\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Of Catarrh and Catharsis}



\author[1]{Patrick Stafler}%
\author[1]{Eddie Landau}%
\author[1]{Hannah Blau}%
\affil[1]{Schneider Children's Medical Center of Israel}%


\vspace{-1em}



  
  \date{June 18, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
The ancient Greeks took the entertainment of their crowds very seriously
and used drama as a way of investigating the world they lived in. The
theatrical re-enactment of suffering and grief in front of a large
audience was to foster compassion, as well as a cathartic release of
emotion that was restorative through a deeply felt interconnection
between actors and audience. When our patients encounter tragedy, we are
also drawn into their ordeal and experience it first hand. Such it was
with Rose.%
\end{abstract}%



\sloppy


Patrick Stafler MD\textsuperscript{1,2}, Edwina Landau
PhD\textsuperscript{1,2}, Hannah Blau MBBS \textsuperscript{1,2}

\textbf{Affiliations:}

Kathy and Lee Graub Cystic Fibrosis Center and Pulmonary Institute,
Schneider Children's Medical Center of Israel, Petach Tikva, Israel

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

\textbf{Address correspondence to:}

Patrick Stafler, Pulmonary Institute, Schneider Children's Medical
Center of Israel, Kaplan Street 14, Petach Tikva, Israel, MAIL:
pstafler@hotmail.com, TEL: +972-54-724-3623

\textbf{Short title:}

Of Catarrh and Catharsis

\textbf{Conflict of Interest Disclosures (includes financial
disclosures):}

None

\textbf{Keywords:}

Tracheomalacia, tracheo-esophageal fistula, mental health

\textbf{Funding/Support:}

No funding was secured for this study.

\textbf{Contributers Statement:}

Dr Patrick Stafler and Dr Edwina Landau conceptualized the manuscript.
Dr Patrick Stafler drafted the initial manuscript. Dr Patrick Stafler,
Dr Edwina Landau and Prof Hannah Blau critically reviewed and revised
the manuscript. All authors approved the final manuscript as submitted
and agree to be accountable for all aspects of the work.

To the Editor,

The ancient Greeks took the entertainment of their crowds very seriously
and used drama as a way of investigating the world they lived in. The
theatrical re-enactment of suffering and grief in front of a large
audience was to foster compassion, as well as a cathartic release of
emotion that was restorative through a deeply felt interconnection
between actors and audience. When our patients encounter tragedy, we are
also drawn into their ordeal and experience it first hand. Such it was
with Rose.

\emph{First Act}

Within minutes of her birth, it became apparent that Rose was unable to
eat. Frothy secretions built up in her mouth and she started to choke.
Rose was affected by one of the most severe foregut malformations,
esophageal atresia with tracheo-esophageal fistula. During the first
month of her embryonal existence, poorly understood disturbances in
molecular, cellular and morphogenetic pathways had led to a failure of
the esophagus to form as a continuous organ and separate from the
trachea.

On day two of life, Rose underwent a four-hour long operation to connect
her esophagus and disconnect it from her trachea. Despite successful
repair, her long and arduous odyssey had only just begun and she
continued to suffer severe pneumonias. Following a battery of tests, her
parents were told the problem was tracheomalacia- Rose's efforts to
clear secretions from her airways were frustrated as her excessively
floppy trachea would collapse with every cough, trapping the mucous in
her lungs. With time, they were told, the trachea would stiffen up and
things would improve. Only they didn't. Rose continued to require daily
intensive airway clearance, frequent hospital admissions and almost
constant antibiotic treatment. She was barely able to attend school
during most of her childhood. Rose's set of challenges resembled those
of Odysseus, Homer's tragic hero: Bloody battles, vicious fights with
life forces, years of isolation, and imprisonment.

With these struggles in mind, it was suggested that Rose receive
psychotherapeutic help. She arrived in the psychologist's room with her
hair disheveled, concealing her face. Initially reticent, she slowly
opened up, primarily through her drawings and songs. Underneath the shy
exterior, was a very funny, talented young teen. Her drawings featured
images of people with masks on their faces and long necks tied in a knot
(Figure 1). She felt choked and unable to truly express herself.

Her inner experience mirrored her external reality. Like Rose's airway
secretions were stuck deep down, unable to reach the surface, so could
her emotions not be expressed, let alone exorcised. Rose developed a
sense of identity founded on her illness- defective, isolated and an
object of pity. ``Everyone looks at me and feels sorry for me''.

But help was at hand. A novel surgical approach for tracheomalacia had
been developed at Boston Children's Hospital. This involved suturing the
back wall of the trachea to the anterior spinal ligament, thereby
achieving airway patency and facilitating effective secretion clearance.
In a case series of nearly 100 children who underwent this repair,
significant and clinically important improvements in all respiratory
outcomes were observed. (1)

\emph{Second Act}

Rose, now aged 15, was flown to Boston, where she underwent posterior
tracheopexy. The operation was successful, and the desired mechanical
results achieved. However, it soon became clear that she was fearful and
confused around her new identity; if she wasn't a sick person, who was
she? She became depressed and anxious. This confused the medical team,
who had anticipated she would now be healed. After so much effort
invested, expertise recruited and tangible progress made, what was she
still unhappy about?

In therapy, Rose started expressing fantasies of being a sea creature,
able to breathe in water but not in air. She seemed to be re-enacting
her life from beginning, in the womb, from non-breathing to breathing,
from retaining to releasing. She began re-constructing her own self,
re-experiencing important parts of what happened in her early life. Her
improved health appeared to enable her to move away from survival mode,
making it safe to put down defenses. As Rose began to expel her sputum
effortlessly, she slowly learned to expel her emotional phlegm. She was
again mirroring her new physical reality with her psychic experience.
The psychologist, through being with her in her pain, could help Rose
re-live earlier experiences not yet realized, so that she was able to
develop a healthier and more integrated self. (2)

\emph{Third Act}

With mechanisms for expelling physical and psychological catarrh in
place, the conditions were now set for Rose, as well as her medical
team, to achieve catharsis. As she started to take more care of her
physical appearance, she became engaged in life, made friends, developed
hobbies and voiced age-appropriate concerns. Throughout the years of
accompanying her, the medical professionals had felt distressed when
Rose struggled. Now they too experienced relief, as she prevailed.

According to Aristotle, pity and terror are instrumental for the
cleansing process on the theatrical stage. (3) Likewise on the medical
stage, our patients' tragedies and triumphs can have a cathartic effect
on us. The intensity of doctor-patient relationships varies, for a
myriad of reasons, many of them rooted in our own psyche. It is not
always easy or intuitive to honestly engage. But once we commit
ourselves, shared emotions tie us not only to the other person, but also
to our own sense of being human and what it means to be alive. This
awareness can purge us of petty concerns and connect us to our own
authentic self.

Odysseus managed to return home eventually. Even after 20 years of
separation, his wife Penelope takes him back. In spite of the many
suitors outside the castle vying to take the reign, he reclaims his
kingdom once again. Rose turns 20 this year. As she says, ``I have a
different sense of being and it feels good''. Like in the Greek
tragedies, she can now reclaim herself and blossom.

\textbf{References}

1. Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Rhein LM, Manfredi
MA, et al. Posterior tracheopexy for severe tracheomalacia. J Pediatr
Surg. 2017;52(6):951-5.

2. Ogden T. Reclaiming unlived life: experiences in psychoanalysis.
Chapter 3: Fear of breakdown and the unlived life. 2016, pp 47-70.

3. Solbakk JH. Catharsis and moral therapy II: An Aristotelian account.
Medicine, health care and philosophy. 2006, 9:141-153.

\textbf{Figure 1.} Rose's drawing at the beginning of psychotherapy,
featuring a person with face mask and long neck tied in a knot\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/FIgure-1/FIgure-1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

