11 Dec., 1960.
Dear Karl,
Please forgive my slowness in answering your last letter, which I enjoyed very much. In fact, and this you may find hard to believe, I have been goaded by it into working nights on the paper on cancer in ulcerative colitis. This paper is now rough typed as I would like it to be, and I have only to retype it properly and then send it to you for forwarding to Al Hurwitz, my co-editor on the Reappraisal Section, who will forward it in turn to OHW. In the meantime, time has flown.
I received an airmail special-delivery letter from Bromberg the day before receipt of your letter, but it arrived late in the day and was not answered before arrival of yours. The death of O'Brien was unknown to me, but is no surprise, as he had had hypertension in addition to his bleeding ulcer for several years. As you know, the Plastic Surgery situation has been a serious problem at KCH. You will find Miss Levine has a folder in my own inimitable handwriting on the problem involved. She probably does not have it in her general files as I kept it in my right-hand desk drawer when I was there, as this seemed less prone to unwanted leakage of information. I am sure she can find it for you. My own appraisal of the situation is as follows, subject to any errors which might arise from faulty recollection. Teplitzky is a strong man who lost his position at KCH because of his insistence on billing insurance companies for blood transfusions given to burn patients. The Commissioner, Martin Kogel, felt this should be billed by the City, as it was a service rendered entirely by City-paid personnel and the only part player by staff was in setting up a pattern of indications for such transfusions. to make a long story short, Teplitzky undertook to make his objections appear in the light of his own righteous indignation over this usurpation of fees by the city. He unfortunately rendered bills for this item without making it known to anyone else, and if I recall correctly, the appearance was one of concealment of such bills. I know Phil Lear regards Teplitzky highly, but I think the consensus is that his record in this regard would appear to the unbiased observer to fall short of lily-white.
Ray Shapiro had his training at KCH but to date has never gotten himself prepared to take his Boards in Plastic Surgery, and would therefore be in difficulties at once with the service relation to the Board of Plastic Surgery if placed officially in charge of service. He also is not a hard-driver, which I suspect is what the service needs to regain the excellence it was once supposed to have. Rubin and Walden are both conscientious and hard-working men, and both had been antagonized by O'Brien, primarily by his habit of participating in case care only to the point necessary to assure his gaining of fees for patient care. Even the expenses of the Society of Graduate Plastic Surgeons of KCH were paid n the last few years from earnings of men working at Meadowbrook Hospital, since apparently O'Brien had control of all funds from KCH and would not relinquish any of them. Neither Rubin nor Walden is regarded by Herb Conway as having had a thorough and broad training in plastic surgery; one of them is better than the other, but I cannot recall which is the stronger one at the moment. Be that as it may, the Board of Plastic Surgery is reported by Conway to have passed the last examinee from here with grave reservations because of shortcomings in training and in quality of performance in the examinations, and it would seem to Herb and to me that there is reason for thinking seriously about the wisdom of revising the organization of the service with this in view.
Bromberg trained under Conway and associates, and comes from an environment in which active sound basic research has been in progress for many years. Perhaps you know of the work at Cornell on tissue transplantation and immunity, some of which has looked very creditable. It would be wise to check, but I think Bromberg had an active part in some of this and would like the opportunity to work in a university atmosphere where he could continue to so such work. He is a hard driver and he is aggressive, as his hurry-up letter to me would indicate, but we have had several conversations, starting several years back, and notes of these will be found in my right drawer or in the main files under his name as prospective staff. Bob Moore was consulted about the situation, and felt as I do that the thing to do was to sit tight while O'Brien was in control, inasmuch as both Conway and Brad Cannon had suggested that probably the Board would crack down on the KCH service, and that at that time it would be proper for me to step in with a solution which would give promise of correcting the situation.
It is true that Rubin and Walden would be happy to return and to work hard again if Bromberg were put in charge, as they indicated to me in conversations notes of which Miss Levine can provide you. It is true that Bromberg is likely to be hard to contain at times, and that it may prove necessary to find someone stronger that Bob Freund to take charge of the head and neck cancer service to keep it where it belongs in the charge of a man with broad general surgical background. Nevertheless, it seemed to me and to Bob Moore that probably this is the proper course to take, namely appointment of Bromberg as Chief of Plastic Surgery, at a time when it seemed easily possible to do so. You must recall that Conway is not exactly a retiring person, and that he may have ideas about gaining some foothold here through Bromberg.
The course to follow is a complicated one to chart, as you can see. Nevertheless it appeared to me that Bromberg seemed the best choice, and the nature of this plan has been made clear to him. In case it is necessary for you to have my expressed approval to go ahead with this appointment, I hereby approve the appointment of Bertram Bromberg as Chief of Plastic Surgery at Kings County Hospital as soon as feasible. He has plans for integrating the training programs her and at Meadowbrook, as we have a large amount of emergency work an almost no elective reconstruction, while the reverse is true there. This also would seem to me an attractive arrangement.
We must bear in mind that the choice must be made from men in practice in our neighborhood, as the position is a volunteer one. It is not as though we could scour the country for the best possible man anywhere, as we do in general and thoracic surgery. Even if we could, I suspect Bromberg might still be considered.
What becomes of Ray Shapiro in all this I do not know. He is already moving his activities out onto the Island, as are all the plastic people, and in the long run I think a hard driver like Bromberg would give us more time and certainly more drive and active organization. I think my talks with Shapiro, notes of which Miss Levine also has, indicate he would stay with us happily if Bromberg came on.
So much for Plastic Surgery, except for one thing. The Oral Surgeons are a capable group, but do not seem to recognize the limitations of their training and competence. I think Bromberg would establish a reasonable working arrangement with them, one which is satisfactory for their board requirements and still safe for the patients, and not on the money grounds we used heretofore.
Would you kindly call Bromberg as soon as you and Bob Moore have reached your decision on this matter. I am sending him no other communication than that a copy of which I enclose. I also enclose the letter he sent me. Please be sure it is duly filed for future reference.
I am sorry indeed that the Committee on Academic Qualifications turned down Wes's application for Markle Fellowship. Do you have an idea why? Was there really a better candidate, which I find it hard to believe, or was it a matter of what I consider the foolish thesis that one department was getting too many Markle Fellowships? What the School needs is the presentation of the strongest possible candidate, and I think no other consideration should prevail. Would appreciate your reaction. Am glad the troubled waters have become smooth again with Wes in any case.
I have been wondering about the bleeding ulcer program also. It seems to me we still have not settled the question of which is the safest means of handling these people. It seems to me that operation on selected patients only, if they are selected on the Dunphy pattern, is the worst way to handle them. Do we really have a better way to select them at hand? Has the program of taking all the bleeding ulcers, regardless of Service of Division, worked well enough since July 1 to give a sufficient number of additional patients to clarify the situation? I should think perhaps the results should have a good statistical analysis before any change is made. What would be your reaction to submission of the whole business to Schuyler Kohl?
It seems to be characteristic of many of our staff that they come to the man in charge to request, demand, or even blackmail him into promotion. Some staff in the past have been dropped because of this latter activity. I agree so fat Ira Teicher seems to me to offer a good deal of promise but that he does not seem to have enough publications of sufficiently sound basic work to pass the Committee on Academic Qualifications. I do think that if he continues as he has in the recent past he will gain his promotion, but I think now that the suggestion should be made that he should be made Professorial Lecturer instead of Clinical Professor. It may be this would be attractive to Ira, but I doubt it. You might ask him to see.
I am in a state of indecision about Roberts. You know as well as I do that Brooklyn abounds with character assassins as well as with skinflints. whether it is still logical or fair to condemn a man because of the places where he works, when apparently great efforts have been made to correct the evils of the former days I do not know. I would feel more comfortable if this were handled as the case of Sydney Cohen, namely set aside until you and I can review all possible evidence together. It is not our duty or right to determine whether a man is honest or guilty, in the last analysis, it is our duty to associate with the Department only those men who are considered by all honest and reputable men in the profession to be free of all possible taint of anything wrong. The failure on our part to appoint a man is in no sense a condemnation. It is simply a judgment of all available information as to the moves which will bring the best and strongest repute to the Department.
Ira Polisar is also not likely at all to get past the Committee. I think it was two years ago that I proposed him, and I do not want that embarrassment again. When his record is unquestionably strong and sound, then it will be time. He is not in the same league with Adrian Kantrowitz or Irv Enquist or Frank Hamm, for example. Have you gotten that technician line away from Polisar yet? I am perplexed about Miller and the Speech and Hearing Program. I do not think we are under any obligation to move him to a State line at all. I think it is up to Ira to run things to the training grant will not be turned down. Last year I sat in with some of the examiners from USHS on this matter, and was put in a highly embarrassing position when it was brought out that he was using men to run his service who were being paid out of the grant to do research and to get trained in research. In fact I got a lecture from John Bordley, the N. and T. man at Johns Hopkins, about the need for research in our thinking in the training of men. I did not like it. If the whole is not to be run in open and above-board fashion, I would rather let it die on the vine than be a participant in any twisting of meanings. I am in doubt about making Dorothy Wolff full time also. You might talk with Bob Moore about this, as he has known her for 25 years, and also has followed the work in question. He feels, if I understand right that she is re-doing what was settled at least 20 years ago.
With regard to Polisar, there is another side to the story, in that the City promised him a large amount of re-built space in the outpatient department, mostly for Speech and Hearing, and that the City has defaulted on much of this. it is now so long ago that I am not certain of my facts, but it would be well to double check before making any firm decisions. Also, the position he holds must be filled by a man in practice in the community, and when Jeff and I went through the Directory of Medical Specialists before Ira's appointment, Ira was the only one he considered at all appropriate for the position in Brooklyn. The situation may have changed somewhat since then, but this fact is worth bearing in mind. Although he s a terrific empire builder and although he seems to have no concept of the meaning of basic research, he is running the service well, with the exception of clashes with other services as to jurisdiction over cases. it would be difficult to replace a man in this position without using a full-time line for the purpose.
I am fascinated with the use of ACD blood for the machine. Was there something entirely faulty with our data on infusion of citrate in dogs when Phil Eder was in the lab? We found then that such infusion was lethal and that infusion into another vessel of compensating amounts of calcium ion did not reduce the lethal effect. Did someone think he knew what results I wanted and switch things to please me? This is worrisome, because until the abstracts of this year's Forum become available, I the question was settled the other way. Certainly the blood problem will be immensely simplified if citrate blood can be used. Are you adding heparin and then calcium just before starting?
Am glad the training grant came through even if shorn so badly. Do the best you can with it.. I am greatly pleased with the progress you and Bob Moore and Jack Stuckey imply in your letters. The intern situation and the resident situation seem to be improving, and we well can stand it!
I hope Gloria did not take my lovely X-mas card to her too literally. I shall be ready to come back when the year is over, I am sure, but have found so much to do in the meantime that I am exhausted most of the time. We have been trying to carry on partial left heart by-pass by means of a large trocar put down the jugular vein, through the atrial system and into the left atrium. We can get it into place regularly with the aid, usually, of fluoroscopy, but it slips sometimes and has to be replaced after a time. There are twelve experiments of such perfusion, turning over 50% of estimated cardiac output for six hours, with two dogs dying. At sacrifice we have had trauma to endocardium here and there, but the hole tends usually to close, though not invariably. We have done a mess of left by-passes with collection of coronary blood and determination of oxygen utilization as measured with coronary sinus blood. There is no doubt about reduction of oxygen use even with small amounts of turnover. We are now testing Sarnoff's time-tension index (Vol. 192 of A.J. Physiol.) and find that in this connection it does not seem to apply at all. There are planned some runs in which we do the above simultaneously to show that Sarnoff's thesis is not correct, I hope. We have also been doing dog work on deep hypothermia, with reference to oxygen use and the nature of the oxygen debt built up on arrest of circulation at arrest below 15 degrees.
Family is fine. Jane is much too interested in a premedical student here, or maybe she is just bored, I do not know. We shall spend X-mas week here and then go for a few days to the mountains in the north for a little rest, skiing, etc. The family can get along in Swedish after a fashion now. Elly and I went as guests of Crafoord to the ceremonies of awarding of Nobel prizes yesterday. They certainly do things in a beautiful fashion. Was able to follow the speeches reasonably well. We also went to the banquets that evening, and along with only 700 other people had dinner with the king. We were right up front and enjoyed it greatly. The manner of public presentation of the Americans was distressing in contrast with the Englishmen and Medawar, the Australian. I can see why the Swedes want to learn English and not to be contaminated with the American language!
I hope you are refining your composure and not being run ragged. Are you getting everything organized so even I can stay on top of it when I come back? Are you and Irv consulting about whether one of you wants to take either six or 12 months as sabbatical next year?
Please give my best to the girls and others in Department. Have sent word for X-mas to Gloria and family, but please reinforce.
Sincerely,
Clarence
11 Dec., 1960
Dear Dr. Bromberg,
Thank you kindly for your letter. I had not known about Gerald O'Brien's death. Have communicated with Dr. Karlson, who will contact you, I believe, within a few days.
In the meantime, let me extend Season's Greetings to you.