of German pathologists
who flourished in the late nineteenth and early twentieth centuries.
He is especially remembered for describing the reticuloendothelial system,
and the bodies that bear his name. He studied in Bonn, Strassburg,
and Göttingen, and graduated from the University of Bonn in 1889.
He was conferred doctor of medicine in 1889; in 1894, he was habilitated
[associate professorship] for pathological anatomy; and became first
assistant at the Institute of pathology in Göttingen under Friedrich
Daniel von Recklinghausen (1833-1910). He became professor of pathology
at Marburg, in 1903; and from 1906 onward was professor in Freiburg
im Breisgau, where he spent the rest of his career, retiring in 1936.
At Freiburg, he established an institute of pathology that attracted
students from all over the world.
"Aschoff made important studies on appendicitis, gallstones, jaundice,
scurvy, and thrombosis, and wrote classical histological descriptions
of rheumatic conditions. He is, however, particularly remembered
for having recognized the phagocytic activity of certain cells found
in diverse tissues, and named them the reticuloendothelial system.
"His outstanding textbook on pathological anatomy went through
many editions, and was used as a standard text for many years.
"Aschoff was the publisher of Beiträge zur pathologischen Anatomie
und zur allgemeinen Pathologie [Contributions to Pathologic Anatomy
and General Pathology; now: Pathology, Research and Practice.]
and Veröffentlichungen aus der (Kriegs-), Gewerbe und
Konstitutionspathologie. [Publications from (Wartime-), Commercial,
and Constitutional Pathology.]"
From:
http://www.whonamedit.com/doctor.cfm/251.html
20. George L. Wied (1921-2004) "... was no longer here,
having passed away in Salzburg, Austria, on July 25th. But as the meeting
unfolded, I realized that George's mark was deeply imprinted on the entire
scientific program, and that his legacy was carried by most of the people
in attendance.
"George Papanicolaou is attributed
with the discovery of the cytologic method for detecting epithelial tumors.
His laboratory at Cornell Medical Center in New York was the culture medium
for the discipline, instructing such notable cytologists as Leopold Koss
and George Wied. The medical specialty itself, however, owes its success
to George Wied, for without him, it is doubtful whether it would have
survived the skepticism of most other medical specialists.
"Dr. Wied had faith in the importance of cytology that was unwavering
and his conviction was transmitted to all who followed him around the globe.
A survivor of Nazi Germany, he was a fierce defender of individual freedoms,
and he translated that zeal into inclusion of all peoples in his vision.
He was an instinctual teacher and taught those around him to convey the
criteria of those strange cellular samples via the Tutorials of Cytology.
His attention to detail was impeccable, a trait that he insisted
his faculty emulate.
"...But where Dr. Wied had the most fun was in the realm of cytology automation.
As I listened Sunday to the presentations of experiences with the "new"
imaging systems and their integration into the clinical cytology laboratory,
I recalled the numerous conferences devoted to development of computerized
scanners. As early as 1951, Dr. Wied recognized that computers would become
an essential part of our daily lives, for data management and communication.
He also realized that the task of screening slides was work intensive,
subjective, and fraught with opportunities for error. If Dr. Wied didn't have
the knowledge himself, he immediately reached out to others who did, and
drafted them to the cause of automating his specialty. One of those recruits
was Peter Bartels, a gifted optical scientist and incredibly creative problem
solver. Together they built a team of researchers at the University
of Chicago that attacked each obstacle to success like an army
of dragon slayers...."
Rosenthal DL.
Remembering George L. Wied, MD, February 7, 1921-July 25, 2004.
CytoJournal. 2005;2:2.
From:
http://www.cytojournal.com/content/2/1/2
21. George N. Papanicolaou (1883-1962) "was born at Kimi
on the island of Evia, in Greece. He was a pioneer in cytology
and early cancer detection. He studied at the University of Athens,
where he received his medical degree in 1904. Six years later,
he received his PhD from the University of Munich, Germany. In 1913,
he emigrated to the USA, in order to work in the Department of Pathology
at New York Hospital and the Department of Anatomy
at the Weill Medical College of Cornell University.
"Papanicolaou first reported that uterine cancer could be diagnosed
by means of a vaginal smear in 1928, but the importance of his work
was not recognized until the publication, together with Herbert Traut,
of Diagnosis of Uterine Cancer by the Vaginal Smear in 1943.
The book discusses the preparation of the vaginal and cervical smear,
physiologic cytologic changes during the menstrual cycle, effect of various
pathological conditions, and the changes seen in the presence of cancer
of the cervix and the endometrium of the uterus. He thus became known
for his invention of Papanicolaou's test, now known as the Pap smear,
which is used worldwide for the detection and prevention of cervical cancer
and other cytologic diseases of the female reproductive system.
"In 1961, Papanicolaou moved to Miami to develop the Papanicolaou Cancer
Research Institute at the University of Miami, but died in 1962 prior
to its opening. Dr. Papanicolaou was a recipient of the Lasker Award."
From Wikipedia:
http://en.wikipedia.org/wiki/George_Papanicolaou
.
Papanicolaou's work saved more lives in the twentieth century than any other
single advance in pathology.
22. Berman JJ. Tumor classification: molecular analysis
meets Aristotle.
BMC Cancer. 2004 Mar 17;4:10.
PMID: 15113444
PubMed Entry
23. Embryogenesis. Embryology is the basis
for our understanding of cancer. See:
Willis RA.
The Borderland of Embyology and Pathology.
London: Butterworths. 1958;:.
ASIN: B0007IXPWK, 33 pages.
Willis RA.
The borderland of embryology and pathology.
Bull N Y Acad Med. 1950 Jul;26(7):440-460.
PMID: 15426876.
PubMed Entry
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29. Sherwood SJ, Start RD, Birdi KS, Cotton DWK, Bunce D.
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31. Geller SA.
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32. Moore GW, Berman JJ.
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Chapter 4. In: Cios KJ.
Medical Data Mining and Knowledge Discovery.
Berlin: Springer Verlag. 2000;4:61-107.
ISBN: 3-7908-1340-0, 502 pages.
Published within the series: "Studies in Fuzziness and Soft Computing",
Physica-Verlag Heidelberg, a Springer-Verlag Company.
35. Rosenthal DL.
Remembering George L. Wied, MD, February 7, 1921-July 25, 2004.
CytoJournal. 2005;2:2.
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36. Petersdorf RG, Beeson PB.
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Medicine. 1961;40:1-30.
Remark about "Sutton's Law" on p. 27.
"Sutton's Law" reflects the uncertainty of a medical diagnosis.
37. Sutton W, Linn E.
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New York: Ballantine Books. 1976;:.
ISBN 0-345-25371-X-195, 422 pages.
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Sutton's Law (Willie Sutton, 1901-1980; American bank robber.)
Report's question: "Willie, why do you always rob banks?"
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Chapter 5. A New Mother's Challenge. pp. 101-131.
p. 126. "Common things are common."
p. 126. "When you hear hoofbeats in the street,
think about horses, not zebras.
p. 127. "... the phrase `zebra retreat' ... describes a doctor's
shying away from a rare diagnosis."
Last Updated: 12/5/2007, by G. William Moore, MD, PhD.