INSIDE STORY

CHICAGO/OCTOBER 1984

gastroenterology [gasrer stomach + enteron. intestine+ logos, study]. The branch of medical science concerned with study of the physiology and pathology of the stomach, intestines, and related structures such as the esophagus, liver, gallbladder, and pancreas. Taber s Cyclopedic Medical Dictionary Most folks his age are still asleep in

their retirement homes when, at five o'clock in the morning, 75-year-old Joseph B. Kirsner, M.D., Ph.D., the world's pre-eminent gastroenterologist, gets out of bed in the spacious Hyde Park high-rise apartment he has lived in for 36 years and prepares to go to work.

Fittingly, for a man who is always advising his patients to eat properly, Dr. Kirsner now sits down to a healthful breakfast being set out by Minnie, his wife of 50 years. Besides orange juice and melon and cereal with banana, he has half a slice of bread and half a cup of coffee.

Then, calling a nearby garage to deliver his car, he sets out for the University of Chicago Medical Center, where he is the Louis Block Distinguished Service Professor of Medicine. Kirsner has been on the faculty for 49 years. "I'd walk over," he tells a visitor, "but I walk five miles a day through hospital corridors making rounds, and that's enough."

By 6:30 a.m. Kirsner is sitting at his desk in the former Billings Hospital next to Medicine 6, the Gastroenterology Clinic, in an unfashionable but comfortable office he carved out of a one-time men's washroom and a storeroom. "My offices have usually been in former storerooms and closets," he says, turning to the neat stacks of paper on his desk. The office Doing what he does best 75-year-old Dr. Joseph Kirsner listens to a patient. furnishings tell something about their owner. A framed saying by Albert Einstein proclaims: MAN IS HERE FOR THE SAKE OF OTHER MEN. Another, by the late football coach Vince Lombardi, says: THE QUALITY OF A MAN'S LlFE lS tN DIRECT PROPORTION TO HIS COMMITMENT TO EXCELLENCE.

On the bookshelves, four medical textbooks Kirsner has written, and several dozen document boxes holding nearly 600 scientific papers and chapters in 12 scientific books, reveal him as a creator of the modern specialty of gastroenterology. Taking a scientific approach, rather than the anecdotal one that prevailed when he came on the scene in the 1930s, Kirsner made his once-disdained specialty respectable by systematically probing the underlying nature of digestive problems. He emerged as the world expert on inflammatory bowel disease¸ulcerative colitis and Crohn's disease¸affecting up to two million Americans with devastating internal inflammation, ulceration, and bleeding, and resulting in the inability of its victims to absorb nourishment as they experience terrible diarrhea. Frequently, the diseased bowel has to be cut away. When Crohn's affects young children it may stunt their growth.

Kirsner's file cabinets hold the names of the 200 gastroenterologists he has trained in the past decades (along with countless medical students, interns, and residents) during two- or three-year fellowships. Many are now leaders in their field. The cabinets also contain correspondence with several gastroenterological societies he helped found as well as letters from patients in every part of the world.

Kirsner's most famous patient with a problem bowel, for whom he makes palace calls, is His Majesty King Hassan 11 of Morocco, Commander of the Faithful, a direct descendant of the Prophet Mohammed and spiritual leader of his nation of 22 million people. "Since February 1976, I've visited him at his palaces 44 or 45 times.'' savs Kirsner, whose Jewishness doesn't seem to bother the Arab king. "I fly to Madrid, where I'm picked up by the king's jet and flown to Fez or Rabat; during my usual two-day stay there I'm put up at a hotel near the palace and am assigned my own chauffeur-driven limousine. I'm happy to report that His Highness is in good health, vigorous and active.'' Satisfied with his treatment, the 55-year-old monarch has made large money gifts to the U. of C. Medical Center. As he sits in the predawn and prepares the dav's work for his administrative assistant and his secretary, on occasion Kirsner undoubtedly reflects on how far he has come from humble origins. The son of Russianimmigrant parents. he grew up in extreme povertv in Dorchester. then the Jewish ghetto of Boston.

His father. a tailor. had to cash in his life insurance policv to pay his son's firstyear tuition of $400 to Tufts University medical school. Thereafter. Kirsner paid his own way by sorting books after school in a library. Summers, he sorted mail from 6 a.m. to 2:30 p.m. at a neighborhood post office, slept for a few hours, and then went downtown to the main post office, where he sorted railway mail until 10 p.m. Despite such rigors, he was elected to Alpha Omega Alpha, the Phi Beta Kappa of medical students.

A proffered internship at Woodlawn Hospital brought Kirsner to Chicago in 1933. "I thought I'd be a general practitioner. but I became very impressed with the University of Chicago, where the doctors. who were paid a salary, worked fulltime." he says. "I wasn't interested in making big money."

He didn't. In the fall of 1935 Kirsner was hired by the U. of C. in the Department of Medicine for $1,000 a year. "By now I was married, and, after a year, when the chief called me in to tell me what a good job I was doing, I thought I'd be getting the raise I needed," Kirsner recalls. '-Instead. the chief pulled out a gray Parker fountain pen and presented it to me as a token of his appreciation! The chief, I learned, took care of the Parker family and had a whole box full of pens." Kirs--------------------------------------------To preserve the privacy of Dr. Kirsner's patients, details of case histories have been altered. ---------------------------------------------ner, who still has the pen, says that the following year he finally got a $200 raise.

Becoming interested in gastroenterology, Kirsner learned his trade from one of the greatest specialists of the era, Dr. Walter Palmer. "He was my teacher and my guide," says Kirsner. "I worked with him seven days and seven nights a week, making rounds every day and being called to patients' bedsides at night." Palmer's photograph is prominent on Kirsner's office wall. Kirsner also got a chance to work with a famous medical refugee from Hitler's Germany, Dr. Rudolf Schindler, who, in 1934, brought to the U. of C. his remarkable gastroscope, a tube with lenses that, when swallowed by the patient, for the first time permitted direct examination of the esophagus and stomach.

Given a storeroom as a laboratory, Kirsner persuaded a pharmaceutical company to supplement his $100-a-year university research budget with a $500 grant. I was my own technician," he says as he reminisces about his pioneer work on peptic ulcer, then the dominant gastrointestinal ailment, which was being treated with the Sippy diet, small amounts of milk and cream every hour and alkaline powders every half-hour. The powders caused alkalosis, a potentially dangerous concentration of alkalis in the blood. Kirsner formulated a modified powder that could better protect against acid secretions.

Earning a Ph.D., Kirsner continued to probe the effects of antacids on the human body, suspending his research only after he enlisted in the U.S. Army Medical Corps in 1943 and requested immediate overseas assignment. He won three battle stars, landing on Omaha Beach shortly after D-day and accompanying the American survivors as the army advanced into Belgium, where a buzz bomb, Hitler's secret weapon, landed in the middle of his hospital. "If I had been in my office I wouldn't be here today," he says, simply.

After the defeat of Germany, Kirsner was put on a transport bound for the invasion of Japan, stopping off in the Philippines, where he treated soldiers with hepatitis, ulcers, and nervous bowels. At night, ever the scholar, he invited newly liberated Dutch medical officers, who had been captives of the Japanese, to munch on chocolate bars from the post exchange and smoke American cigarettes in his tent while he questioned them about the effects of the atomic bomb on survivors of the Hiroshima and Nagasaki blasts. Dutch prisoners had been exposed to the bombs' radiation at both of those places.

Landing in bombed-out Nagoya, Japan, in the fall of 1945, Kirsner helped set up a military hospital in the 14-story telephone building, one of the very few intact structures, and remained there as a major ­ until his return to Chicago in mid-1946. By then, he had a four-year-old son, Rob ert, who later in life disappointed his father temporarily when he dropped out of medical school after a year but who redeemed himself by earning a Ph.D. in linguistics. The Kirsners' only child is now an authority on the Dutch language and an associate professor at UCLA.

At the U. of C., Kirsner returned to hls pleasant 14-hour-a-day grind. finishing his research on ulcers and beginning to focus on the capstone of his life's v.-ork. inflammatory bowel disease. Ten years atter he had returned from overseas, he was producing an incredible 14 or 15 scientific articles a year for medical journals. Even after he had been appointed chief of staff of the U. of C. Hospitals in 1971, a post he held for five years, Kirsner continued his research in the time between seeing patients and training new gastroenterologists. Many important articles resulted.

Nowadays, Kirsner takes it just a little bit easier, trying, after only 11 hours or so to go home, where he changes his clothing to slacks and an open shirt and. at 5:30 p m., watches the news (one of the few occasions when he indulges in television) No cocktails; he drinks only socially. A typical dinner is wholesome: tomato juice or soup, salad, baked chicken. half a potato, fruit, yogurt, and Sanka.

Then, while Minnie Kirsner turns to a mystery novel in French, the doctor retires to a book-lined study containing mementos such as his medals from the U.S Army and various professional societies and a color photo of King Hassan.

A cabinet holds many hundreds of 35 millimeter slides of diseased bowels: Kirsner frequently spends an evening organizing them for an upcoming lecture. This is also a good time for writings which is done on long vellow legal pads. then typed up by a secretary and revised by Kirsner as many as 15 times. Kirsner admits that he expects such meticulousness in others. * believe in doing things right," he said. "I won't tolerate mediocrity or indifference I don't mind firing people."

Next morning, early, finds Kirsner back in his office. There he dons his standard uniform, a white lab coat over pants, a white shirt, and a blue-striped tie. His I.D. badge is unusual in that it displays a small diamond, awarded him by his colleagues on his 40th anniversary at the medical center. Somehow he seems taller than his five feet nine inches; the hair on the back of his head remains black, fiercely resisting the encroaching silver. His eyes gleam alertly behind gold-framed glasses. By the time his office aides have arrived at 8:45 Kirsner has a day's work ready for them.

"Hives are not a usual symptom of Crohn's disease," he dictates. in response to a letter from a patient in California "Check with a physician in your community. An antihistamine may be helpful.~

Kirsner takes a call from a man in Pittsburgh. Forty percent of his patients come from beyond the metropolitan area '-They call in for an appointment and for many of them it is the end of the road," Klrsner says. "But we can't schedule more than six, eight, ten new patients a week¸I want my residents to have time to listen to them. "

Listening while taking a careful case history and performing a careful physical examination are to Kirsner the most important things his people do. "The young doctors today like to rely too much on machinery and the laboratory," he says. "If I had my way I'd charge $500 for an imtial exam to make it possible to do a thorough job, and $300 for a second vislt." Why a second exam? "On the second go-round patients will remember things they didn't the first time."

Not that Kirsner disdains the wonders of modern technology. The thorough work-ups he orders for a new inpatient may cost $5,000 to $10,000 and take days to complete. They include such marvels as double-contrast X-rays after air mixed with barium has been pumped into the colon and the stomach to give a more exact picture. Endoscopes, marvelous $8,000 bundles of fiber optics in a tube swallowed by the patient or introduced through the rectum into the colon for its entire length, use a cold, intense light to illuminate every nook and cranny. Normal tissue is an orange red, glistening and shiny, without ulceration or congestion. In Crohn's colitis and ulcerative colitis there is congestion, swelling, ulceration, and mucus. A tiny grasping tool inserted through the endoscope snips off a bit of tissue for microscopic examination. Photographs are taken. Diagnosis can be precise.

In addition, Kirsner relies on CAT scans to show cross sections of the body angiography to illuminate blood vessels by injecting dye into them, ultrasound for ____________________ __ DR. KIRSNER'S RX For the medical profession Reform is need- [ if ed. I regard medicine as a calling, like the priesthood, and I deplore its commercialize j Be tion. The doctor of today is better trained, | It far better educated, and far more known 0 edgeable than in my generation but far less I committed to medicine as a calling. For heartburn. If you're prone to it, don't | smoke or drink alcohol. For stress and its effect on digestion: Do I everything possible to attain and retain | good health. Develop a caring for others, ' we have lost interest in our neighbors. Be j lucky with the mate you choose; try to find | someone with similar goals and principles. | Have a purpose in life, and this means serv ice to others. For belching and flatulence: Very often they are the result of poor eating habits. Some nervous people swallow a lot of air while | talking; others, while smoking or chewing I gum. Walking is good exercise for getting go rid of gas. J. S. | _ _____________ such organs as the pancreas and gallbladder, and special instruments to peer into the bile ducts and the pancreatic ducts with X-rays. "Sure, it takes time and it's costly," Kirsner says. "But the most costeffective thing I can do for patients like mine, who may have suffered for years, is to come up at last with a solution for their problems. "

When the results of all the tests are in, Kirsner sits down with the patient and his or her relatives and goes over all the data and the X-rays in detail to provide an explanation of the symptoms and recommend a treatment plan. In many cases the patient is returned to the referring physician to carry out the treatment; in others Kirsner may treat the patient himself before sending the person back, and some patients may continue with him.

Every morning Kirsner drops in at his clinlc and peers into the examination cubicles where the staff doctors and fellows are working. "I no longer do endoscopies," Kirsner says. "What I'm doing now is servmg as a consultant."

A young blond woman wearing a hospital gown smiles wanly as Kirsner pulls open a cubicle curtain and greets her. For the past three years she has been coming here from her home in Fort Wayne, Indiana, for treatment of Crohn's disease. Now that she is moving to El Paso, Texas, she will be able to return only rarely. "You're sure you know how to take care of yourself?" Kirsner asks worriedly. The woman nods her head yes.

Turning to a visitor, Kirsner says, "In treating inflammatory bowel disease, the concept is the total person: good general health, reasonable physical activity, adequate rest, and regular eating habits. Since some foods are more laxative than others, we tend to avoid raw fruits and raw vegetables and recommend cooked fruits and cooked vegetables. We also eliminate milk m some patients who cannot digest milk 8 sugar¸the lactose produces irritating acids that can cause diarrhea.

"Diet is only one way of controlling bowel activity," he continues. "We prescribe mild sedative antispasmodics such as phenobarbital with belladonna. We try to reduce the inflammatory process with sulfa and antibiotics; in severe cases we attempt to dampen it with steroids. More subtly, we prescribe drugs to suppress abnormal Immune responses by the body that enhance inflammation. But my prescription pad is not important; what's important is a program of treatment."

When medical approaches fail, surgery may be necessary. Fifty percent of Crohn's sufferers and 20 percent of those with ulcerative colitis wind up in operating rooms.

Invariably, the lives of Kirsner's patients have been radically affected by their disease. In another cubicle Kirsner confronts a dark-haired woman of 30 who whispers that she has just called off her impending marriage because of her terrible constipation. This is no joke. The question of bowel movements¸as many as two dozen a day for one man with ulcerative colitis or none for a week as in the case of this woman¸dominates these patients' lives. Desperate, she asks if Dr. Kirsner would recommend a new operation, shortemng the bowel, as a means of curing constipation. Kirsner is no big fan of this procedure but feels that in this case, "where this patient's constipation is absolutely destroying her life, I would say let her explore these possibilities."

This woman, Kirsner suspects, like many constipation sufferers, may be the victim of long-time bad habits, taking enemas and laxatives and thus bypassing her normal reflexes. "Most patients with constipation can be treated medically," he says. "Again, it's a matter of regulating diet and maintaining regular bowel habits, adding fiber or bulk when necessary and treating spasm when it is present."

A visitor tells Kirsner that his father¸ "from the old country"¸upon rising at four in the morning would add the juice of a lemon to a glass of boiled water rather than take laxatives. "Not a bad idea," agrees Kirsner. "That stimulates the gastrocolic reflex. But you should also eat breakfast and have a regular time for a bowel movement, morning and/or night. It's important to maintain regularity. But don't use the bathroom as a library; for some people that's an escape."

In another cubicle, an outpatient, an older man with Crohn's disease, is lying on an examining table with a blood-pressure apparatus attached to his left arm. Having just had an endoscopy, he has to be observed for an hour and a half to make sure he's all right. "I slept through the whole thing," he says. He should have, since Valium or Demerol is injected into a vein during this procedure.

He asks an older woman with an irritable bowel whether she has been under any tensions. Nothing in particular, she says: A long-time friend died; a daughter is getting married. Kirsner nods. This may be significant information. "These are mysterious diseases," he tells the visitor. "I believe there's a biochemical and hormonal relationship between the brain and the gut, that there are communicators between them. We may eventually have a biochemical explanation of the stress phenomenon. Just because we don't understand it now, we shouldn't dismiss it."

(The emotional origins of some gastrointestinal disturbances cannot be ignored according to Kirsner, who offers this case history: "My patient, an actress who spent a lot of time on the road making appearances in theatres, complained of cramps nausea, gas, and belching. Six months after I treated her, she telephoned me to say she was feeling great. But another six months later her symptoms were hack. she had discovered that her husband had been unfaithful whenever she was out of town. All along. she'd been uncertain of him, and her digestive tract reflected that.")

The crowded Gastroenterology Clinic shows signs of all the hard use it has had in these past years, but this will be remedied in the near future. Twenty-two years ago grateful Kirsner patients formed the Gastrointestinal Research Foundation of Chicago to support their doctor's research. Now they are helping raise money to build the Joseph B. Kirsner Center for Digestive Diseases on the fourth floor of Billings Hospital. Kirsner will no longer have to convert a storeroom into an office. There will be some 17,000 square feet of space for labs, offices, and conference rooms to serve the ten faculty members, a dozen fellows, and assorted research assistants, nutritionists, and secretaries. It is 10 a.m. and time for Kirsner to make patient rounds in the luxurious new Mitchell Hospital. At 5 Northwest Mitchell, the Gl floor, most of the 24 beds (nearly all in one-bed rooms) are occupied. Every Thursday Kirsner presides here over what he calls life situation rounds, underlining his belief that you cannot separate digestive diseases from the way a person lives. In a conference room a coffee maker gurgles, and doughnuts and coffee cake paid for by the department are put out as the 14 persons attending sit down around a long table with Kirsner at its head. He is 45 years older than the next-oldest person in the room. Those present include two social workers; the medical student, intern, medical resident, and attending physician assigned to the floor; a resident in psychiatry; and the assistant head nurse.

Kirsner listens intently as the medical student carefully sums up the case of a 25-year-old nurse from Des Moines who has been referred here by her psychiatrist after suffering chronic pain in the abdomen. Despite previous excision of her gallbladder and treatment for an ulcer, she is still afflicted with terrible pain that comes in waves five times daily and with spasms of the colon, 45 to 50 times a day.

Kirsner (scratching his chin): "My hunch is you're not going to find anything, but it's important to check out a certain number of studies."

Dr. Stephen Deutsch, a young gastroenterologist whom Kirsner trained as a fellow: "We'll probably end up labeling her an irritable bowel.* She's a typical medical person, getting haphazard tests and seeking advice in the hospital corridors."

Kirsner: "We'll clarify the problems strengthen the role of the psychiatrist, and set forth the goals so she's not always blaming physicians for not solving her problems. " - The resident in psychiatry, an earnest looking young woman, says that she had better see this patient to determine wheth er she is suffering from depression. Kirs ner: "We'll tell her we like to evaluate all aspects, including the psychiatric."

The medical resident reports on a 71year-old man from New York City, a retired vice-president of a major corporation, who complains of rectal and abdominal pain and of having 16 bowel movements on some days: "Our diagnosis is irritable bowel syndrome. He's on belladonna and a bland diet. Tomorrow he gets an endoscopy. The good news is that he at last has agreed to give up smoking. He gave me his cigarettes." Kirsner nods approval. He himself last smoked in 1951 he threw his cigarettes into a Minnesota lake when he became disgusted with coughing so much that he frightened the fish away. He's convinced that cigarettes can be a direct cause of digestive diseases.

"What I want to know," he asks, "is Did we get this man's tray situation straightened out?" Yesterday, Kirsner had threatened to fire whoever was responsible when, instead of the bland food that had been ordered, another patient's breakfast tray was delivered to the man. The resident says that the head of food service is having the man's trays hand-carried to his bedside.

A young female social worker comments on the case of a 20-year-old Matteson woman with Crohn's disease, who works as a bookkeeper in her father's heating and air-conditioning business: The patient, beautiful and popular, has a boyfriend and enjoys dancing and jogging. She is being given antibiotics, and the nutrition specialists have taken her off food by mouth and are supplying calories by means of parenteral hyperalimentation ¸a complex formula of water, dextrose minerals, vitamins, and other components is piped directly into the subclavian vein at the collarbone. Her badly inflamed small intestine hasn't been doing a good job of absorbing nutrients, and it will now have a much-needed chance to rest. After there has been some healing, surgery will be performed.

The psychological effects of abdominal surgery can sometimes be devastating. ____________________________ *Irritable bowel syndrome: a collection ox symptoms gas, nausea, abdominal cramps, diarrhea, constipa tion which are chronic and, often, go unrecognued ____________________________ In Crohn's disease of the small bowel, however, there is no need for the patient's process of elimination to be handled by a rubber bag attached to her side; the diseased portion of bowel is simply removed and the good sections are sewn together.

When Crohn's disease has badly damaged the colon, sometimes the entire large bowel is removed and the patient's elimination is carried out into a bag at the end of the small bowel: an ileostomy.

For persons with very bad ulcerative colitis, the entire colon and rectum are removed, but surgeons are cleverly beginning to preserve the muscular layer of the rectum and connect it to the ileum¸the small bowel¸so that normal elimination can be accomplished.

"I'm concerned about this girl," says the social worker. "I had a long talk with her this morning. There's a discrepancy between her knowledge that Crohn's is a chronic disease and her expectation that she can get better. What she really fears is that this will be the first of many surgeries. "

Kirsner (speaking very quietly): "She's really very disappointed. People do hope against hope that they'll be different. I think she'll run some risk after surgery. That's why it's important now to quiet the inflammatory condition so well that when the surgeon operates on her it will be quelled for a long, long time."

Deutsch, the young gastroenterologist: "I'm willing to talk to her boyfriend about all this."

Followed by the medical student, intern, resident, and young gastroenterologist, Kirsner now makes the rounds of every room on the floor. He is fatherly with an anxious woman in her 20s whom he is sending back to Maine with instructions to feed herself with parenteral fluids while she is asleep by hooking herself to a bedside machine. "I don't like to send a patient home with a prescription," he tells her. "You have to be taught how to take care of yourself."

Outside, in the hall, he tells the visitor: "A therapeutic program has to be initiated properly with the hope it will work. Otherwise, what will it accomplish? Detail! Detail! Detail! With a patient like this, nothing is too unimportant." Kirsner peers into his wallet, where some tiny notes he has written to himself are pinned to the leather. He looks to see what he might have forgotten about this patient.

Soon it is time for lunch in the doctors' dining room and, for the first time today, Kirsner reveals that he is not a perfect gastroenterologist. True, the lunch he orders is healthful chicken noodle soup, crackers, cottage cheese, and tea. He gulps it down, however, in only 15 minutes. "I know I shouldn't be eating so fast," Kirsner admits ruefully. But he is eager to get upstairs to Medicine 6. There is still so much to do before night falls. ;,