NEW ENGLAND JOURNAL OF MEDICINE CHRISTMAS

 

Unique Case of Aerial Sleigh-Borne Present-Deliverer's Syndrome 

Source: North Pole Journal of Medicine, vol 1 no.1, December 1997 Author: Dr. Iman Elf, M.D. 

On January 2, 1997, Mr. C, an obese, white caucasian male, who appeared approximately 65 years old, but who could not accurately state his age, presented to my family practice office with complaints of generalized aches and pains, sore red eyes, depression, and general malaise. The patient's face was erythematic, and he was in mild respiratory distress, although his demeanor was jolly. He attributed these symptoms to being "not as young as I used to be, HO! HO! HO!", but thought he should have them checked out.

The patient's occupation is delivering presents once a year, on December 25th, to many people worldwide. He flies in a sleigh pulled by eight reindeer, and gains access to homes via chimneys. He has performed this work for as long as he can remember. Upon examination and ascertaining Mr. C's medical history, I have discovered what I believe to be a unique and heretofore undescribed medical syndrome related to this man's occupation and lifestyle, named Aerial Sleigh-Borne Present-Deliverer's Syndrome, or ASBPDS for short.

Medical History: Mr. C. admits to drinking only once a year, and only when someone puts rum in the eggnog left for him to consume during his working hours. However, I believe his bulbous nose and erythematic face may indicate long-term ethanol abuse. He has smoked pipe tobacco for many years, although workplace regulations at the North Pole have forced him to cut back to one or two pipes per day for the last 5 years. He has had no major illnesses or surgeries in the past. He has no known allergies. Travel history is extensive, as he visits nearly every location in the world annually. He has had all his immunizations, including all available vaccines for tropical diseases. He does little exercise and eats large meals with high sugar and cholesterol levels, and a high percentage of calories derived from fat (he subsists all year on food he collects on Dec. 25, which consists mainly of eggnog, Cola drinks, and cookies).

Family history was unavailable, as the patient could not name any relatives.

Physical Examination and Review of Systems, With Social/Occupational Correlates: The patient wears corrective lenses, and has 20/80 vision. His conjunctivae were hyperalgesic and erythematous, and Fluorescein staining revealed numerous randomly occurring corneal abrasions. This appears to be caused by dust, debris, and other particles which strike his eyes at high velocity during his flights. He has headaches nearly every day, usually starting half way through the day, and worsened by stress. He had extensive ecchymoses, abrasions, lacerations, and first-degree burns on his head, arms, legs, and back, which I believe to be caused mainly by trauma experienced during repeated chimney descents and falls from his sleigh. Collisions with birds during his flight, gunshot wounds (while flying over Chicago) and bites consistent with reindeer teeth may also have contributed to these wounds. 

Patches of leukoderma and anesthesia on his nose, cheeks, penis, and distal digits are consistent with frostbite caused by periods of hypothermia during high-altitude flights. He had a blood pressure of 150/95, a heart rate of 90 beats/minute, and a respiratory rate of 40. He has had shortness of breath for several years, which worsens during exertion. 

He has no evidence of acute cardiac or pulmonary failure, but it was my opinion that he is quite unfit due to his mainly sedentary lifestyle and poor eating habits which, along with his stress, smoking, and male gender, place him at high risk for coronary heart disease, myocardial infarction, emphysema and other problems. Blood tests subsequently revealed higher-than-normal CO levels, which I attribute to smoke inhalation during chimney descent into non-extinguished fireplaces. He has experienced chronic back pain for several years. A neurological examination was consistent with a mild herniation of his L4-L5 or L5-S1 disk, which probably resulted from carrying a heavy sack of toys, enduring bumpy sleigh rides, and his jarring feet-first falls to the bottom of chimneys. Mr. C. had a swollen left scrotum, which, upon biopsy, was diagnosed as scrotal cancer, the likely etiology being the soot from chimneys. 

Psychiatric Examination and Social/Occupational Correlates: Mr. C's depression has been chronic for several years. I do not believe it to be organic in nature - rather, he has a number of unresolved issues in his personal and professional life which cause him distress. He exhibits long-term amnesia, and cannot recall any events more than 5 years ago. This may be due to a repressed psychological trauma he experienced, head trauma, or, more likely, the mythical nature of his existence. Although the patient has a jolly demeanor, he expresses profound unhappiness.

He reports anger at not receiving royalties for the widespread commercial use of his likeness and name. Although he reports satisfaction with the sex he has with his wife, I sense he may feel erotic impulses when children sit on his lap, and I worry he may have pedophillic tendencies. This could be the subconscious reason he employs only vertically-challenged workers ("elfs"), but I believe his hiring practices are more likely a reaction formation due to body-image problems stemming from his obesity.

The patient feels annoyed and worried when he is told many people do not believe he exists, and I feel this may develop into a serious identity crisis if not dealt with.  He reports great stress over having to choose which gifts to give to children, and a feeling of guilt and inadequacy over the decisions he makes as to which children are "naughty" and "nice".  Because he experiences total darkness lasting many months during winter at the North Pole, Seasonal Affective Disorder (SAD) may be a contributor to his depression.

Treatment and Counseling: All Mr. C's wounds were cleaned and dressed, and he was prescribed an antibiotic ointment for his eyes. A referral to a physiotherapist was made to ameliorate his disk problem.

On February 9, a bilateral orchidectomy was performed, and no further cancer has been detected as of this writing. He was counselled to wash soot from his body regularly, to avoid lit-fire chimney descents where practicable, and to consider switching to a closed,  heated, pressurized sleigh. He refused suggestions to add a helmet and protective accessories to his uniform.

He was put on a high-fibre, low cholesterol diet, and advised to reduce his smoking and drinking. He has shown success with these lifestyle changes so far, although it remains to be seen whether he will be able to resist the treats left out for him next Christmas. He visits a psychiatrist weekly, and reports doing "Not too bad, HO! HO! HO!".

Conclusions: Physicians, when presented with aerial sleigh-borne present-deliverers exhibiting more than a few of these symptoms, should seriously consider ASBPDS as their differential diagnosis. I encourage other physicians with access to patients working in allied professions (e.g.Nightly Teeth-Purchasers or Annual Candied Egg Providers) to investigate whether analogous anatomical/ physiological/psychological syndromes exist. The happiness of children everywhere depend on effective management of these syndromes."
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THANKS FOR READING ALL YEAR LONG

AND

MERRY, MERRY CHRISTMAS

- 30 -

A VISIT FROM ST. NICHOLAS

 

'Twas the night before Christmas, when all through the house

Not a creature was stirring, not even a mouse;

The stockings were hung by the chimney with care,

In hopes that St. Nicholas soon would be there;

The children were nestled all snug in their beds,

While visions of sugar-plums danced in their heads;

And mamma in her 'kerchief, and I in my cap,

Had just settled down for a long winter's nap,

When out on the lawn there arose such a clatter,

I sprang from the bed to see what was the matter.

Away to the window I flew like a flash,

Tore open the shutters and threw up the sash.

The moon on the breast of the new-fallen snow

Gave the lustre of mid-day to objects below,

When, what to my wondering eyes should appear,

But a miniature sleigh, and eight tiny reindeer,

With a little old driver, so lively and quick,

I knew in a moment it must be St. Nick.

More rapid than eagles his coursers they came,

And he whistled, and shouted, and called them by name;

"Now, Dasher! Now, Dancer! Now, Prancer and Vixen!

On, Comet! On Cupid! On, Donder and Blitzen!

To the top of the porch! to the top of the wall!

Now dash away! dash away! dash away all!"

As dry leaves that before the wild hurricane fly,

When they meet with an obstacle, mount to the sky,

So up to the house-top the coursers they flew,

With the sleigh full of toys, and St. Nicholas too.

And then, in a twinkling, I heard on the roof

The prancing and pawing of each little hoof.

As I drew in my hand, and was turning around,

Down the chimney St. Nicholas came with a bound.

He was dressed all in fur, from his head to his foot,

And his clothes were all tarnished with ashes and soot;

A bundle of toys he had flung on his back,

And he looked like a peddler just opening his pack.

His eyes -- how they twinkled! his dimples how merry!

His cheeks were like roses, his nose like a cherry!

His droll little mouth was drawn up like a bow,

And the beard of his chin was as white as the snow;

The stump of a pipe he held tight in his teeth,

And the smoke it encircled his head like a wreath;

He had a broad face and a little round belly,

That shook, when he laughed like a bowlful of jelly.

He was chubby and plump, a right jolly old elf,

And I laughed when I saw him, in spite of myself;

A wink of his eye and a twist of his head,

Soon gave me to know I had nothing to dread;

He spoke not a word, but went straight to his work,

And filled all the stockings; then turned with a jerk,

And laying his finger aside of his nose,

And giving a nod, up the chimney he rose;

He sprang to his sleigh, to his team gave a whistle,

And away they all flew like the down of a thistle.

But I heard him exclaim, ere he drove out of sight,

"Happy Christmas to all, and to all a good-night."

- 30 - 

A NUTCRACKER CHRISTMAS

I find it curious that Ernst Theodore Hoffman (above) is considered a romantic. I think of him as a manic depressive, and justified as one considering that Napoleon spent most of Ernest’s life turning Europe into a slaughterhouse. As a young adult Ernst did fall in love, but the lady was married. And when she turned up pregnant Ernest’s family shipped him off to Poland, where he labored as a petty bureaucrat.  But he spent his free time composing classical music and writing vaguely creepy stories. 

One of his more successful tales was a sort of 19^th century “Jaws”, except instead of a 25 foot Great White Shark, Ernest’s villain was a mouse bent upon revenge. In Hoffman's story seven year old Maria receives a mechanical doll as a Christmas present, which her older brother Fritz promptly breaks. She sits up late trying to repair the toy, until an army of mice attack her doll.  She saves the toy by throwing her shoe at the rodents.  Now, maybe I'm just waiting for the other shoe to drop, but I think this idea has ballet written all over it.  Interestingly, that idea never occurred to Ernst.

Nor did it occur to Alexander Dumas (above), the vulgar and prolific son of a French nobleman and a Haitian slave woman. See, Alex liked the Parisian good life a lot more than he liked writing. He had at least 40 mistresses, but he made enough to afford his profligate lifestyle by out doing Andy Warhol at marketing his art. Alex kept a warehouse full of writers who ground out stories under his direction, such as “The Count of Monte Cristo” and “The Three Musketeers”, and its sequels. 

And one of his minor best sellers was a direct steal of Ernst's hallucination, which Dumas changed just enough to avoid a lawsuit – like changing Maria's name to Clara.

Then, seventy years after Ernst died of syphilis (the ultimate romance disease), and 12 years after Dumas died of a stroke in 1870, the ballet idea finally did occur to Marius Petpa (above), celebrated head of the Bolshoi Ballet Company in Russia. 

In 1882 the Imperial Theaters hired Marius and Pyotr Illyich Tchaikovsky (above) to create the “Sleeping Beauty” ballet. This was such a critical and financial success that it established the Bolshoi as the world's premier ballet company, and Marius as a world class genius. 

And then like a modern Hollywood studio looking for a project to fit it's marquee talent, in 1890, the theatre brought the pair together again.  But this time, having over inflated these two monumental egos, the management merely suggested a sort of theatrical sandwich – a double header, both a serious but short opera and a light, meaning short,  ballet staged on the same night.. Marius would script the story for both, and Pyotr would put them both to music. 

The one act opera was clearly intended to be the meat in this theatrical happy meal, and being the foremost Russian composer of the day, Pyotr (above) got first choice of subject matter. He decided on a Danish story of a blind princess named Iolanta.. 

But then, early in February of 1891, in Saint Petersburg (above), Marius handed Pyotr a detailed synopsis and bar-by-musical bar outline for a two act classical ballet based on the story Dumas had filched.

Pyotr was appalled. He though it childish and unworthy of serious application. But, if it meant he got paid to write another opera, he would somehow make this silly ballet work. After struggling for a month he tried to remain optimistic. He wrote to one of his brothers, “I am working with all my strength and reconciling myself to the subject of the ballet.” But he also admitted “I am experiencing a kind of crisis.” This was good, since Pyotr had a lot of experience with those.

See, Pyotr had a secret which held the potential to turn every problem in his life into a crises. He was approaching fifty, and had reached an uneasy equilibrium with his homosexuality. 

He had tried to go straight but his marriage to Antonina Ivanova (above) had blown up after little more than a month. This raised again the threat of exposure by envious and bigoted Czarist court and church officials, who at any moment could end his career.  Each contract, including this one, could be his last. 

What little stability existed in his life was supplied by his younger sister Aleksandra (above, left) and her seven children with Lev Davydov (above, right). Pyotr wrote many of his 11 operas, six symphonies and three ballets on their Ukrainian estate near Kamenka. And now, in March, while on his way to a concert tour of America, and still trying to come up with something presentable for Marius's ballet, he learned of Aleksandra's death.

He had just seen Aleksandra (above) over the Christmas holidays, so he must have known how ill she was. Still, Pyotr was hysterical. And then, pausing in Rouen, France, he managed his grief  by putting it to work.  

His genius was always his ability to combine the Russian musical themes with Western ones, and to subjugate his true identity into the restraints of his art. And in the “grand pas de deux” for the lead dance character of Clara, he weaved in threads from the Russian Orthodox funeral service  The musical themes of the entire ballet became darker and more nuanced. As one critic has put it, “In Clara, he found a parallel for his sister.”  A ballet about wealthy Victorian children, became, with the talent of Pyotr's genius, a work for people of all ages and for all time.

When Pyotr returned from his wildly successful 25 day American tour (he inaugurated Carnegie Hall in Manhattan) he delivered his musical score to Marius in St. Petersburg, to be animated.  

But as the opportunity approached, the world renown genius, Marius (above), suffered his own crises of self confidence. The primary symptom of this understandable panic was an attack of Pemphigus vulgaris, a debilitating skin disease, usually afflicting Ashkebazi Jews – of which Marius was one. Scratching his itching skin produced open sours, which made it impossible for Marius to concentrate on the ballet. So his assistant, Lev Ivanov, took over.

Lev (above) had been with the Bolshoi since he was eight, and had a natural talent as a musician, as well as being an excellent dancer. But where Marius was a classical ballet master, Lev was, like poor Ernest, a romantic. He followed Marius's general guidelines. He had to, the music had already been composed based on them.  But Lev also arranged his dancers like an impressionist painter, throwing patterns of sugar plumb fairies and swirling lines of snowflakes on point, about the stage. 

It was the shape and flow of the dance that interested Lev, and somehow the combination of all these hearts and souls, the romantic Ernst Hoffman and the hedonist Alexander Duma , the classicist Marius and the dark Pyotr, and now that other romantic Lev, they all gave birth, on 15 January, 1890, to the premier of “The Nutcracker” ballet at the Mariinsky Theater in St. Petersburg, Russia.

The audiences seem to have been enthusiastic, giving five curtain calls to the Sugar Plum Fairy. The next morning Pyotr wrote to his brother, “The opera in particular was to everyone’s liking ... The productions of both...were superb” But it was a very long evening, with the Nutcracker not ending until well after midnight. 

The weary critics took it out on the dancers, calling the lead ballerina (above) corpulent and pudgy. The battle scene between the mice and the nutcracker confused them: “Disorderly pushing about from corner to corner and running backwards and forwards – quite amateurish,” complained one. 

The Grand Pas de Deux, so inspiring to the composer, was labeled ponderous and “completely insipid”. A week later Pyotr wrote to another brother, “Once again I am not embittered by such criticism. Nevertheless, I have been in a loathsome spirit, as I usually am...in such circumstances.” After just 11 performances the double bill was closed.

Less than a year later, in October 1893 Pyotr would die during a cholera outbreak, his secret still secure. Although many have suggested he committed suicide, he did not. Lev Ivanov followed nine years later. Finances forced him to work until his death “in harness”, in December of 1901. About the same time the Bolshoi brought in the upstart Alexander Gorsky to replace the aging Marius (above) as director. While watching his intended replacement rehearsing on his stage, Marius was heard to shout, “Will someone tell that young man that I am not yet dead?!.” Within a year it did not matter; Marius was quietly retired. He did die in 1910, at the age of 92.

A year after its premier the opera Iolanta would be preformed by itself in Hamburg, Germany. But although still performed occasionally, it is now largely forgotten. The Nutcracker, on the other hand, had to wait almost 20 years before it would be performed again, staged this time by the Bolshoi's new director Alexander Gorsky, in Moscow. 

He saved it.  Alexander savaged Marius choices, paring away minor roles, replacing the children cast as Clara and the prince, with adults, thus adding a romantic story line for them.  Standing alone, the ballet was now far better received, and short enough for modern attention spans. And after the Second World War, it became the classical Christmas season production for every ballet company in the world, responsible for up to 40% of their income.

It just goes to show you – those silly romantics may be naive simpletons, but their ideas grow stronger with time because they are positive and simple, and keep being reinvented. When in doubt, we are always inspired by the romantics within us.

                                     - 30 -