"The Best Greens I Ever Ate"

     This recipe was given to me by my son, Eli, who decided to opt out of the cafeteria plan in his last year of college.  Instead, he cooks most of his meals on the weekends in an apartment kitchen, and eats them all week.   
     He sent me an email with this recipe, which he invented with his new girlfriend one Sunday evening.  I assumed he referred to them as "the best greens ever," because he was happily in love.  
     But then I cooked them up for myself, and they really are the best ever.

1 pound collard greens
1/2 cup olive oil
4 Tbsp pepper oil (in Chinese grocery stores)
2 onions, chopped
8 cloves garlic, chopped
2 yellow or red bell peppers, chopped
2 tomatoes, chopped
1 can tomato paste
3 Tbsp dried, or 1/2 cup fresh, oregano
1 Tbsp dried, or 1/4 cup fresh, basil
1/2 tsp cayenne
1 tsp salt
1/4 cup soy sauce
(MSG)

Wash collards and chop central stalks into tiny pieces.  Chop leafy parts and set aside.
Heat oils in a large cooking pot or frying pan.
Stir in collard stalks, peppers and onions, and cook, until soft.
Add garlic, tomatoes, tomato paste, cayenne, and salt.  Stir until well-integrated.
Add collards in bunches, cooking until wilted, and adding more.  Use additional pepper oil if necessary, stirring constantly.
Add oregano, basil, soy sauce (and MSG, if desired), seasoning more to taste. Stir in over a few minutes.  Serve alongside jasmine rice.
Enjoy!

A New Cause of Carpal Tunnel Syndrome

     Yesterday I saw a patient, Ms. B., age twenty-seven, with carpal tunnel syndrome.  She wanted a referral for surgery.
     You know the symptoms:  numbness and tingling over the palm of the hand, worse at bedtime; weakness, especially when picking up small things. 
     Carpal tunnel syndrome was first recognized as a medical problem when factories multipled during the Industrial Revolution, employing lots of workers to do repetitive jobs with their hands on assembly lines.  The snapping motion of the wrist being flexed and extended causes tissues to swell where the forearm and wrist meet, clamping down on a tunnel through which the median nerve passes.  The median nerve supplies sensation to the palm, thumb and two and a half fingers, and innervates some of the muscles as well.
     When I first opened a clinic in Hawthorne there was a sewing factory in town, and many of the workers came to me with carpal tunnel syndrome.  Georgia Pacific had a timber mill there, too, and some of the workers had the same symptoms.  These days I diagnosis it more often in patients who make a living at the computer.
     Tapping her wrist over the median nerve--known as Tinel's sign--caused a tingling, electric sensation across the hillock of muscle at the base of her thumb.  Putting the backs of her hands together for a minute, knuckles over knuckles--known as Phalen's test-- made her hands numb.  These confirmed her diagnosis.
     Ms. B. didn't have a job, and wasn't a computer junkie.
     Her problem was too much texting.
     "Show me how you use your phone to text," I requested.
     She picked up the iPhone with her non-dominant right hand and began texting singlehandedly, rotating her wrist repeatedly in order to reach various places on the keyboard.  She was really fast.
     "Whoa!" I said.  "You're pretty skillful there.  How much time do you spend texting each day?"
     "I text all day long," she said, sort of proudly.   
     She was an expert at the keyboard.  In fact, the text she was sending to a friend, as an example for me, was several paragraphs long, and took only a minute or so to create.
     I began to realize that texting, and being texted to, must mean people really care about one another.  It's proof of love, I guess.  It's a way of saying, all day, "I'm here! I'm here!  Can you hear me?" and getting messages back from the huge, dark, empty-looking universe--from other life-forms who are somewhat like us.  It's an appeasement of loneliness.  But there are downsides to this.form of self-comfort.
     Lesson:  Excessive iPhone texting can lead to carpal tunnel syndrome.
     I taught Ms. B. how to do stretches to distend the carpal space and release compression on the nerve it allows to pass through.  She experienced immediate relief of the pain. 
     I gave her a wrist-forearm splint to use at night, when reversion to the fetal position puts the human hand in the worst possible configuration for those who suffer with this form of neuropathy.  The splint will prevent her from folding her wrists down.
     Then, to reverse the condition and stop her symptoms, I suggested a carpal tunnel corticosteroid shot.  It's a simple treatment, usually painless, and side-effect free.  One study showed that it was superior to surgery--more patients who under go surgery have recurrence of the problem than those who get a shot.
     Any patient who will agree to have a needle stuck into her wrist must be suffering a lot.
     Ms. B. said, "Go get the shot, please."
     So I measured the medication into a syringe, sterilized the skin over Ms. B.'s wrist with Povidone-iodine and alcohol, asked a nurse to freeze-anesthetize the area using ethyl choloride spray, and deposited the medication straight into the carpal tunnel. 
     Ms. B., didn't even flinch.
     I don't think she'll need that referral to a surgeon. 
     But I did tell her to stop texting so much. 
     Fat chance.

Placebos and Nocebos

     I don't have a problem with placebos.  They don't seem like lies or hoaxes, so much as useful adjuncts in the practice of medicine.  It's difficult, in fact, to know when a "real" treatment is working, and when it's the placebo that's effecting the cure--that's how "real" placebos are.
      Placebos may be pills that contain no "active" ingredients--the snake oils of the nineteenth century-- or they may do their deed in the guise of therapies like EDTA chelation, colonics, high-dose vitamin C, colloidal silver, craniosacral therapy, anthroposophical medicine, homeopathy, and hundreds more.
     Nor is it necessary to "trick" patients into taking placebos.  Believing in a therapy is important, but believing that it is science-based is not a big deal.  The placebo effect is in full force even when patients are told they are being given a placebo, and that it may work.  This was proven by medical researcher and acupuncturist, Ted Kaptchuk, who showed in a study on irritable-bowel syndrome that participants reported relief from their symptoms when they were told they were being given placebos. Was it simply the fact that they were being taken seriously, and the long conversation about the placebo-effect that led to these surprising results?  Or are such results only surprising in an era so hoodwinked by the absolutism of science that we can't entertain any other ideas about how the world works?
     When I opted for acupuncture treatment last year--and again this month--I "knew" that it was not scientific and has never been proven to work.  In a way, I was purchasing a placebo, with full understanding of what it was, namely, nothing at all.  Nevertheless, the acupuncture treatments worked--and for some reason this makes perfect sense to me.
     MRI's and PET scans have shed a little light on the biological underpinnings of placebos by demonstrating alterations in brain metabolism similar to those induced by "real" medicine.  We are beginning to understand that beneficial chemicals are secreted by the nervous system, and affects the brain, when a good treatment is administered, regardless of the actual components of that treatment.  In fact, what makes any treatment good is that it works.  It is even likely that so-called incurable diseases might be cured via the mysterious handiwork of placebos.
     Many years ago I read a book with the irresistible title, Remarkable Recovery.  It chronicled in rather haphazard form the astounding cures experienced by a motley group of patients--people who bore no relationto one another, except that they were in extremis, far gone with illness.  They were emaciated, had widely metastatic cancers or debilitated hearts, and were sometimes days away from death.  Doctors had given up on most of them.
     Then, in a reversal that could only be termed miraculous, they were cured--sometimes overnight.  The explanations offered by the patients themselves followed no pattern and simply could not be accepted by the medical community.  Some said they prayed, or did meditation;  some followed macrobiotic or raw diets, or introduced strange foods;  some quit smoking, others started;  some went on a pilgrimage or made peace with loved ones, while others started conflicts; and many chose unconventional treatments.  There was no consistency in the illness-cure connection, so the cases were sort of forgotten in the annals of medicine.   It was as though, in the absence of logical elucidation, theses cases had to be banished to the sidelines of western medicine.  They could not be believed.  
     The author, Marc Barasch,  gathered them up, however, like breadcrusts dropped by Hansel in the darkening woods, in the hope, perhaps, of following their path to the cottage of the hag who surely was responsible for such aberrant results.  The hag has yet to reveal her truth.
     Barasch concluded that while extraordinary healings might give us clues about how the human organism repairs itself, and why some people get well and others don't, he could not say what exactly those clues were, or what they might mean.
     While doctors might be skeptical about the power of placebos, they are fully aware of the "nocebo effect."  

      Placebo:  A non-medicine which, when administered along with a suggestion that it will have a positive or curative effect, and taken by a person with specific symptoms, results in significant improvement in those symptoms.

     Nocebo:  A non-medicine which, when administered to a person along with the suggestion that it may have side effects, results in that person experiencing those particular side effects.

     The Power of Suggestion:  An effect on brain chemistry--especially involving endorphins, but probably many substances--resulting from powerful messages conveyed by an interaction of one person with another person, or by reading, hoping, fearing, hearing or thinking about the possibility of such an effect.

     The advertising industry has harmed medicine by listing in harrowing detail all the possible side effects of the pharmaceuticals being promoted--especially on television, where the "fine print" is audible, and therefore inescapable.  While I am not opposed to giving patients a heads-up about common repercussions of treatment, putting them in context within a caring relationship goes a long way toward calming the disquietude of  "too much information," and the nocebo effect that may ensue.
     The placebo effect does not work with patients who have Alzheimer's.  Neither does it wwork, we presume, in animals.  When I recommend MSM to patients who have arthritis--telling them that lame horses sometimes walk as though they are not in pain after a few doses of the white crystalline veterinary version--it's a way of "proving" that MSM is better than a placebo.  But there's no way to separate the effects in humans or placebos and real medicine.  Even in double-blind placebo-controlled studies the participants wonder whether they're getting the real stuff or the placebo, and their suspicion has to have an effect, too.
     If you expect to undergo a treatment, it starts to work even before you receive it.  Alzheimer's patients don't get the beneficial surge of brain hormones triggered by expectation, and neither do horses.
     Kaptchuk, the world's expert on placebos, is quoted in the December 12, 2011 New Yorker article, "The Power of Nothing"--

          "Anything that gets people away from the conveyor belts that move from the pharmaceutical houses to doctors and on to patients is worth considering.  Anything.  We need to stop pretending it's all about molecular biology.  Serious illnesses are affected by aesthetics, by art, and by the moral questions that are negotiated between practitioners and patients.  Chiropractors never say that your pain is all in your head.  But orthopedists do it all the time.  What a fucking way to try and help someone heal.  Do you know how evil that is?"

     I could propose a psychological theory that explains the placebo effect, and it would be as good as any other theory so far.  Even if alterations in brain chemistry are deemed the "real" explanation for the effects of medicines and placebos, we haven't yet figured out how to measure expectation.
     But we all know when we feel an expectation, and how it's full of possibility.  In the weeks leading up to my call to the acupuncturist, I was already expecting to be cured of my symptoms.  Once I made the appointment the expectation was ramped up a few notches.  By the time I got there, whatever the acupuncturist did was bound to effect a cure.  And, it was worth paying for.
     

  

Michael Specter wrote a terrific article about placebos, "The Power of Nothing," published in the December 12, 2011 issue of The New Yorker.

Chattermouths

     When he was very young my son, Simon, invented the word "chattermouths" to refer to people who talked so much he stopped listening and could only heed the funny way their mouths kept moving up and down without anything coming out.  I realized he was experiencing a form of noise pollution.
     After that, I suggested that we have a day of silence in our household.  No one was allowed to talk.  It might have been interesting, but we couldn't comply for more than a day.  Raising four boys was a noisy task.
     My kids are [mostly] gone now, but there is still too much commotion everywhere, especially cyber-commotion.  The grown-up world of media advertising and overall information flooding (just knowing so much information is out there is enough to drown us with what-ifs that don't even apply to us) is causing our internal systems to crash.
     Have people always chattermouthed so much?  Are we equipped neurologically to handle the ruckus?
    In the clinic, sometimes a patient tells me so much I think we're both going to succumb in the relentless tide of words.  One sentence follows another, and another, with parentheses and asides, down major thoroughfares and alleyways and onto boat ramps and finally into the miles-deep gray-black vastness of the sea.
    "Stop!" I want to shout.  "I can't think!"
     But instead of saying something so rude, I ask myself what the too-much-talking-one is trying to do,  in contradistinction from the patient's conscious motive for coming to the doctor.  What little termagant has pushed to the front of the crowd, grabbed the microphone, and laid claim to the session?  Why has the patient allowed this long-tongued devil to upstage the two of us?
    Maybe the patient is terrified of hearing bad news, and therefore creates an obstacle course of stories and gossip for protection.  Or he may wish to please, skimming everything off the surface of his life for me, the scientist, to scrutinize.  Maybe it's loneliness that triggers the word-waterfall in which we're both drenched.
     Medical training teaches us that a patient will disclose to the doctor the exact diagnosis and the cure, if  the doctor will just listen long enough.
     There is often a moment when I've reached my limit, overwhelmed by stories and seeming trivialities, wondering, "Why won't this patient be quiet so I can figure out what's wrong?"  Then, I go back through the flow of words and catch one that lights up, a Eureka! moment.  It's an unexpected, and a highly irrational way to make a diagnosis, but sometimes it works.
     This happened three weeks ago.  A patient I hardly knew couldn't slow down her flow of words.  She'd been to six different doctors and had a lot to say about what they'd prescribed and what they hadn't done, and how many tests she'd undergone:  CT scans, MRI, ultrasound, blood tests, colon biopsies.  The she started to tell me the story of her life.  On and on she went, asking intermittently for pain medicine to help with the bad bouts of abdominal pain she had every so often, so that I was beginning to wonder if maybe she was a drug-seeker.
     "I was gonna stop going to you doctors for fear y'all are thinking I just want pain pills," she said, reading my mind.  "But my neighbor said, 'Try my doctor, she's good, she'll help you...'-- So that's why I'm here."
     Flattery, I thought.  Typical of people who want pain meds to trade or sell on the streets.  Florida is the premier state for controlled prescriptions.  Last I heard, we were dispensing twenty times more narcotics in Florida than all the other states put together.
     Then I hit the Rewind and Play buttons on my brain's remote control, and heard,  for fear ya'll...for fear ya'll...for fear ya...porphyria--Yikes!  Could she have porphyria?
     Acute Intermittent Porphyria is so rare a doctor is not likely to make more than one correct diagnosis in a lifetime.  It's beongs to a group of hereditary disorders characterized by problems making heme, a blood protein.  As a result, porphyrins, which are precursors for heme, build up, causing neuropathy and bouts of abdominal pain.  The pain can be severe and disabling, and no one quite understands the mechanism by which porphyrins lead to pain, but they interact with bile and other stomach enzymes, which offers a clue.
     The patient took home a kit to collect her urine for twenty-four hours, and two weeks later the results from Quest Lab confirmed the diagnosis:  porphria.  She really did need pain medicine, for times when the porphyria acted up.  Not prescribing pain pills would be cruel.
     The patient wasn't surprised or impressed by my diagnostic acumen.
     "I knew something was wrong," she said.  "You don't have to convince me."
     Recently, an old friend told me that he thinks doctors talk too much, not patients.  We physicians are more impressed with what we know and what we have to say than the patients are.  Most of what doctors say is irrelevant or uninteresting, he said, and not what he wants to know.  The more I think about it, the more I wonder if he's right.
     The real chattermouths may be us, the doctors, not our patients who are want us to leave the enthusiasm and know-it-allness of doctoring behind, so we can listen to them, and they can be heard.
     I know I've got to stop chattermouthing, and hit Replay more often. 

Patients, #12: Acupuncture

     Last year, after the government raided my office and I could see how my future was going to be like a building at the epicenter of an earthquake--a crumbling heap of concrete, wainscoting, drywall, roofing, with sinks and kitchenware strewn about in the rubble...and with sub-personalities that sort of belonged to me, wandering aimlessly, like people lost in a catastrophe--at that time, I began to experience chest pain.
     Not only chest pain, but the presentiment of being unable to breathe.  When I lay down at night to read or sleep, my heart flopped below my sternum like a fish at the end of a line on the marred wooden deck of a boat, signaling extreme distress.  If I took a deep inspiration, I couldn't fill my lungs.  The pleura halted mid-breath, balloon-like, stiff, as though about to burst.
     I tried the usual things doctors do to avoid going to the doctor.
     Everyone knows doctors make terrible patients.  For one thing, we don't go to other doctors.  We think we know better.  We don't like subjecting ourselves to other people's judgments, which feel accusatory.  So, I stayed away from my medical colleagues, did Valsalva maneuvers and carotid massage to reset the patterned rhythm of my heart,  took propanolol and hawthorne berry extract, avoided caffeine, and tried to meditate.
     But whenever I meditated I could feel my heart tripping.  There was a character in there with a bad limp, taking a step, and dragging a leg, taking another step, and bump-bump-bumping along.  Focusing on my breathing--a standard technique for calming the mind--only brought to the foreground my inability to take in deep, restorative breaths.
     I did an EKG at the clinic one afternoon:  sure enough, every third beat was an odd one--the guy with the limp--and the other two were saying, "Come on, get it together, man!" in a rhythm the textbooks call trigeminy.
     I couldn't bear the thought of seeing a cardiologist.  He might want to do a cardiac catheterization, and I knew I wouldn't agree to that.  He'd tell me to wear monitors, or return for a thallium stress test, or try one or another prescription drugs and, like other "noncompliant" patients, I wouldn't do those things--I might not even show up for the next appointment.
     It's bad, being a doctor.  You think you can see through all the tricks of other doctors.  You don't really like what they do.  You don't believe in them, at least not for yourself--and believing is just about everything.
     So I called an acupuncturist I had visited fifteen years ago, a woman who had completed her training in China, who was from China, and whose English remained authentic in its choppiness.  I remember having had to fill in words for her, when she got stuck.  I remember that she told me stories about her life in China, about her father's political resistance, her grandmother's loving protection, and the horrors her family endured in the Great Leap Forward.  Someone who'd been through all that must be the real deal.
     She gave me an appointment right away and when I arrived, her office was serenely empty.  Here was a woman who knew how to manage her schedule.  There weren't patients piled on top of one another, she didn't run late, and she must really know how to say No.  (I, on the other hand, have always maintained a strict policy of Yes:  "Sure, come on in!  I'll see you.  We'll take care of you.  It's one minute to closing?  No matter--you're sick, I'll help.  Come one, come all!"  For this reason, my clinic waiting room has always been overflowing, and I run late, and have to say to everyone, "This isn't Walmart!  We don't promise instant-service-instant-cure!   But I will take you seriously").
     Therefore, the Chinese acupuncturist's office and clinical style were, for me, completely other.  Maybe that was Step One in my cure.  The acupuncturist herself was unwilling to "explain" her methods--which was Step Two.  And Step Three:  I submitted myself wholly into her care  I did what she said, I stuck out my tongue, I held out my wrists for her to check my pulses in nine positions.  I lay on the table in the dim lamplight, staring at diagrams of the human body with dots and lines running along pathways that didn't correspond  to anything western, to any model I understood, and I let her twirl sixteen horsehair-thin wires into places as far removed from my heart as my palms, ankles, head, and forearms until they smarted and sent currents of sparking energy in all directions.
     "That's the blocked energy pathways opening up," she said obscurely, "to let the chi circulate again."
     Sure enough, my heart started thrashing around in a way that was worse than before.
     "The problem is  not better, it's worse," I told her.
     "Don't worry," she said, unperturbed.  "Take some deep breath.  Tie to relax."
     She tinkered with the needles, stopping only when she saw me grimace, and left the room.  Then she returned every twenty minutes to tinker some more.  Between times, it was silent as a church.  I even heard the noise in my head settle into a pew, and bow down.
     I remained in treatment two hours.  After the needles came out, there was a round of suction cups on my back, followed by placement of tiny seeds on my ears, attached with sticky-tape.  She told me to press the eight seeds--hard, round, black products of the vaccaria plant, used in auricular therapy--four times a day for best results, and to leave them there for two weeks.
     The magic worked.  That night, my palpitations were ninety percent gone.  After two more treatments over the following weeks, they disappeared for good.  Moreover, I felt calmer, slept better, and was able to take the long view, scanning the rubble of my future and planning its clean-up.
     It was important for me to undergo treatment that would petition my inner healer to come forward.  Some people call this the placebo effect.  Whatever else acupuncture might do (and clinical studies have never confirmed that acupuncture works), my belief triggered a biological or chemical response to my condition, and led to resolution of my symptoms.
     So, last week when my heart ululations came back, I presumed once again that my system was "out of balance," and went back to my acupuncturist.  Her office was unchanged, a tranquil place with no other people, and she told me more stories, as though they were relevant--stories about her brother whose mental illness was caused by a bout of meningitis, and whose short, sad life forty years ago still brought her a portion of grief every day.  Perhaps she was getting as much out of my visits as I was getting from her, something that happens all the time for me, in my clinic.
     After the next two visits with her, and once my chi is moving freely, I will scan the horizon of my life and put together a plan for picking up debris, hanging more drywall, rebuilding the kitchen, starting something new.  As for the government and its agents, I'm going to send them to a shed out back, by the pond, where the alligator--who is getting hungry--lurks.
      

Closing My Medical Practice

     Quitting most jobs is easy.  You walk away and don't come back, or you give two weeks' notice--and then walk away and don't come back.
     Quitting a solo medical clinic is more complicated. 
     As I leave behind my life and profession I am undergoing a slow-motion psychic shock, like the subsurface rumbling and shifting that precede an earthquake.  It's comforting to know that many people go through this in so-called mid-life.  I wait it out as one waits out grief, standing guard as the entire edifice of my self-as-I-know-it comes down.  I can report on this process, as though telling a story, but I am unable in the midst of it to give advice.
    Wrapping up a medical business has to start at least three months before closing the doors for good, but some experts recommended starting two years in advance, especially if the practice is transitioning to new ownership.
     First come the letters.  Every insurance carrier must be notified that I am no longer "participating" in the plan.  Here's a sample of the eighty-five letters I have sent to insurance companies:

     Dear Plan Administrator:
          Pursuant to our contractual agreement, this letter of October 26, 2012 serves
      as sufficient notice by Colasante Clinc, PA/Ona Colasante, MD for the action of
     terminating our contractual agreement to provide care to your membership. 
     This termination shall be effective January 31, 2013 with the closing of
     Colasante Clinic, PA located at 810 NW 16th Avenue, Gainesville, FL. 32601.
                            Respectfully,  Ona Colasante MD

Information relating to plan numbers, my NPI, license, and tax ID numbers are included in the letters, and I sent them return-receipt-requested.  That way the insurance carriers can't claim that I have abandoned their clients.  Next, I'll notify AHCA, the medical board, the vendors who send supplies, and the local pharmacies.  The building will probably stand empty, and the bank that foreclosed on the prior owner (caught in the bank loan mess) and had to take over my lease will try to lease or sell it cheap.
     It would be easier if another doctor, clinic or group were to take over the existing clinic--then my employees wouldn't end up on the unemployment rolls and patients could continue to get medical care at the same neighborhood location. 
     But who wants to take over a clinic that's "under investigation"?  It doesn't seem to matter that my "contaminated" Medicare number would follow me, and not attach itself to a new business in the same location.  It doesn't matter that a new physician wouldn't be affected by the government's interest in me.  The place has been blasphemed, and no one wants it.  I might as well have been the victim of voodoo.
     I have considered selling all the clinic equipment, but the market is slow and it would take a lot of time and hassle.  Besides, my bookkeeper says medical equipment depreciates by 40% in the first year.  Therefore, I've decided to donate all the equipment to nonprofit entities.  A few pieces are slated to go to Guatemala.  Anyone want medical equipment?
     I called an office meeting last week and told all my employees about my decision to close up.  I must have been saying, "I'm sorry, I'm sorry," a lot, because they asked me to stop.  "It's not your fault," they said.  "You're a great doctor.  This is a crime."  I asked them what they planned to do with themselves after January 31st.  Three said they would go back to school.  One is likely to tend chickens, plant a garden, and wait for fate to knock on the door.  Another wants to run for public office.  Another is leaving the country.
     I am going to take a lesson from the government, and make a resolution not to rush through life. If the FBI can take ten years to tell me why it raided my clinic, chaoticized my calling, and anathematized my name, surely I can take a few years to count grasshoppers, look after my dozen chickens, mark up all the books in my library, and imagine the future in the vast banks of clouds overhead.
    

    

Salem Witchcraft Trial Procedure

The following "procedure" for trying and sentencing witches was taken from the Salem Witchcraft website, address below.  It's one idea of fairness.  Thank goodness for the Enlightenment,  because we're not like this any more, right?  http://law2.umkc.edu/faculty/projects/ftrials/salem/SALEM.HTM 

1. The afflicted person makes a complaint to the Magistrate about a suspected witch.  The complaint is sometimes made through a third person. 2.  The Magistrate issues a warrant for the arrest of the accused person. 3.  The accused person is taken into custody and examined by two or more Magistrates.  If, after listening to testimony, the Magistrate believes that the accused person is probably guilty, the accused is sent to jail for possible reexamination and to await trial. 4.  The case is presented to the Grand Jury.  Depositions relating to the guilt or innocence of the accused are entered into evidence. 5.  If the accused is indicted by the Grand Jury, he or she is tried before the Court of Oyer and Terminer.  A jury, instructed by the Court, decides the defendant's guilt. 6.  The convicted defendant receives his or her sentence from the Court.  In each case at Salem, the convicted defendant was sentenced to be hanged on a specified date. 7.  The Sheriff and his deputies carry out the sentence of death on the specified date.