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THE POX

William C. Roberts, MD

Deborah Hayden has written a wonderful book on syphilis, in which she describes the history of syphilis and its illness in some very prominent figures (1). About 15% of the earth's population in the 19th century apparently had syphilis at some time.

Ludwig van Beethoven (1770–1827): Whether Beethoven actually had syphilis has been debated for decades. He was known to associate with prostitutes. Beethoven's own doctor and friend for 10 years (1806–1816) weighed in on the side that Beethoven did indeed have syphilis. Sir William Osler also favored the syphilitic diagnosis in Beethoven. Leo Jacobssohn, an otologist, in 1910 and in 1927, argued in favor of syphilis as a cause of Beethoven's deafness from damage to the eighth cranial nerve.

Ludwig van Beethoven was born to a poor family in Bonn in 1770. He studied harpsichord, piano, viola, and organ, and while he was still quite young his ability to improvise on the piano gained him access to the musical drawing rooms of the city. He dressed elegantly, like a court musician, and his silver belt sported a sword. In 1797, he had a severe fever, and that started his long-term health problems. Several physicians diagnosed syphilis, and he was treated with mercury salve, the treatment for syphilis at the time. The loss of his hearing above all else caused Beethoven distress. Many believed that Beethoven showed signs of paresis in the last months of his life. When Beethoven died in 1827, Drs. Johann Wagner and Karl Rokitansky performed the autopsy in Beethoven's house. The autopsy findings apparently were consistent with syphilitic meningovasculitis. To examine the ears more carefully, Dr. Wagner collected portions of the temporal bone on both sides of the head. In 1863, Beethoven's body was disinterred and placed in a metal casket to be preserved.

Franz Schubert (1797–1828): He was one of 14 children in a Viennese Catholic family. He studied violin and piano at home and learned the organ in church. He wrote his first symphony when he was 16. By the time he died, he had produced 1000 compositions, including 600 songs full of sorrow and yearning. He received little recognition in his lifetime and lived in relative poverty. Most scholars now assume that Schubert was infected in 1822 when he was 25. From then on, his excellent health was replaced by painful episodes and deep depressions, alternating with periods of apparent good health.

Robert Schumann (1810–1856): He was an artistic child who composed music and poetry, sang, and played the flute, cello, and piano. “In 1831, I was syphilitic and treated with arsenic,” he had stated. He married in 1840, many years past the infectious period. Schumann was always productive and creative despite the many illnesses he experienced. His happy marriage and his children provided a stability missing in the lives of probably most syphilitics.

Charles Baudelaire (1821–1867): His most famous volume of poetry, Les fleurs du mal (Flowers of Evil), so scandalized his contemporaries with its theme of beauty and corruption that he was charged with obscenity, and 6 of the poems having to do with lesbians and vampires were suppressed by the Ministry of the Interior. Baudelaire explained to his mother that Les fleurs du mal was a witness to his disgust and hatred of everything. Another poet called him “the cursed poet.” Baudelaire knew he was syphilitic, but how much of his disgust and hatred was related to the disease is unclear. His correspondence appears to date his syphilitic onset to 1839 when he was 18 and lived in the Latin Quarter in Paris. His notebooks contained addresses of prostitutes.

Mary Todd Lincoln (1818–1882) and Abraham Lincoln (18091865): Mary Todd's family was socially prominent in Kentucky. In 1839, she met Abraham Lincoln and after a long courtship and one broken engagement, they were married in 1842. Of their 4 sons, only Robert survived to adulthood. After President Lincoln's assassination by John Wilkes Booth on April 15, 1865, Mary Todd traveled to Europe and eventually moved to Chicago. In Chicago she was perceived as quite odd. She roamed the streets with cash and negotiable bonds pinned to her undergarments. She went on elaborate shopping sprees, buying truckloads of drapes when she had no home to furnish. At one point she bought 84 pairs of kid gloves in less than a month. In 1875, while staying at a hotel with her son, Robert, she wandered half-dressed into the elevator, mistaking it for the bathroom. When Robert tried to help her return to her room, she screamed that her son was trying to murder her. A despairing Robert finally sought a warrant for her arrest to ensure her safety and that of the community. At her trial, it took only 10 minutes for the all-male jury to find her eligible for the state hospital for the insane, another way of saying that she was unfit to be elsewhere. A doctor diagnosed degeneration of brain tissue or dementia at the time. In 1882, a disorder of the spinal cord and reflex paralysis of the iris was diagnosed. The spinal condition progressed. She was unable to walk safely without assistance, and eventually paralysis of the legs ensued. Her sight was reduced to one tenth of normal. Her pupils were fixed. A report in 1999, reviewing the work of her 4 physicians, concluded that hers was a clear case of tabes dorsalis.

Abraham Lincoln told his biographer, friend, and law partner of 18 years, William Hearndon, that he had been infected with syphilis in 1835 or 1836. Hearndon, believing both Mary Todd and Abraham Lincoln had syphilis, suspected it in the premature death of 3 Lincoln children. Lincoln fans were angered when Gore Vidal suggested on NBC's Today show and again on the Larry King program that Mary Todd Lincoln had tertiary syphilis or paresis. They were further enraged when he speculated that she had been infected by her husband. Abe Lincoln was known to take mercury, presumably for his condition. He took the “little blue pills” at least until a few months after his inauguration in 1861. Mary Todd tried them in 1869 but had a severe reaction and apparently discontinued them immediately.

Gustave Flaubert (1821–1880): He apparently developed “the pox” in 1842 after frequenting prostitutes.

Guy de Maupassant (1850–1893): He grew up in Normandy, the location of many of his stories. When he returned from the Franco-Prussian War, he joined the literary circle, which included Emile Zola, Ivan Turgenev, Henry James, and Gustave Flaubert, his friend and mentor. He developed syphilis about 1876 and freely admitted having “the pox.”

Vincent van Gogh (1853–1890): Scholars have had a tough time agreeing on the proper diagnosis for him. The New York Times (November 1990) counted 152 posthumous diagnoses. As Deborah Hayden wrote: “A good syphilologist armed with this information about a previous colleague's diagnosis would ask…: Was there a severe fever following a high-risk sexual experience? Was there a sudden change from relative good health to a lifetime of illnesses consistent with syphilis ? And finally, were there indications of changes in character warning of approaching paresis? Since the answer to all of these questions is yes, the probability of syphilis in Vincent's case is very high.” Vincent's brother Theo had syphilis, and Vincent knew it and shared that information with his physician, Dr. Cavenaille. Paul Gauguin corresponded with both Vincent and Theo van Gogh, and he had an undisputed case of syphilis. It is likely that Vincent developed syphilis in 1882 and that he visited prostitutes occasionally. His health up to that time had always been excellent, but thereafter it never was. Vincent painted one or more prostitutes, who told him of their becoming infected, of the infection's spread during its active period, and of the relapses during the following years. Vincent also fell in love with a prostitute.

Friedrich Nietzsche (1844–1900): Scholars who find Nietzsche's last works to be the most mature expression of his philosophy oppose suggestions that there were signs of impending madness. The story of Nietzsche's sudden plummet from the most advanced thought of his time to raving dementia is often told as if there were a razor's edge demarcation between sanity and tertiary syphilis. Sigmund Freud stated clearly: “Nietzsche was a paretic”…. Illness became his fate… The degree of introspection achieved by Nietzsche had never been achieved by anyone, nor is it likely ever to be reached again… The most essential factor must still be added: the role that paresis played in Nietzsche's life. It is the loosening process resulting from paresis that gave him the capacity for the quite extraordinary achievement of seeing through all layers and recognizing the instincts at the very bases. In that way, he placed his paretic disposition at the service of science.”

Elizabeth Nietzsche collected Nietzsche's manuscripts as an adoring little sister. That trove grew to be the Weinmar Archive, a building Elizabeth established to house her brother's papers and her brother as well. He spent his last insane years living upstairs. Elizabeth raised money, negotiated publishing contracts, and managed a staff of workers (mostly Nazis after Hitler came to power), who catalogued his work. She published all of his collected works from 1892 on, plus 81 articles and a 3-volume biography. She became known throughout Europe as a woman of letters and the guardian of Nietzsche's legacy. Elizabeth, however, was a devout Lutheran, a rabid anti-Semite, and a fierce nationalist who revered Hitler. Elizabeth, thus, was unsuited to represent a man who was anti-anti-Semitic and antipatriotic and who wrote God's obituary and the script for demolishing everything she held sacred. Elizabeth was a pathological liar. She tried to cover up her brother's syphilitic disease, but medical records were not covered up; they yielded the proper diagnosis.

Oscar Wilde (1854–1900): According to his friend Robert Sherard, Oscar Wilde “knew himself to be a syphilitic.” His 4 main friends revealed that they all knew his secret and that physicians had diagnosed syphilis as the cause of the ear infection that led to the brain infection that caused his death.

Karen Blixen (Isak Dinesen) (1885–1962): When she was 28, Karen Dinesen traveled to East Africa, married her cousin Bror von Blixen-Fineke, thus gaining the title baroness, and started a coffee plantation of nearly 1500 acres near Nairobi. She lived much of her life in British East Africa, growing coffee beans, hunting lions, and writing stories using the pen name Isak Dinesen. Her collections include Seven Gothic Tales, Winters' Tales, and Out of Africa. The latter, an autobiographical work, was made into a popular film. Although she was nominated twice for the Nobel Prize, it went instead to her husband's friend, Ernest Hemingway (Bror was the model for the white hunter in Hemingway's “The Short Happy Life of Francis Macomber”), in 1954, and 3 years later to Albert Camus. Blixen married Bror in 1914 and developed syphilis at the end of the year, probably due to his adventures in the Masai community, where the disease was epidemic. At first Karen Blixen thought the fever, insomnia, and weight loss pointed to malaria, but the following year, still suffering from insomnia, she took too high a dose of sleeping pills, and her husband found her in a stupor. After vomiting for 2 days she consulted an English physician in Nairobi, who confirmed the diagnosis of syphilis and prescribed mercury tablets for a year. Later, she was found to have a positive blood Wassermann test and also signs of mercury poisoning. She was then treated with salvarsan.

James Joyce (1882–1941): The author of Ulysses developed syphilis in 1904 after visiting “Nighttown” in Dublin. Joyce's father also may have had syphilis. Joyce had an iridectomy to enlarge his tiny fixed pupil. In 1916, Ezra Pound apparently sent a physician to Joyce to treat Joyce's syphilis.

Adolf Hitler (1889–1945): Although innumerable volumes have been written about him, syphilis in Hitler has been infrequently discussed. In 1936, Hitler hired a famous syphilologist, Theo Morell, to be his private physician. Hitler's presenting symptoms (shin lesions and extreme gastric crisis) would have put any syphilologist on high alert. Morell apparently was so alerted. From a secret diary Morell began in 1941, it appears that Hitler had cardiovascular syphilis. Putzi Hanfstaengl, a friend from the days of the beer halls in the 1920s, published in his memoirs that Hitler was infected in Vienna in 1908. Rumors abounded in Hitler's own time that he was infected by a Jewish prostitute in Vienna. A well-known London syphilologist, T. Anwyl-Davies, believed that Hitler was in the tertiary stage of disease at the end of World War II. Toward the end of Hitler's life, his mania and lunatic ravings, his palsy of his left hand and leg, his continual itching, his insomnia, and his head and stomach pain are findings typical of advanced syphilis.

DEMOCIDE

From the time that Saddam Hussein took control of Iraq in 1979 until his removal in 2003, an estimated 290,000 people went missing in Iraq, according to estimates made recently by Human Rights Watch (2). Most are presumed dead, the victims of state-sponsored killing sprees aimed at eliminating challenges to Saddam's rule. But compared with other state-sponsored killings in other countries in the 20th century, Hussein's atrocities barely register.

R. J. Rummel, a professor emeritus of political science at the University of Hawaii, has compiled statistics accounting for the number of people killed worldwide by “democide”, a term he coined to describe intentional killings by governments—whether by induced famine, forced labor, assassinations, extrajudicial executions, massacres, or full—scale genocide—of civilians or military noncombatants. Although the actual number of people killed by democide is virtually unknown, Rummel's books on the subject—Death by Government (1994) and Statistics of Democide (1997)—provide the most comprehensive estimates available. Rummel estimates that from 1900 to 1987, governments murdered almost 170 million people, a figure that far exceeds the 34 million battle deaths thought to have resulted from all the international and civil wars fought during the same period.

Democide, of course, is not a new phenomenon, but state sponsored killing accelerated greatly in the 20th century. The reasons for this are varied and include advances in technology, communications, and transportation, all of which enhanced and streamlined the logistics of mass killing. Genocide, the most egregious form of state-sponsored murder, has historically occurred to eliminate threats or to acquire wealth and territory. Until the 20th century, victims of genocide were usually selected on the basis of where they were, but in the past century victims were more often selected on the basis of who they were. Hitler, Stalin, and Mao committed the most state-sponsored murders in the 20th century, killing (by Rummel's estimate) >100 million people. The leader who killed the largest proportion of his own population was Pol Pot, who murdered about a third of Cambodia's people in only 4 years. Hitler killed about 6% of the population of Nazi-Occupied Europe, and Saddam Hussein killed about 1% of Iraq's population.

Democide most often occurs under authoritarian regimes during or in the immediate aftermath of wars. Democratic governments were responsible for only about 1% of the 20th century's death toll from democide. The conditions most likely to lead to democide include economic isolation, the political dominance of a minority elite, and a history of previous genocides. Per capita income probably also plays a role.

Physicians work hard in trying to save the lives of individuals, and yet demagogic rulers come along and wipe out in brief time periods far more individuals than numerous doctors could save in a lifetime.

SAFETY RECORDS OF OLDER DRIVERS

Fain from Tucson, Arizona, recently published a beautiful editorial entitled “Should older drivers have to prove that they are able to drive?” (3). This question itself presumes certain truths: 1) the older driver is an unsafe driver; 2) the proportion of older drivers on the road will continue to dramatically increase; 3) the unsafe older driver can be accurately predicted through valid screening tools and tests; 4) public policy that targets and restricts older drivers as a group is beneficial to society as a whole. She then asked how accurate these 4 presumptions were.

The older driver is much less likely to be involved in a motor vehicle crash than a driver from any other age group and statistically presents a lesser danger on the road than the younger driver! The number of drivers involved in motor vehicle crashes declines steadily from age 20 years. Indeed, most crashes and fatalities involve men <25 years of age, not older drivers. Statistically, renewing the license of a 70-year-old male driver for another year poses on average 40% less threat to other road users than renewing the license of a 40-year-old male driver. Older drivers, aware of their limitations, tend to drive far fewer miles and avoid driving at night, in heavy traffic, or in bad weather. Another way to look at driver safety involves statistically adjusting the rate of crashes and/or fatalities by miles driven. For the older driver, however, especially >75 years of age, the rate of crashes and/or fatalities per mile driven is higher, approaching the higher crash and fatality rate of the younger driver. These per-mile-driven statistics have received disproportional attention, according to Fain, even though the absolute number of crashes and fatalities per older driver represents a small proportion of such events for all drivers.

Efforts to predict crash risk based on advanced age, medical problems, or medication profiles have been largely unsuccessful. Limited associations between certain visual impairments and crashes have been found in several studies. Only weak associations have been found between crash risk and older persons with cardiac disease, diabetes mellitus, sleep apnea, arthritis, history of falls, Parkinson disease, foot abnormalities, or stroke. Ingestion of certain substances and medications, such as alcohol, sedative hypnotic agents, and psychotropics, is known to increase crash risk; these risks, however, apply to drivers of all ages. Older drivers' greater experience and their risk reduction behaviors (driving more slowly and avoiding congested roadways) appear to compensate for most age-related declines. Clear standards or guidelines for assessing driving competence have not yet been developed or validated for the older driver.

The automobile is a powerful tool of independence and provides freedom through mobility for all Americans, especially the elderly. Most Americans, including the older ones, are dependent on their cars for their transportation needs, including medical visits, shopping, attendance at religious services, and socialization. Driving cessation is a devastating event and results in a loss of freedom and a loss of individual autonomy. Decisions to revoke an older person's driving privileges should be based on clear, predictable danger to others. The burden of the dramatic loss of freedom should be weighed against any potential benefits of improved motor vehicle safety. Rather than attempting to curtail the older driver's privileges, society might look for ways to maintain the older driver's safe mobility. Although driving is a privilege conferred by the state, physicians have a shared responsibility to balance the needs of their individual patients with the good of society. Dr. Fain recommends that physicians take a driving history in patients, assess their physical or mental impairments that might adversely affect their driving abilities, recommend therapy that might eliminate the impairment, and/or suggest a change in driving patterns to minimize risk.

MORBID OBESITY

We all know that body weight has increased considerably in recent years. It is estimated that the average American adult in the 1990s gained 1 lb per year. Sturm from Santa Monica, California (4), using data from the Behavioral Risk Factor Surveillance System, found that between 1986 and 2000, the prevalence of body mass index (BMI) of ≥40 kg/m² (about 100 lb [45 kg] overweight) quadrupled from about 1 in 200 adult Americans to 1 in 50; the prevalence of a BMI of ≥50 increased by a factor of 5, from about 1 in 2000 to 1 in 400. In contrast, BMI from 30 to 39 kg/m² roughly doubled during the same period from about 1 in 10 to 1 in 5. BMI >40 is increasing at a much faster rate than is BMI from 30 to 39 kg/m².

LIFETIME RISK OF DEVELOPING DIABETES MELLITUS

Using data from the National Health Interview Survey (1984–2000), Narayan and associates (5) from the Centers for Disease Control and Prevention in Atlanta, Georgia, estimated lifetime risk of developing diabetes mellitus for individuals born in the USA in 2000. Their estimate was that 33% of the males and 39% of the females would develop diabetes in their lifetime! Women have a higher lifetime risk at all ages. The highest estimated lifetime risk is among Hispanics (males, 45%; females, 53%). Individuals diagnosed as having diabetes, of course, have large reductions in life expectancy. These authors estimated that among those diagnosed with diabetes at age 40, men will lose 12 life years and 19 quality-adjusted life years and women will lose 14 life years and 22 quality-adjusted life years. It's best to keep the body weight way down, and diabetes is essentially prevented.

NONLIPID EFFECTS OF STATINS

The statins reduce cardiovascular events to a greater extent than can be explained by their effects on lipids. Balk and colleagues (6) from Boston, Massachusetts, did a MEDLINE search of articles from 1980 to 2003 and found that all statins are effective in lowering C-reactive protein (CRP) levels and that the effect is not dose dependent. There was no correlation between the statin's effect on CRP and its effects on lipids or cardiovascular outcomes. Statins have no effect on fibrinogen levels and little effect on tissue plasminogen activator or plasminogen activator inhibitor. Platelet aggregation data are inconclusive. Thus, among the nonlipid serum markers examined, only CRP levels are statistically significantly affected by statins.

GLOBAL MORTALITY ATTRIBUTED TO SMOKING

Using very complicated formulas, Ezzati and Lopez (7) estimated the number of deaths in 2000 from cigarette smoking. Of the planet's approximate 6.2 billion people, an estimated 1.1 billion smoke cigarettes and 930 million of them live in low income and middle-income countries. These authors estimated that in 2000, 4.84 million people died prematurely because of smoking: 2.41 million in developing and 2.43 million in industrialized countries, of whom 3.8 million were men. The leading causes of death from smoking were cardiovascular disease (1.7 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths). More men now die from smoking in developing countries (2.0 million) than in industrialized nations (1.8 million). Spending on cigarettes, of course, is wasted money, and developing countries particularly need all the money they can get for useful endeavors, not destructive ones.

EMPTYING THE OCEANS

I recently codirected a cardiology meeting held on a cruise ship that periodically stopped in various ports in the Mediterranean. One stop was Agadir, Morocco, where in 1960 an earthquake killed 15,000 people in 15 seconds and flattened the town. Another stop was Tenerife, Canary Islands, where several decades ago 2 jumbo jets collided on the runway killing 576 persons, the worst plane crash in history. Most meals on and off the ship featured fish, my favorite and only flesh, so I was delighted.

The June 9, 2003, issue of US News & World Report carried a piece entitled “Fished Out” (8). The point of the piece is that intensive fishing is dwindling the fish stock in the oceans. Americans ate 4.2 billion pounds of fish in 2001. Seafood now is a $55 billion industry in the USA. Many of the methods that provide the fish, crustaceans, and mollusks are destroying the very ocean habitats and ecosystems needed to rebuild the stocks. Wild shrimp, for example, live on the sea floor and are usually caught with weighted nets that drag along the bottom. For every pound of crustacean caught in the nets, 10 lb of other fish are also caught and returned dead to the oceans.

The USA used to be fish stick and tuna salad country. In 2002, the USA imported nearly 190,000 tons of canned tuna (>1 billion 6-oz cans). In 2001, shrimp overtook tuna as the USA's favorite seafood. Swordfish and mahi-mahi steaks are becoming as common as once-exotic sushi. International fleets of fishing vessels work year round to supply the new hunger in the West and to feed the growing demand in affluent areas in Asia. Spurred by government subsidies, guided by sonar, satellites, and aircraft, and deploying acres of nets and lines 50 miles long, the global armada essentially spares no fish. As one recreational fisherman stated, “The fish have nowhere to hide.” The result, according to several scientists, is that the number of large ocean fish—cod, tuna, swordfish, marlin, and shark—has plummeted by 90% since industrialized fishing got going after World War II.

The pursuit of one fish often hits other species hard. Gill nets, trawls, and long-line hooks catch nontargeted fish and other marine life, including seals, dolphins, and endangered sea turtles. This “bycatch,” which is generally discarded, makes up roughly 25% of the total catch. Baited long-line hooks also kill hundreds of thousands of sea birds each year. And the trawls used to catch bottom dwellers, like shrimp, cod, flounder, and pollock, flattened sponges, corals, and rocky nooks and crannies where baby fish need to hide if they are to survive to adulthood. The rush to catch large fish may bring about a complete reorganization of ocean ecosystems. Many depleted species, like the North Atlantic cod, may never recover because their habitat has been destroyed or too few survivors remain to find mates. Extreme fishing pressure also can force magnificent fish to evolve into something considerably less grand. The average size of a spawning pink salmon in Alaska has dropped by 35% over the past 20 years because only those thin enough to squirm through the mesh of a gill net survive to reproduce.

Some examples of overfishing: cod, which supported a massive fishery in the Atlantic for centuries, has been heavily depleted by factory trawlers since 1950. Many fishing grounds have been closed or restricted, but stocks have been slow to recover. The cod's delicate white flesh was a mainstay of fish and chips; it has largely been replaced by Alaska pollock, now the world's largest fishery. Cod can reach 200 lb but now are rarely found above 20 lb. The related Pacific cod is in better shape. Young cod are sold as scrod, as are haddock and pollock. Bluefin tuna can reach 1500 lb in the Atlantic Ocean. Smaller Pacific bluefins are born in the Sea of Japan and then migrate thousands of miles east. These powerful, warm-blooded swimmers can reach 25 miles an hour and cross an ocean in 3 weeks. They are caught with long lines, herded into nets, and fattened like cattle in a feedlot. Bluefins are so scarce in many regions that a single fish can fetch tens of thousands of dollars in Japan, where this tuna is prized for sushi. The Patagonian toothfish, which has been rechristened “Chilean sea bass” (it is actually unrelated to any saltwater bass), has been hit hard by legal and illegal long-line fishing. The toothfish takes 10 years to mature, can live at least 40 years, can grow to 7′, and is found at depths of up to 12,000' in waters near Antarctica. Swordfish are found worldwide and migrate from the tropics to temperate waters in the summer; they are caught by long lines and drift nets. The fish, which use their swords to kill other fish and squid, can reach 1400 lb, but heavy demand for swordfish steaks has led to overfishing and pushed the average size down to <100 lb.

Fish are the only flesh listed among the top 10 foods for humans, and we appear to be wiping them out.

SEVEN MARATHONS ON SEVEN CONTINENTS IN SEVEN DAYS

Sir Ranulph Fiennes, aged 59, and Dr. Michael Stroud, aged 49 and a physician, in late October and early November 2003 ran 7 marathons (26 miles, 385 yards, or 42 kilometers, 195 meters) in 7 days in 7 different continents (9). The marathons were run in Chili, Falkland Islands, Sidney, Singapore, London (United Kingdom), Cairo, and New York City, a total of 183 miles on foot while traveling 45,000 miles by commercial airline between the runs. Ranulph Fiennes had a coronary artery bypass graft operation 6 months earlier after having a heart attack!

AROUND ALONE

Around Alone, which started in 1982, is considered by many to be the most physically daunting sport event on earth (10). Competitors sail alone around the globe following a 5-stage course (USA to United Kingdom, United Kingdom to South Africa, South Africa to New Zealand, New Zealand to Brazil, and Brazil to the USA) measuring 28,800 miles. Its degree of difficulty can be displayed best through an arcane yet noteworthy statistic: More people have flown into space than have successfully raced alone around the world. Around Alone offers no prize money. The first boat across the line gets a small silver victory platter! It is competition for competition's sake. After a brief prologue from Newport, Rhode Island, to New York City, the race got under way in earnest on September 15, 2002. Thirteen skippers set sail for Torbay, United Kingdom, 3000 nautical miles away. This 2-week leg was the shortest of the five.

American Brad Van Liew's boat, Freedom America, was 50′ long and 16′ wide and had a carbon-fiber hull and a 72′ mast. The navigation station and primary living quarters was a cell 9′ long, 14′ wide, and barely tall enough to stand in. The forward windows had the curvature of an aircraft windscreen. The aeronautical control panel offered gauges on air temperature and wind speed, a barometer, a compass, and a Global Positioning System. An Iridium satellite phone allowed regular downloading of weather information and e-mail and a daily call to his wife. Van Liew slept in 25-minute catnaps while strapped into a bunk against the hull. There were no shower facilities or running water, and a bucket served as the toilet. The boat was built for racing. The second leg, 6 weeks at sea, brought solitude, doldrums, and storms. Van Liew won all 5 legs. He completed the race on May 4, 2003, when docking in Newport. He had spent 148 days at sea and became the first American to win Around Alone since his mentor, Mike Plant, won in 1987. This was Van Liew's second Around Alone: in 1998–1999 he had finished third. Why does a man with a beautiful wife, a lovely daughter, and a home near the sea risk it all in such a dangerous adventure?

THE MATTERHORN AND HEART TRANSPLANTATION

In August 2003, 42-year-old Kelly Perkins, a petite American, became the first heart transplant recipient to climb to the top of the Matterhorn in Switzerland (11). It took her and her mates 11.5 hours to ascend and descend the 4478-meter pyramid-shaped peak, which is challenging even for mountaineers in prime health because it is exposed and there are no resting places. Before August 1992, she and her husband had run about 5 miles daily for several years, but then she suddenly developed heart failure, and a diagnosis of idiopathic dilated cardiomyopathy was made. Initially an automatic implantable cardioverter fibrillator was inserted, but worsening heart failure prompted the cardiac transplant in 1995. Six months after her transplant, she climbed the Half Dome in Yosemite National Park. In 1997, she ascended the 4418-meter summit of Mount Whitney in California, becoming the only person to reach the summit with 2 different hearts. In 1998, she and her husband climbed the 3776-meter Mount Fuji, and in 2001, they climbed the 5895-meter Mount Kilimanjaro in Tanzania. Good for you, Kelly Perkins.

—William Clifford Roberts, MD