WILLIAM SHAINLINE MIDDLETON National Library of Medicine Bethesda, Maryland 1971 TABLE OF CONTENTS Introduction i - ii Curriculum Vitae of Williams. Middleton iii - V Bibliography of Williams. Middleton vi - xxiv Transcript of Interview 1 - 494 Recollections of Maude Hazel Webster Middleton 495 - 517 "Heads and Tales"; Vignettes of colleagues and associates 518 - 597 Index 598 - 608 Appendix: Panel Chairmen - Drug Efficacy Study 609 - 610 Policy Advisory Conunittee - Drug Efficacy Study 611 - 612 Letter to James L. Goddard from Ro Keith Cannan, November 10, 1966 613 - 615 Proposed revision - Consent for Use of Investiga­ tional new drugs on humans: statement of policy, November 18, 1966 616 - 617 Memorandum to R. Keith Cannan from James L. Goddard, March 31, 1966 618 - 621 Tape-transcript correlation 622 i • Introduction This oral history memoir is the culmination of a series of tape recorded interviews held with Dr. William S. Middleton in Madison, Wisconsin and Bethesda, Maryland in July and November, 1968 and February, 19690 This transcript is the final edited copy which re­ sulted from roughly 28 hours of interview. The transcript has been edited by both the interviewer, Dr. Peter D. Olch, of the National Library of Medicine, and Dro Middletono The first two interview sessions were held in Dro Middleton's home in Madison and the last in the John Shaw Billings Study of the National Library of Medicineo Dr. Middleton's memoir is basically autobiographical in fonnat. Bound with the interview is Dr. Middleton's oral memoir of his wife, Maude Hazel Webster Middleton, and a collection of reminiscences of former friends, associates, and acquaintances entitled "Heads and Tales." Dr. Middleton's memoir provides an oral history of the origins and early years of the University of Wisconsin Medical School, a vivid narration of military medicine in World War I and World War II, a description of the Department of Medicine and Surgery of the Veterans Administration from 1955 to 1963, a thoughtful description of the initial years of the NAS-NRC sponsored Drug Research Board and the subsequent Drug Efficacy Study, as well as numerous other topics which have been encompassed by his long and distinguished career in internal medicine. Dro Middleton is reknowned for his abilities as a ii clinician, teacher, and public speaker. The latter talent is obvious from examining the text of his oral commentary. The interviewer found Dr. Middleton a most lucid respondent. In preparation for these interviews, the interviewer reviewed a signif­ icant portion of Dro Middleton's personal papers preserved in the National Library of Medicine, and consulted the following publications: Clark, Paul F. The University of Wisconsin Medical School, A Chronical, 1848-19480 Madison: The University of Wisconsin Press, 1967. U.S. Congresso Medical Care of Veterans. House Committee Print No. 4, 90th Congress, 1st Sessiono Washington: U.S. G.P.O., April 17, 1967. Piersol, George M. Gateway of Honor, The American College of Physicians, 1915-1959. Lancaster: Lancaster Press, 1962. Corner, George w. Two Centuries of Medicine: A History of the School of Medicine, University of Pennsylvania. Philadelphia: Lippin­ cott, 1965. U.S. War Department, Surgeon General's Office. Medical Department of the United States Army in the World War. Prepared under the direction of M.W. Ireland, 1921-29. 15 v. in 17. U.S. Department of the Army, Office of the Surgeon General. The Medical Department of the United States Army [in World War II]. Washington, 1952~ o (See specifically, Internal Medicine in World War II, Vol. I - Activities of Medical Consultants, Chapter IV - European Theater of Operations, by Williams. Middleton) iii CURRICULUM VITAE William S. Middleton, M.D. ADDRESS: 2114 Adams Street, Madison, Wisconsin BIRTHPLACE : Norristown, Pennsylvania (Jan. 7, 1890) MARITAL STATUS: Married Maude Ho Webster, 1921 (Died 1968) PRESENT POSITION: Emeritus Professor of Medicine; Emeritus Dean, University of Wisconsin Medical School, Madison, Wisconsin PROFESSION: Physician (Internal Medicine); Medical Educator and Administrator CAREER: MoD• Degree: University of Pennsylvania, 1911 Intern: Philadelphia General Hospital, 1911-12 Clinical Instructor of University of Wisconsin Medical School, Medicine: 1912-15 Assistant Professor of University of Wisconsin Medical School, Medicine: 1915-25 Lieutenant and Captain, U.S. Army, with British and American Medical Officers Expeditionary Forces in France, World Reserve Corps: War I, 1917-19 Associate Professor of University of Wisconsin Medical School, Medicine: 1925-33 Professor of Medicine: University of Wisconsin Medical School, 1933-60 Dean of Medical School: University of Wisconsin, 1935-55 Lieutenant Colonel and U.S. Army Medical Corps, European Theater Colonel, Chief Con­ of Operations, 1942-45 sultant in Medicine: Chief Medical Director: Department of Medicine and Surgery, Veterans Administration, Washington, D.C. (Leave of Absence, University of Wisconsin),1955-63 iv Emeritus Professor of University of Wisconsin Medical School, Medicine: 1960- Dean Emeritus: 1960- GUEST LECTURESHIPS AND VISITING ACADEMIC APPOINTMENTS: Galen Visiting Professor of Medicine, University of Michigan Medical School, 1940 Ernest A. Sommer Memorial Lectureship (Medicine), University of Oregon Medical School, 1941 David J. Davis Lectureship, University of Illinois, 1947 Walter Estell Lee Lectureship, Graduate School of Medicine, University of Pennsylvania, 1951 Visiting Professor of Medicine, University of Oklahoma School of Medicine, 1963-64 Visiting Professor of Medicine, University of Oklahoma School of Medicine, October, 1969 HONORS CONFERRED: Sc.D. Degree: University of Pennsylvania, 1946 (Honorary) D.Sc. Degree: Cambridge University, 1950 (Honorary) LL.D Degree: Temple University, 1956 (Honorary) L.HoD• Degree: Franklin and Marshall College, 1927 (Honorary) Litt.D. Degree: Marquette University, 1958 (Honorary) Council Award: Wisconsin State Medical Society, 1938 Alumni Award of Meri t: ~niversity of Pennsylvania, 1945 Centennial Award: Northwestern University, 1951 Alfred Stengel Memor ial American College of Physicians, 1962 Award: Erwin R. Schmidt Award Interstate Medical Association, 1966 for Teaching: Alumni Award for Dis tin- guished Teaching: University of Wisconsin, 1969 Legion of Merit with Oak Leaf Cluster (U.S.) Croix de Guerre with Palm (France) Distinguished Service Medal (U.S.) Honorary Officer, Order of the British Empire (Military) Kings Own Old Comrades Association SOCIETY MEMBERSHIPS: Honorary Honorary Fellow, Royal Society of Medicine V Association of Physicians of Great Britain and Ireland Honolulu County Medical Society Spokane Society of Internal Medicine Minnesota Society of Internal Medicine Asociacion Medica de Puerto Rico Sociedad de Medicina Interna de Buenos Aires American College of Hospital Administrators Constantinian Society Elective Master, American College of Physicians (President, 1950) Fellow, Royal College of Physicians (London) Fellow, College of Physicians of Philadelphia American Association for the Advancement of Science Association of American Physicians American Society for Clinical Investigation Central Society for Clinical Research (President, 1933) American Clinical and Climatological Association Society for Experimental Biology and Medicine American Association for History of Medicine (President, 1934) Wisconsin Academy of Sciences, Arts and Letters Society of U.S. Medical Consultants Society of the Cincinnati American Medical Association; Medical Society of D.Co Alpha Omega Alpha Phi Beta Pi Phi Kappa Phi Sigma Xi Sigma Sigma Phi Beta Kappa Alpha Tau Omega vi BIBLIOGRAPHY William S. Middleton Middleton, W.S. The Efficiency of Typhoid Vaccines Prepared at Different Temperatures. Therapeutic Gaz July 15, 1911. Middleton, W.S., and Shumacker, L. The Cardiac Effects of Immoderate College Athletics. JAMA 62:1136-44 Apr. 11, 1914. Middleton, W.S. High School Athletics. American Physical Education Review 273-8 1914. Barrett, M.T., Middleton, W.S., and Smith, A.J. The Tonsils as a Habitat of Oral Endamebas. JAMA 63:1746-9 Nov. 14, 1914. Middleton, W.S. The Effect of Athletic Training on the Heart. American Physical Education Review 1-15 Mar., 1915. Middleton, W.S. The Cardiac Accidents of a Year's College Sports. Wisconsin Med J No. 10 13:1-7 Mar., 1915. Middleton, W.S. The Influence of Athletic Training on Blood Pressure. Amer J Med Sci No. 3 150:426 Sep., 1915. Evans, J.S., and Middleton, W.S. Endamebic Pyorrhea and Its Complications. JAMA 64:422-5 Jan. 30, 1915. Evans, J.S., Middleton, W.S., and Smith, A.J. Tonsillar Endamebiasis and Thyroid Disturbanceso Amer J Med Sci 151:210 Feb., 1916. Drane, R., Gwathmey, J.T., Middleton, W.S., and Yates, J.L. Laboratory of Surgical Research Central Medical Department Laboratory, American Expeditionary Forces, A.P.O. No.721, France. Boston Med Surg J No. 15 180:405-17 Apr. 10, 1919. Middleton, W.S. Charles Caldwell, A Biographic Sketch. Ann Med Hist 156-78 1920. Eyster, J.A.E., and Middleton, W.So Auriculoventricular Heart Block in Children. Amer J Dis Children 19:131-6 Febo, 1920. Middleton, W.S. The Medical Reserve Corps and the Civilian Practitioner. Wisconsin Med J No. 10 XVIII Mar., 1920. Middleton, W.S., and Zellmer, C.E. Encephalitis Epidemica; A Case Report. Wisconsin Med J - vii Middleton, w.s. The John Kearsleys. Ann Med Hist No. 4 3:391-402 1921. Middleton, WoS. A Case of Aneurysm of the Aorta With Unusual Pressure Signs. Wisconsin Med J 21:189-190 Oct., 1922. Middleton, W.S. Caspar Wistar, Jr. Ann Med Hist No. 1 4:64-76 1922. Middleton, W.S. Decreased Intraocular Tension in Diabetic Coma; A Clinical Note Wisconsin Med J No. 12 XXI May, 1923. Middleton, W.s. Lower Lobe Pulmonary Tuberculosis. American Review of Tuberculosis No. 5 7:307-313 July, 1923. Middleton, W.S. Costodiaphragmatic Adhesions and Their Influence on the Respiratory Function. Amer J Med Sci Noo 2 166:222 Augo, 1923. Coon, H.M., Gilman, R.L., Middleton, W.S., Overton, O.Vo, and Sevringhaus, E.L. The Present Status of the Management of Diabetes Mellitus. Wisconsin Med J Noo 5 XXII Oct., 1923. Middleton, WoS. William Edmonds Hornero Ann Med Hist No. 1 5:33-44 1923. Middleton, W.S. Joseph Leidy, Scientist. Ann Med Hist No. 2 5:100-102 1923. Middleton, w.s. Palpation of the Spleen. Amer J Med Sci No. 1 167:118 Jan., 1924. Eyster, J.A.E., and Middleton, W.S. Cardio-vascular Reactions to Hemorrhage and Transfusion in Man Amer J Physiol Noo 3 68:581-585 May, 1924. Eyster, J.A.Eo, and Middleton, W.So Clinical Studies on Venous Pressure. Arch Intern Med 34:228-242 Aug., 19240 Middleton, W.S. A Biographic History of Physical Diagnosis. Ann Med Hist No. 4 6:426-452 1924. Middleton, W.S., and Thewlis, E. The Leukocytic Picture in.Catarrhal Jaundice (Cholangitis). Amer J Med Sci No. 1 169:59 Jan., 1925. Middleton, W.S. The Occurrence of Pellagra in Wisconsin: A Case Report. Wisconsin Med J No. 9 23:503 Feb., 19250 Middleton, WoS., and Thewlis, E. The Leukocytic Phase of Hemoclastic Shock. J Lab Clin Med No. 6 X Mar., 1925. Middleton, w.s. John Bartram, Botanist. The Scientific Monthly 21: 191-216 Aug., 1925. viii Middleton, W.S. Healed Miliary Tuberculosis of the Lung. Amer J Roentgen No. 3 14:218-221 Sep., 19250 Middleton, W.S. Venous Pulse Pressure; A Clinical Note Arch Intern Med 36:444 Sep., 1925. Middleton, W.S. Typhoid Fever Complicated by Parenchymatous and Fatty Degeneration of the Liver; A Case Report. Wisconsin Med J No. 6 24:319 Nov., 1925. Middleton, W.S. The Positive Centrifugal Venous Pulse; With a New Method for Its Detectiono Amer J Med Sci No. 3 171:341 Mar., 1926. Middleton, W.S. The Influenza Epidemic of 1920. Wisconsin Med J No. 5 25:237 May, 1926. Middleton, WoS. Sauerkraut in the Treatment of Vomiting. Wisconsin Med J No. 11 25:554 Nov., 1926. Middleton, W.S. John Redman. Ann Med Hist No. 3 8:213-223 1926. Chen, K.K., and Middleton, WoSo Ephedrine; A Clinical Study. Arch Intern Med 39:385-403 Mar., 1927. Middleton, W.S. The Saucer Defonnity of the Diaphragm With an Inquiry Into Its Origin. Amer J Roentgen No. 6 17:630-633 June, 1927. Eyster, J.A.E., and Middleton, W.S. Venous Pressure as a Guide to Vene­ section in Congestive Heart Failure. Amer J Med Sci No. 4 174:486 Oct., 1927. Middleton, W.S. Abscess of the Frontal Lobe Complicating Frontal Sinus­ itis: A Case Report. Wisconsin Med J Nov., 1927. Middleton, W.S. Coronary Disease. Minn Med 743-753 Dec., 1927. Middleton, W.S. John Morgan; Father of Medical Education in North America. Ann Med Hist No. 1 9:13-26 1927. Middleton, W.S. The Medical Aspect of Robert Hookeo Ann Med Hist No. 3 9:227-243 1927. Medlar, E.M., and Middleton, W.S. Aneurysm of the Left Ventricle. Amer Heart J No. 3 3:346 Feb., 1928. Middleton, WoS. Medical Advance in the Twentieth Century. Phi Beta Pi Quarterly 1-14 May, 1928. Middleton, W.S. The Erythropoietic Response of the Various Anemias to Liver Therapy. J.AMA 91:857-863 Sep. 22, 19280 ix Middleton, W. S., and Smiles, C.J. Spontaneous Rupture of the Heart: A Case Report. Wisconsin Med J Nov., 1928. Middleton, W.S. The Positive Cent rifugal Venous Pulse. Amer Heart J No. 2 4:161 Dec., 1928. Middleton, W.S. Venous Pressure. Anesth Analg (Cleveland) Nov. and Dec., 1928. Middleton, W.S. The Yellow Fever Epidemic of 1793 in Philadelphia. Ann Med Hist No. 4 10:434-450 1928. Middleton, WoS. Heart Disease; The Bacteriology. Wisconsin Med J Febo, 1929. McKinley, E.D., Middleton, W.S., and Van Valzah, R. The Water Balance in Cardiac Decompensation. Amer J Med Sci 177:244 Feb.,1929. Burns, R.E., and Middleton, W.S. Carbon Dioxide in the Treatment of Hypostatic Pulmonary Congestion; A Preliminary Report. Amer J Med Sci No. 4 177:564 Apro, 19290 Clark, P.F., Middleton, W.S., and Wilson, O.M. The Permeability of the Respiratory Tract to Antigens. Amer Rev Tuberc No. 1 20:106-113 July, 1929. Middleton, w.s. Further Experiences with Venesection in Congestive Heart Failure. Amer Heart J No. 6 4:641 Aug., 1929. Middleton, W.S. Liver Therapy and the Pernicious Anemia Problem Wisconsin Med J 577-588 Deco, 1929. Meyer, 0.0., and Middleton, w.s. The Influence of Respiration on Venous Pressure J Clin Invest No. 1 8:1-14 Dec., 19290 Meyer, 0.0., and Middleton, W.S. Venous Pressure in General Anesthesia J Clin Invest No. 1 8:15-24 Dec., 1929. Middleton, W.S. Philip Syng Physick. Ann Med Hist No. 5 1:562-82. Middleton, W.S. Aids tot he Diagnosis of Tuberculous Meningitis Wisconsin Med J 438:441 Aug., 1930. Middleton, W.S. Blood Pressure Determination. Amer J Nurs Noo 10 XXX Oct., 1930. Middleton, W.S., and Stiehm, R.H. The Influence of Gastric Juice on Erythropoiesis in Pernicious Anemia Amer J Med Sci No. 6 153:809 Dec., 1930. X Middleton, W.S. John Syng Dorseyo Ann Med Hist No. 6 2:587-601 1930. Middleton, W.S., and Oatway, W.R. Insulin Shock and the Myocardium. Amer J Med Sci No. 1 171:39 Jan., 1931. Middleton, WoS., Pohle, E.Ao, and Ritchie, G. Adenocarcinoma of the Bronchus; With Widespread Metastaseso J Radiological Soc of N America 16:945 June, 1931. Gale, J.Wo, and Middleton, W.S. Scaleniotomy in the Surgical Treatment of Pulmonary Tuberculosis. Arch Surg (Chicago)' 23:38-46 July, 1931. Bach, M.J., and Middleton, w.s. Multiple Myeloma and Diabetes Insipidus. JAMA 97:306-308 Aug., 1931. Middleton, W.S. The Occasional Fulminating Course of Encephalitis Epidemica Arch Neurol Psychiat 26:607-609 Sept., 1931. Middleton, W.S. Syphilitic Aortitis in Retrospect. Ann Intern Med No. 3 5:294-306 Sept., 1931. Middleton, WoS. How the Connnunity Hospital Can Best Serve Its Neighborhood. The Modern Hospital No. 4 37:60-62 Oct., 1931. Middleton, W.S., and Reese, R.H. Mechanical Compression of the Spinal Cord by Tumorous Leukemic Infiltration. JAMA 98:212-217 Jano, 1932. Gale, J.W., and Middleton, W.S. The Effect of Paralysis of the Hemi­ diaphragm on Intercostal Activity. Amer Rev Tuberc No. 1 25:99-107 Jan., 1932. Gale, J.W., and Middleton, W.S. What Surgery Has to Offer the Patient with Pulmonary Tuberculosis. Wisconsin Med J 91-95 Feb., 1932. Middleton, w.s. Syphilitic Aortitis. 1931 Milwaukee Proc Inter-State Post-Graduate Medical Assembly of N America 76-82 1932. Middleton, W.S. Syphilitic Aortitis. Jackson County Medical Society Middleton, W.s. Treatment of Lobar Pneumonia. Kansas City Southwest Clin Soc Bull No. 3 VIII Mar. 8, 1932. Middleton, WoS. Carcinoma of the Lung. Minn Med 15:256 Apr., 1932. Middleton, W.S., and Oatway, W.H. Correlation of Lingual Changes with Other Clinical Data. Arch Intern Med 49:860-876 May, 1932. Bradley, H.C., Gonce, J.E., Middleton, W.S., and Nichols, M.S. The Inefficacy of Spleen Extract in the Treatment of Lymphatic Leukemia. Amer J Med Sci No. 6 183:850 June, 1932. xi Middleton, W.S. The Clinical Study of the Atrophic Tongueo Ann Intern Med Noo 3 6:352-361 Sept., 1932. Middleton, w.s. Parenterally Administered Liver Extract in Pernicious Anemia. Wisconsin Med J 763-767 Novo, 19320 Middleton, W.S. The Prognosis and Treatment of Syphilitic Aortitis. J Missouri Med Assn 567-573 Deco, 1932. Middleton, W.S. William Shippen. Ann Med Hist Nos. 5 & 6 4:440-452, 538-549 1932. Middleton, W.S. The Treatment of Lobar Pneumonia. Peoria Medical News 3-10 Feb., 1933. Middleton, W.S. Nephritis; A Clinical Analysis. Proc of 1933 Meeting Hawaii Territorial Med Assn(Honolulu) April-May, 1933. Middleton, WoS. Clinical Teaching in the Philadelphia Almshouse and Hospital. Old Bleckley Numbers of Medical Life 97:284 Mar., April, May, June, 1933 (Froben Press). Middleton, W.S. Maternal Illnesses Complicating Pregnancy, Curtis' Obstetrics and Gynecology Chap. XXIX (Phila.: WoBo Saunders Co., 1933), p. 947-1005. Middleton, W.S. The Internist in Relation to Obstetrics and Gynecology, Chap. CVI (Phila.: W.Bo Saunders Co., 1933), Poll32-1156. Hutter, A.M., Middleton, W.S., and Steenbock, Ho Vitamin B Deficiency and the Atrophic Tongue. JAMA 101:1305-1308 Oct., 1933. Meyer, 0.0., Middleton, W.S., and Thewlis, E. Leukocytosis After Parenteral Injection of Liver Extract. Amer J Med Sci No. 1 188:49 July, 1934. Middleton, w.s. Recent Trends in Medicine. Northwest Med No. 1 34:1 Jan., 1935. Meyer, O.Oo, Middleton, W.S., and Thewlis, E. Therapeutic Failure With Certain Organic Substances in Leukemia. Folia Haemat (Leipzig) 53:166-171 1935. Arnold, H.L., Chen, K.K., and Middleton, w.s. The Action of Thevetin, A Cardiac Glucosid, and Its Clinical Appl:ication. Amer J Med Sci No. 2 189:193 Feb., 1935. Meyer, OoO., and Middleton, W.S. The Clinical Expressions of Marrow Insufficienc~ Wisconsin Med J Apr., 1935. xii Meyer, o.Oo, and Middleton, W.S. Marrow Insufficiencyo Ann Inter Med No. 12 8:1575-1590 June, 1935. Middleton, W.S. Special Editorialo Wisconsin Med J 479-481 June, 1935. Middleton, W.So Postoperative Pulmonary Complications. Iowa State Med ~ Aug., 1935. Mccarter, JoC., and Middleton, WoS. The Diagnosis of Periarteritis Nodosa. Amer J Med Sci No. 3 190:291 Sept., 1935. Middleton, W.S. The Prognosis and Treatment of Coronary Occlusion. Minn Med 18:710 Nov., 1935. Middleton, W.S. Chronic Nonsuppurative Arthritis. Kansas City Southwest Clinical Soc Dec., 1935. Middleton, W.S. University of Wisconsin Postgraduate Suggestion. Wisconsin Med J Dec.,. 1935. Middleton, W.S. William Wood Gerhard. Ann Med Hist No. 1 7:1-18 19350 Middleton, W.S. Samuel Jackson. Ann Med Hist No. 6 7:538-549 1935. Chen, K.Ko, and Middleton, WoS• Clinical Results from Oral Administra- tion of Thevetin, A Cardiac Glucoside. Amer Heart J No. 1 11:75 Jan., 1936. Middleton, WoS. Disease of the Lymph Nodes. J. Iowa State Med Soc 1-35 Febo, 1936. Meyer, O.O., Middleton, W.S., and Pohle, E.A. The Influence of Roentgen Therapy Upon the Basal Metabolism in Leukemia. Radiology No. 5 26:586-594 May, 19360 Daniels, E.Ro, and Middleton, W.So Clinical Experiences with Reduced Doses of Thevetin Orally Administered. Ann Intern Med No. 4 10:505-513 Oct., 1936. Middleton, W.S. Women in Medicine. The Medical Woman's J 292-295 Nov., 1936. Middleton, W.S. Some Circulatory Problems of Surgery. Northwest Med No. 11 35:403 Nov., 19360 Middleton, W.S., Pohle, E.A., and Ritchie, G. Lymphosarcoma of the Mediastinum With Metastases to the Skeleton. Amer J Cancer No. 3 28:559-564 Nov., 1936. xiii Middleton, w.s. Benjamin Smith Barton. Ann Med Hist No. 6 8:477-491 Novo, 1936. Middleton, W.S. Jason Valentine O'Brien Lawrence. Bull Soc Med Hist Chicago 5:52-68 Jan., 1937. Middleton, WoSo, and Paul, L.W. Sarcoma of the Stomach. Radiology No. 4 28:486-490 Apr., 1937. Middleton, w.s. Some Clinical Caprices of Hodgkin's Disease. Ann Intern Med No. 3 11:448-468 Sept., 1937. Middleton, w.s., and Porter, R.R. The Diagnosis of Spontaneous Dissecting Aneurysm of the Aorta.. Trans Ass Amer Physicians 52:67 1937. Middleton, w.s. Foreword to High Blood Pressure and Longevity and Other Essays Selected from the Published Writings of David Riesman (Phila.: John C. Winston Co., 1937. Middleton, W.S. Periarteritis Nodosa: Modern Concepts of Cardiovascular Disease. Amer Heart J No. 6 VII June, 1938. Middleton, w.s. Cardiosclerosis Complicating Prostatism. J Urol No. 1 40:55-61 July, 1938. Middleton, W.S. Acute Coronary Occlusion. J Oklahoma Med Ass Aug., 1938. Middleton, w.s. The X-ray Technician's Place in Present-day Medicine. The X-ray Technician 10:55 Sept., 1938. Middleton, W.S. Cholera Epidemics in Iowa County, Wisconsin. Wisconsin Med J Oct., 1938. Middleton, w.s. Samuel Powel Griffitts. Ann Med Hist No. 6 10:474-490 1938. Middleton, w.s. George Elgie Brown: Activities in Medical Organizations. (Privately published) Middleton, w.s. A Medical Appraisal of the Surgery of Pulmonary Tubercu­ losis. Proc Inter-State Postgraduate Med Assembly of N America Phila. Oct. and Nov., 1938. Middleton, W.S. The Specific Treatment of Pneumococcus Pneumonia. Trans 49th Annual Meeting Hawaii Territorial Med Ass 144-151 1939. Middleton, W.S. Some Therapeutic Experiences Including a Consideration of Certain Familiar and Unfamiliar Drugs. Trans 49th Annual Meeting Hawaii Territorial Med Ass 152-158 1939. xiv Middleton, W.S. Postoperative Pulmonary Complications. Trans 49th Annual Meeting Hawaii Territorial Med Ass 1939. Middleton, W.S. The Problem of So-called Idiopathic or Essential Hypertension with Some Suggestions in Management. Trans 49th Annual Meeting Hawaii Territorial Med Ass 1939. Middleton, W.S. Bronchiogenic Carcinoma; A Challenge in Diagnosis and Treatment. Trans 49th Annual Meeting Hawaii Territorial Med Ass 12-16 1939. Middleton, W.S. The Anemias: Their Interpretation and Treatment. Trans 49th Annual Meeting Hawaii Territorial Med Ass 11-22 1939. Middleton, W.S. Some Clinical Problems in Allergy. Trans 49th Annual Meeting Hawaii Territorial Med Ass 10-18 1939. Middleton, W.S. Some Pituitary-Gonadal Relationships and Their Practical Implications. Trans 49th Annual Meeting Hawaii Territorial Med Ass 12-20 1939. Burke, M., and Middleton, W.S. Streptococcus Viridans Endocarditis Lenta. Amer J Med Sci No. 3 198:301-323 Sept., 1939. Middleton, W.S. Some Rationalized Therapeutic Experiences. The Missis- sippi Doctor 654-658 May, 1940. Middleton, W~S. Doctor William Snow Miller and His Seminar. Bull Hist Med No. 7 8:1067-1072 July, 1940. Middleton, W.S. Protection of the Circulation in Surgery. Southwest Med 221-223 July, 1940. Middleton, w.s. Bleckley in the Changing World of Medicine. The General Magazine and Historical Chronicle July, 1940. Middleton, W.S. Masquerades of Bronchiogenic Carcinoma. Southwest Med 287-295 Sept., 1940. Middleton, W.S. Medicine in County Institutions. Proc 40th Annual Convention Ass Wisconsin County Asylums June, 1941. Middleton, w.s. Some Lay Contributors to Medicine. Phi Kappa Phi J 167 Dec., 1941. Middleton, W.S. Thomas Cadwalader and His Essay. Ann Med Hist 3rd ser. 3:101 1941. Middleton, W.S. Medicine at Valley Forge. Ann Med Hist 3rd ser. 3:461 1941. xv Middleton, W.S. Joseph Parrish; Quaker Preceptor. Ann Med Hist 3rd Sero 4:343 1942. Middleton, WoS. Manuscript Notes of John Syng Dorsey. Trans and Studies college of Physicians, Philadelphia 10:20 Apro, 1942. Middleton, W.So Sarcoidosis. Cecil's Medicine 6th Ed. 1943. Middleton, W.So Primary Atypical Pneumoniao Proc Cardiff Med Soc 50 1942-43. Middleton, W.S. Abdominal Pain in Pulmonary Thrombosis. Ann Intern Med 18:345 Mar., 1943. Middleton, W.S. Dysentery in the European Theater of Operations. Inter- Allied Conferences on War Medicine Apr., 1943. Middleton, W.S. Infective Hepatitis. Medical Annual 1944. Middleton, W.S. Primary Atypical Pneumoniao Medical Annual 1945. Middleton, W.S. Medicine: The United States Army. Medical Annual July, 1945. Middleton, WoSo Wisconsin's Medical School: The University of Wisconsin Medical School. Wisconsin Med J 34 1946. Middleton, WoS. Forward! University Convocation, May 8, 1946. Middleton, W.S. The Medical Tradition at Pennsylvania (Medical Convoca­ tion Address, March 16, 1946)0 The General Magazine and Historical Chronicle 225 Summer, 1946. Middleton, W.So Foreword to Diabetes, A Concise Presentation, by Henry J. Johns (St. Louis: c.v. Mosby Co., 1946). Middleton, W.S. Infectious (Viral) Hepatitis. J Iowa Med Sept., 1946. Middleton, WoS., and Ritchie, G. The Tetralogy of Fallot: An Account of a Patient with this Condition Surviving Over Forty-five Years Amer Heart J 33:250 Feb., 1947. Middleton, W.S. Medicine in the European Theater of Operations. Ann Intern Med 26:191 Feb., 1947. Middleton, w.s. Sarcoidosiso Cecil's Medicine 7th Edo 1947. Middleton, W.So Foreword to Functional Cardiovascular Disease, by Meyer Friedman (Baltimore: Williams & Wilkins, 1947). xvi Middleton, W.S., Nesbit, W.M., and Paul, L.W. Congenital Aplasia of the Lung. Amer J. Roentgen 57:446 Apr., 1947. Middleton, W.S. Address of Welcome. Symposium on Isotopes in Biology and Medicine Sept. 10, 1947. Middleton, w.s. Eben J. Carey: Teamwork Was His Strength. Phi Chi Quart 412 Oct., 1947. Middleton, W.S. Some Clinical Experiences in the European Theater of Operations. J Missouri Med Ass 735 Oct., 1947. Middleton, W.S. The Medical Management of Thyrotoxicosis. J Indiana Med Ass 41:295 Mar., 1948. Middleton, W.S. Viral Pneumonia. Rocky Mountain Med J Apr., 1948. Middleton, W.S. Rickettsial Diseases of Importance in the United States. Chicago Med Soc Bull 51:143 Aug., 28, 1948. Middleton, W.S. Infectious Arteritis. Ann Intern Med 29:1093 Dec., 1948. Middleton, w.s. Current Therapeutic Procedures in Coronary Disease. Rocky Mountain Med J Jan., 1949. Dickie, H.A., and Middleton, w.s. Some Clinical Expressions of Sarcoido­ sis (Boeck). Wisconsin Med J May, 1949. Middleton, w.s. Discussion of Dr. Malamud's Paper. JAMA 140:351 May 21, 1949. Middleton, W.S. Graduate Training in Internal Medicine. Trends in Medical Education, New York Academy Med Institute on Med Ed 1947 1949. Middleton, W.S. Therapia Magna Sterilisans. The Health Center J (Ohio State Univ.) 2:52 Mar., 1949. Middleton, W.S. Streptomycin Therapy of Hemophilus Influenzae Endocar­ ditis Lenta. Ann Intern Med 31:511 Sept., 1949. Middleton, w.s. Memoir of Joseph Spragg Evans. Trans and Studies College Physicians 2 Philadelphia 4th ser. 17:119 Dec., 1949. Middleton, W.S. Rickettsial Diseases in the United States. Proc 58th Annual Meeting Ass Life Insurance Med Directors of America Oct. 13, 1949 (1950). Middleton, W.S. The Medical Preceptorial Plan at the University of Wisconsin. Quart Phi Beta Pi 47:11 Mar., 1950. xvii Middleton, W.S. Coccidioidomycosis. Medical Annual 1950. Albright, E.C., and Middleton, W.So The Uptake of Radioactive Iodine by the Thyroid of Leukemic Patients Blood 5:764 Aug., 1950. Middleton, W.S. Should We Train More Doctors? First Annual Wisconsin Rural Health Conference Sept. 22, 1950. Middleton, WoSo The Consultant Program in Peace and War. Medical service Officers Basic Course, Army Medical Service Graduate School, Army Medical Center, Washington, D.C. Feb. 16, 1951. Middleton, W.S. Some Reflections on Medical Education. Ann Intern Med 34:1457 June, 1951. Middleton, W.S. The Destiny of the American College of Physicians. Ann Intern Med 35:1 July, 1951. Middleton, w.s. Philadelphia Medicine: Events and Personalities (Second Walter Estell Lee Lecture, Graduate School of Medicine, Sept., 1951). General Mag and Hist Chron 44:177 Spring, 1951. Middleton, W.So Sarcoidosis. Cecil's Medicine 8th Ed. 1951. Middleton, W.So The Changing Emphasis in the Management of Renal Diseases. Postgrad Med 11:371 May, 19520 Middleton, W.S. The Golden Age of Medicineo Western J Surg Ob-Gyn 60:288 June, 1952. Middleton, W.S. Health Leadership from the University of Wisconsin Medical School. Health-Bimonthly Bull Wisconsin State Board of Health, Po 22. Sept.-Octo, 1952. Middleton, W.S. Some Newer Antimicrobial Agents. Medical Annual 46 1952. Middleton, W.S. Facts About the University of Wisconsin Medical School 1952. Middleton, w.s. Physiological Methods in Clinical Practice (Beaumont Lecture, Wayne County Medical Society, Detroit, Feb. 2, 1953) (Springfield, Ill: C. Co Thomas)o Middleton, W.S. Some Clinical Expressions of Diffuse Collagen Disorder. Med Clin N America 37:1697 Novo, 19530 Middleton, W.S. The Harvey Hospital. Wisconsin Med J 53:226 Apr.­ May, 1954. xviii Middleton, W.S. New Face, New Wings for University of Wisconsin Hospitals. Wisconsin Alumnus Feb., 1954. Middleton, WoS. Minutes of SHAPE Meeting, Paris, May 12, 1954. Summary Remarks. Middleton, W.S. Discussion on Collagen Disorders. Fourth International Congress on Internal Medicine, Stockholm, 1954. Acta Med Skand Suppl Middleton, W.S. Tangible and Intangible Values in Modern Medicine. Med Bull State Univ of Iowa 6 Summer, 1954. Middleton, W.S. Tangible and Intangible Values in Modern Medicine. Bull Biol Sci Fd Ltd 1.2:2 2 Oct.-Feb., 1954, 1955. Middleton, W.S. Tangible and Intangible Values in Modern Medicine. Pharos 1 Nov., 1954. Middleton, W.S. The Riddle of Sarcoidosis (Hutchinson-Boeck Granuloma­ tosis). Ann Intern Med 41:465 Sept., 1954. Middleton, W.S. Preceptorships: A Review. J Student AMA Oct., 1954. Middleton, W.S. Current Concepts in the Management of the Anemias (Abstract). Proc Sixth Annual Science Assembly, Ann Acad Gen Prac 1954. Middleton, W.S. Life Insurance and Medical Education. Proc 49th Annual Meeting American Life Convention 42 Oct. 6, 1954. Middleton, W.S. Zoonoses: A Public Health Responsibility Conunon to Veterinary and Human Medicine. Vet Sci News 8:30 Jan. 15, 1955. Middleton, W.So Collagen Disturbances Encountered in General Practice. Postgrad Med 17:107 Feb., 1955. Middleton, W.S. The Value of Specialty Boards, Editorialo Minn Med Mar., 1955. Middleton, W.S. The Care of the Cardiac Patient (Frederick Conrad Narr Lecture, Kansas City Heart Assn., Apr. 21, 1954). Missouri Med 429 June, 1955. Middleton, w.s. The Patient-Physician Relationship. Wisconsin Med J 54:288 June, 1955. Middleton, W.S. The Patient-Physician Relationship. Pharos Feb., 1956. xix Middleton, W.S. Clinical Pathologic~l Conference (American College of Physicians, Philadelphia, Apr. 26, 1955). N Eng J Med 253:193 Aug. 4, 1955. Middleton, W.S. The First Medical Faculty of the University of Wisconsin. Wisconsin Med J 54:378, 428 Aug.-Septo, 1955. Middleton, W.S. Sarcoidosis. Cecil's Medicine 9th Ed. 1955. Middleton, W.S. The Medical Tradition of Michigan. Univ. of Michigan Med Bull 21:293 Oct., 1955. Middleton, W.S. Secondary Pulmonary Infections Complicating Antimi­ crobial Therapy of Pneumonia. Phila Med 51:737 Jan. 20, 1956. Middleton, W.S. The Hematopoietic Effects of Irradiation Injuryo Milit Med 118:251 Apr., 1956. Middleton, WoS. The Natural History of Disease (Frank Billings Memorial Lecture). Arch Intern Med 98:401 Octo, 1956. (Also JAMA) Middleton, W.S. Changing Concepts of Treatment (Sister Patricia Memorial Lecture). Proc Second International Congress Med Records Lib 249 Oct. 5, 1956. Middleton, W.S. The Diagnosis and Treatment of Acute Pneumonia. Delaware Med J 28:249 Oct., 1956. Middleton, W.S. Zoonoses: A Serious Medical Problem. Wisconsin Med J 55:1189 Nov., 1956. Middleton, W.S. Medicine and West Virginia University. W Virginia Med J 53:478 Nov., 1957. Middleton, w.s. Medical Education in the Veterans Administration. Resident Physician 4:124 Jan., 1958. Middleton, W.So Some Medical Aspects of Diseases of the Liver and Pancreas. W Virginia Med J 54:1 Jan., 1958. Middleton, W.S. Necrotizing Arteritis (Case Report)o W Virginia Med J 54:136 Apr., 1958. Middleton, W.S. From the Patient's Viewpoint. Phares 3 Apr., 1958. Middleton, W.S. Not by Bread Alone. J Lancet 160 May, 1958. Middleton, W.S. The Medical Library of the University of Wisconsin. To Univ. of Wisconsin Medical Alumni (Milwaukee) May 6, 1958. xx Middleton, w.s. Role of the General Practitioner and Internist in Dealing With Emotional Reactions to Illness. J Amer Med Wom Ass 13:491 Dec., 1958. Middleton, w.s. The Veterans Administration in a National Emergency. Milit Med 124:17 Jan., 1959. Middleton, W.s. The Expanding Field of Pulmonary Diseases. Med Clin N Amer 43:3 Jan., 1959. Middleton, W.S. Random Sampling. D M & S Med Bull Feb. 6, 1959. Middleton, w.s. Aneurysm of the Aorta. Northwest Med 361 Mar., 1959. Middleton, w.s. The Intelligent Use of Laboratories. Univ Michigan Med Cent J 25:190 June, 1959. Middleton, w.s. The Human Touch in Medicine (First W.S.M. Lecture of Wisconsin Society of Internal Medicine). Wisconsin Med J 58:553 Sept., 1959. Middleton, w.s. Books and Physicians. Pharos 211 Oct., 1959. Middleton, W.S. Charles Caldwell; A Biographic Sketch (Reprinted from Ann Med Hist 3:156 1921) J Med Educ 34:965 Oct., 1959. Middleton, W.S. The Veterans Administration in Civil Defense. Presented in Symposium on Civil Defense in the Federal Government, 10th County Medical Societies Civil Defense Conference, Chicago Nov. 7, 1959. Middleton, W.S. The Medical Franklin. The Pennsylvania Gazette 14-16 Nov.-Dec., 1959. Middleton, W.S. The Stuff of a Medical Career. Ohio State Univ. Health Center J 10:2 Jan., 1960. Middleton, w.s. The Stuff of a Medical Career. Pharos 67 Apr., 1960. Middleton, W.S. Medicine in the Veterans Administratian. Milit Med 125:21 Jan., 1960. Middleton, W.S. A New Drug is Born. JAMA 174:136 Sept. 24, 1960. Middleton, W. S. Medical Education in the Veterans Administration, Editorial. Med Ann DC 29:629 Nov., 1960. Middleton, W.S. Hospital Administration in National Emergencies. Pre­ sented under OCIM and USPHS at National Conference on Hospital Manage­ ment under Disaster Circumstances, Brooklyn Dec. 6, 1960. xxi Middleton, WoS. Reporting. o • A Tool of Management. Proc Veterans Administration Managers' Conference Oct., 1960 (Dynamic Management in a Public Enterprise, Washington, DoC.) Middleton, W.S. The Role of the Medical Consultant. Pharos 24:145 July, 1961. Middleton, W.S. European Theater of Operations, Part I. Chief Consul­ tant in Medicine, Chapter IV Activities of Medical Consultants European Theater of Operations 1961. Middleton, WoSo Medicine in the Veterans Administration, 1960. Milit Med 136:28 Jan., 1961. Middleton, WoS. John Augustine English Eyster, 1881-19600 Trans Ass Amer Physicians 34:16 1961. Middleton, W.S. Unaccustomed As I Am. JAMA 178:308 Octo 21, 1961. Middleton, W.So William Davison Stovall; A Tribute To A Personalityo Wisconsin Med J 60:539 Oct., 19610 Middleton, W.So Veteran Medicine; 1961. Milit Med 127:22 Jano, 1962. Middleton, W.So Let's Give the Hospital Back to the Patients!; Editorial. Med Ann DC 31:103 Feb., 19620 Middleton, W.So Symposium on the Management of Medical Emergencies, Foreword. Middleton, W.So Medicine Before Automation; Editorials. Arch Intern Med 109:51 Mar., 1962. Middleton, W.S. Medical Education and the Veterans Administrationo Nu Sigma Nu Bull 47:33 1962. Middleton, W.So Diffuse Systemic Sclerosiso The Alfred Stengel Memorial Lecture. Ann Intern Med 57:183 Aug., 1962. Middleton, W.So Unaccustomed As I Am (Reprinted from JAMA Oct., 1961) Today's Speech 10:6 Septo, 1962. Middleton, W.S. Certain Clinical Manifestations of Atherosclerosis and Suggestions For Their Control. Amer J Med Sci 244:403 Oct., 19620 Middleton, W.S. Mesenteric Arterial Insufficiency (Abdominal Angina) W Virginia Med J 59:1 Jan., 1963. Middleton, W.S. Veteran Medicine; 1962. Milit Med 128:16 Jano, 1963. xxii Middleton, W.S. The Heart in Sarcoidosis (Hutchinson-Boeck Granuloma­ tosis). Wisconsin Med J 62:109 Feb., 19630 Middleton, W.So Some Medical Reflections On Aging. Geriatrics 18:168 Mar., 1963. Middleton, W.S. Abdominal Pain in the Aged. W Virginia Med J 59:65 Mar., 19630 Middleton, W.So Increased Longevity and Its Consequences. Milit Med 128:319 Apr., 1963. Middleton, w.s. The Retirement of Preceptors. Wisconsin Med Alumni Bull 4:10 Summer, 1963. Middleton, W.S. Walter L. Bierring, M.Do, and The American Board of Internal Medicine J Lancet 83:466 Dec., 19630 Middleton, w.s. The Civilian Practitioner and Military Medicine; Guest Editorial. Milit Med 129:272 Mar., 1964. Middleton, W.S. Deans and Dienerso Wisconsin Med Alumni Bull Jano, 1964. Middleton, W.S. Good Methods and a Proper Point of Viewo J Lancet 84:261 Aug., 1964. Middleton, WoS. Drug Research Board-Address Before the Pharmaceutical Manufacturers Association, New York Dec. 7, 1964. Middleton, WoSo Doctor William Jo Bleckwenn-Memorial Services, 1964. Middleton, W.So Felix Pascalis-Ouvi~re and the Yellow Fever Epidemic of 17930 Bull Hist Med 38:497 Nov.-Dec., 19640 Middleton, WoS. William Alexander Werrell (1893-1964). Amer Intern Med 62:174 Jan., 1965. Middleton, W.So Continuing Education in Medical Ramblingo Phares 28 Jan., 1965. Middleton, W.S. Affections of the Aortic Arch. Milit Med 130:158 Feb., 1965. Middleton, W.S. Balance in Modern Medicineo J Okla Med Ass 58:84 Mar., 1965. Middleton, W.S. Turner's Lane Hospital. Bull Hist Med 40:14 Jan.­ Feb., 1966. xxiii Middleton, W.S. Chair of Medicine at Cincinnati. Cincinnati J Med 47:155 1966. Middleton, w.s. Wisconsin Men in Chicago Medicine, David J. Davis Lecture, University of Illinois. Middleton, W.S. Erwin R. Schmidt Interstate Teaching Award. Wisconsin Med J 65:23 July, 1966. Middleton, W.S. Some Unusual Sources of Upper Gastrointestinal Hemorrhage. J Lancet 86:395 Aug., 1966. Middleton, W.S. Basic Science in Medical Education and in Qualification for the Practice of Medicine, Invitational Conference, National Board of Medical Examiners, Discussion 1966. Middleton, W.S. Medical Education; A Projection. Wisconsin Med Alumni Quart 6:20 Fall, 1966. Middleton, w.s. Medical Bridges. Pharos 29:116 Oct., 1966. Middleton, W.S. Medicine in the United States; The Road from Yesterday to Today. J Lancet 86:523 Nov., 1966. Middleton, W.S. Foreword to The University of Wisconsin Medical School, A Chronicle, 1848-1948, by P.F. Clark. Middleton, W.S. Speaking for Posterity. Wisconsin Med Alumni Quart 7:26 Summer, 1967. Middleton, W.S. The Ascendancy of Adverse Drug Reactions. Bull Ass Med Puerto Rico 59:265 July, 1967. Middleton, W.S. Military Medicine: Its Role in World Health. Milit Med 133:257 Apr., 1968. Middleton, w.s. Some Clinical Expressions of Antibody Deficiency and Autoinn:nune Reactions. Wisconsin Med J 67:289 June, 1968. Middleton, w.s. Gleanings From Medical Inquiries and Observations of Benjamin Rush. Trans Coll Physicians Phila 36:55-60 July, 1968. Middleton, W.S. The Evolution of Modern Cardiology; Being in Some Measure the Experience of a Stethoscope (1908-1968). W~Virginia Med J 65:31 Feb., 1969. Middleton, W.S. We Honor Max J. Fox, M.D. Wisconsin Med Alumni Quart 9:3 Spring, 1969. xxiv Middleton, W.S. Medical Practice; A Case Report. J Okla Med Ass 63:236 June, 1969. Curreri, A.R., and Middleton, WoS. Aplastic Anemia; Case Report of an Apparent Response to the Transplantation of Rib Marrowo Wisconsin Med J 68:270 Sept., 19690 Middleton, W.S. Preceptorshipo University of Wisconsin Medical School (TV Lecture for Alumni and Extension Functions). Spring, 1969. Middleton, WoS. Foreword to Medical Schooling in South Carolina, by Kenneth Mo Lynch, Columbia, SoC.: R.L. Bryan Co., 1970. 1 The date is July 30, 1968. This is Dr. Peter D. Olch, of the National Library of Medicine, visiting in the home of Dr. Williams. Middleton in Madison, Wisconsin. Dr. M.: It's very gracious of you to visit me in my home and to share with me some of my experiences in medicine. Dr. O.: This morning, which is really the first interview that Dr. Middleton and I have had--are having, we hope to discuss informally the family background of Dr. Middleton and his early education. I think I said to you yesterday, actually, this was one area where I found it rather difficult to do any reading ahead of time, and in a sense you would be on your own. I might just invite you to give me some background information in your genealogy and we can more or less take it from there as we go on. Dr. M.: The Middleton family came to this country in the mid-18th century. The paternal branch settled in south Jersey. Any Middletons with connections will have arisen from this root. There are two other Middleton clans, one in New York and the other in South Carolina. Apparently, they arose from the common stock in England and there are available genealogic maps of these connections. The maternal origin of the Middleton family was Powell. The Powells, settling in south Jersey, were obviously of Welsh origin. They had one notable detail in their history, presently recorded on a tablet in the 2 Memorial Chapel at Valley Forge. Some fifteen sons served in the Revolutionary Army. Of this number, six died for the cause. The maternal branch of my mother's family was the only inmediate immigrant group. The Davis's came from Abersychan, Wales. The forebear was an ironmaster who came to this country to work in the iron mills of south­ eastern Pennsylvania. Her paternal origin was Swedish from the Shainlines (Shenlen), who came to this country in the mid-18th century. On the maternal side, the Holsteins (Hollsten) settled on the Delaware with the original Swedish immigration in the mid or early 17th century. It's an interesting circumstance because this marriage between the two Swedish families means that one quarter of my blood is Swedish. On my mother's as well as my father's side, there is an element to give me one-half Welsh blood. The patronymic Middleton, of course, is English, so I am one quarter English. The genealogy of the Holsteins has been very carefully preserved in a documented form, The Family Holstein, by Anna Holstein. She was an outstanding collateral relative, in that, as a Daughter of the American Revolution, she was responsible for maintaining the Washington head­ quarters at Valley Forge for a national shrine. Dr. O.: Is this the text you were showing me a few minutes ago? I'll get that reference because we'll want to have that. Dr. M.: The Shainline-Holstein relationship was one of intense pride. Of the origin on the paternal side of my family, I had little interest iii 3 until recent years, but there are now extant genealogic charts of this branch of our family. My father, Daniel Shepherd Middleton, was born in 1860 in Stockton, New Jersey, which is now absorbed into Camden. His boyhood was spent largely in New Jersey on the farm of his grand­ father, SaIIn.1el Powell, either the river farm where Gloucester is now located, or near Almonesson where there was a truck farm, growing small fruits, vegetables--tomatoes, particularly--and melons. His parents had, however, moved to Pennsylvania by this time, and he spent his early adolescent years and all of his adult life in Norristown, Pennsylvania. My mother was born in Conshohocken, Pennsylvania in 1863, and her entire life was spent in Pennsylvania, a major portion of it in Norristown, Montgomery County, Pennsylvania. After the com.non school education, my father went into a grocery business with a brother. This effort failed. He then went into the wholesale confectionary business, which was his activity for the rest of his natural life. Father died in 1936 of coronary thrombosis and myocardial infarction. Mother died in 1946 of a cerebrovascular accident. If I may characterize my parents, I would say that my father was a very energetic, dedicated individual with a fine sense of humor and a great devotion to his family of four chil­ dren, two daughters and two sonso He was religious; an active member first of the Methodist church and latterly of the Presbyterian church. When the folks moved to Jeffersonville, Pennsylvania, a suburb of Norristown, he became quite active in this church. Mother was a very 4 warm individual with keen ambition for her children. Mother was responsible for the desire that all of us have an opportunity superior to her conman school education. The fact that she had the intense pride in family that was lacking in my father's make-up, was an added circum­ stance that influenced all of us. My paternal grandfather, Samuel Powell Middleton, was an interesting character. He was rather austere. A great lover of roses and orchids, an unusual hobby in the '90s; apparently all of his spare money, which came from a rather limited income as a cabinetmaker and patterrunaker, went into this hobby. I have a very interesting recollection of Grandfather Middleton. As a youngster I was curious-minded. He was making some sort of a solution to spray his roses. I did not realize that I was disturbing him and insisted on knowing what he was putting into this solution. He ignored my repeated question. It was only after a period of years that I learned that, to make a better emulsion, he was adding shaved whale oil soap to his spray! The Middleton family had the interesting tradition that for three gener­ ations they had been teetotallers. One of my later intimates and close friends, Dr. Frederick c. Narr, was visiting us in Norristown. At dinner with my family, Fred said, "Dad, you've kept saying that the Middletons have always been teetotallers for three generations. Was your father a pretty healthy man?" "No," Dad said, "you know, he wasn't too healthy. He always had stomach trouble." Fred asked, "Did he ever do anything for his stomach trouble?" Dad said, "Yes, each spring we 5 would take out at least a bushel basketful of empty Hostetter's Bitters bottles from the cellar!" Fred broke into uproarous laughter and said, "You know, Dad, that's one of the poorest whiskeys on the market!" So was broken the chain of the teetotallerso This grandfather was not one to encourage ease or rapport with his grandchildren. He had lost his wife when she was in her early forties from Bright's disease. The aunt--the single daughter among these six brothers, Aunt Mattie--kept the household together. A remarkable woman, she quietly wielded great force in her family and community. There's an interesting further light on the Powell family that had so many sons in the Revolutionary Waro By the single father and mother, there were twenty sons and one daughter. The father would introduce the subject of his large family by saying that he had twenty sons and each son had a sistero ''What do you mean? You have forty children?" "Oh, no," he answered, "twenty-one!" On the tombstone of the mother of his twenty-one children, in Almonessin, New Jersey, there is an inscription: "Some have children, some have none; here lies the mother of twenty-one." Within the past year this was reported in a Philadel­ phia newspaper. There are not very many families of these proportions nowadays. The farm activity of the Powell family apparently was the focal point for the Middletons of Norristown, who went there regularly on their holidays or for their sununers. Unless you transpose yourself to 6 another period, it is very difficult to understand how a household could accommodate all the offspring of the second generation coming to the grandparents' farm in New Jersey. Returning to my father, he was very interested in the health of his four childreno The family life of that particular period was close in the home--music and readingo In his free time, my father cultivated an adjacent gardeno This, of course, helped to supplement his small incomeo We sold the surplus from the garden in the neighborhood for personal income or for the family extraso I recall particularly the outingso On the free Saturday or Sunday morning, after services, we were taken on walks. From time to time, my dad would line the four of us up and put us through breathing exercises to be sure that we had appropriate expansion and ventilation, I supposeo He was intensely interested in maintaining a healthy family. Dro Oo: I gather he was not a smoker. Dr. M.: He was not a smoker. Of course, at the period of my childhood and youth, cigarette smoking was quite limited. Only one uncle, and then later an in-law--a further uncle--smoked the pipe; so there were only two male members of the Middleton family who indulged in tobacco in any form. My maternal grandfather, DeWitt Clinton Shainline, was, of course, of the age that should have seen service in the Civil Waro He volunteered for service, but the examining physician recognized him at once and said, 7 "Clinton, what are you doing here? I know you're blind in one eye." He was not accepted for service. But he was always militarily interested. He had three brothers in the service in the Civil War. There was always the reiterated statement, "You know, William, you are the great-great-great-grandnephew of General Anthony Wayne!" On November 5, 1801, Elizabeth Wayne Hayman, niece of Anthony Wayne, was married to George Washington Holstein in the uncle's home, Waynes­ borough. Our sideboard and the double table in our dining room were made for this bride and groom (1801). A chest of drawers and a mirror, wedding gifts from the Wayne's to this niece, are likewise our prized possessions. Grandfather Shainline was a very gentle soul. In a family discussion taking some friend or neighbor over the hurdles, they would turn to granddad for the final verdict. Inevitably he would say, "I think all has been said that can be said," which ended the conversation. Grand­ father was a tall gentleman, white hair, white beard, with tobacco streaks from his chewing tobacco down at the corner of his mouth. He was my last court of appeal! It seems strange after these years to recall. For a particular election, my father was an independent voter. At dinner, mother asked him how he had voted, "Dan, what did you do on your ballot?" and he said, ''Nancy, I split my ticket!" Being a curious minded youngster, this was a question I couldn't settle at home. I had to go see my grandfather. I asked, "Granddad, what is splitting one's ticket?" He said, "What do you mean, William?" I told him what father 8 had said in answer to mother. He said, ''William, I am a Pennsylvania Republican. For fifty-two years I have voted the straight Republican ticket. A Pennsylvania Republican never splits his ticket!" (Laughter) Dr. O.: So this was the explanation! Dr. M.: The home life was a very warm one. We had our regular places at the table. The blessing was asked at each meal. If there were guests, it was a silent blessing to avoid possible embarrassment of the visitors. The strictness of our upbringing from a religious standpoint stemmed from father's side of the family. Mother was an Episcopalian. Although she went to services in whatever church my father was a member, she always maintained that she was an Episcopalian. When possible, she attended services in Old Swedes' Church in Swedeland across the Schuyl­ kill river from Norristown. Sunday was a day either of attendance upon the Sunday school and church--two services a day----- Dr. O.: Morning and evening? Dr. M.: No, the Sunday school or perhaps the morning and evening services. The reading at home on Sunday was limited to the religious tracts or books. We read nothing of a secular order. Even through medical school down to the present time, I would do no medical reading on Sunday. I'll read anything else I want to read for a change of pace, but singularly I have a respite from my medical reading on Sunday. If I'm writing a paper or preparing for some presentation, I do not work on the Sabbath. It is one of those religious customs of an earlier generation that is not commonly observed in this day. 9 The piano, with my sister Rena--a splendid pianist and organist, was a gathering point for the family and friends. Singing songs, hymns, or whatever might occur was part of the common recreation of that period. Dr. O.: I was just going to say, which is practically totally lacking today. Dr. M.: Totally lacking. This was, of course, before the days of the widespread phonograph, the radio, and television. The last named monster (television) hadn't even been thought of in that period. Of course, the first phonographs were an unusual development in my youth; but not until I was well along in adolescence did we have a Victrola. It was practically devoted to classical music and hymns. The musical talent of the family which was marked in several branches was lacking in my own makeup. My brother and both sisters had excellent voices; I had none! They ruined my chance in that direction by referring to me as the Philly doubird of the very early days! Largely as a result of my upbringing, I've always enjoyed music. On Sunday, weather permitting, father would take the youngsters for memorable walks. Interestingly, we commonly went to Norris City Cemetery, where his forebears were buried, or to other cemeteries in Norristown (there were two cemeteries there), or into the country. Father was interested in nature without the curiosity to delve into the real knowledge of the flora and fauna. He was a great hunter and fish­ erman in the simple sense that southeastern Pennsylvania afforded. 10 For example, hunting was rabbit hunting. I was brought up with beagle hounds. "Ring" was my dog. By the way, I have his collar that is marked by a tag reading: "Ring, Wm. s. Middleton, Norristown, Pennsylvania." The love of animals has always been a part of our daily life and upbringing. There was always still-fishing or trolling with artificial bait for bass in the Perkiomen and Skippack Creeks. The quiet solitude of fishing appealed to dad and to me. My younger brother, Dick--his name was Joseph Carson but he went under the nick­ name of "Dick" to all friends, was totally uncontrolled out-of-doors, as far as fishing was concerned. On one occasion my dad said, "Dick, the next time I bring you along, I'm going to leave you home!" Dick had decided to skip stones on the water while we were fishing! Dr. O.: That's the bane of any fisherman's existence. Dr. M.: So that we had the communion with nature without really the incentive to detailed information regarding the birds, the beasts, and the flowers that we should have known intimately from the contacts that we had. We knew them grossly. We knew the common birds. But my interest in ornithology came after I went to Wisconsin. My father had a deep interest in Valley Forge. Long before it was given any attention as a local and national shrine, he would take us there. As I've indicated, the great-aunt--Anna Holstein--had been responsible for sparing the Washington's headquarters at Valley Forge eventually to become a shrine. Reverend Herbert Burke, an Episcopal 11 minister, had the same vision as my father. They commonly talked about the future of Valley Forge as a shrine. My father was not active in its ultimate consunnnation. Public minded yes, but without the capacity to lead or to become other than a very ardent supporter of such a movement. My parents' limited education led them to bring into our home more and more books for their children's studyo They maintained the fixed determination that all of us should have proper educationso My older sister, Rena {christened Verina Shainline), was a very dedicated, highly intelligent girl and woman. She taught grade school after she finished high schoolo In summer sessions she attended courses at Ursinus College, Collegeville, Pennsylvania, and eventually took a secre­ tarial course at Pierce Business College in Philadelphiao Her health was not sturdy. Fortunately, one of her former students induced her to go into horticulture. She joined in partnership with this former pupil, Idella Krauseo They were very successful and very highly regarded in circles around Philadelphia. They supervised the Philadel­ phia Zoologic Garden and a number of the gardens on Main Lineo Dr. o.: Landscape gardening, planning, etcetera? Dro Mo: That's right, planning, planting, and maintaining gardenso Rena found herself and had a very happy existence in this relation. At 75 she died from a cerebrovascular accidento I always think of these phases in her development and her intense interest in nature from iiiiiiiiiiiiiii 12 a studious standpoint. In other words, she knew botany. She knew garden planning. She knew flower arrangement. Perhaps in the last named relation she was most conspicuous. A scholarly student always. For many years, Rena taught a large class of young women in the Sunday School of the Jeffersonville Presbyterian Church. She was its first woman elder. The brother, Joseph Carson Middleton, after finishing high school, matriculated in the School of Veterinary Medicine at the University of Pennsylvania. He withdrew after one semester because of ill health. Thereupon joined my father in the wholesale confectionary business. For a very short time after his marriage to Eve Reifsnyder, he went into the manufacturing of candy. Later he became a contractor and experienced material success in building small houses. He died two years ago from a ruptured gangrenous cholecystitis. He had three daughters but no sons; and two grandchildren by the youngest daughter. The second daughter married into a family of three. The first daughter had two children of her own--two boys. My remaining sister, Catharine Shainline Middleton, survives. After high school, her education was continued in the Temple University School of Education--largely kinder­ garten. She taught for a time and then went into secretarial work in the Pennsylvania Railroad and later in the Provident Trust Company, Philadelphia. She is now retired and lives in Norristown. The older sister, Rena Shainline Middleton, was the most studious and the most scholarly of our family. Dr. O.: Did either of your sisters have any sons? iiiiiii 13 Dr. M.: No, neither married, so that the name 'Middleton' runs out in our particular branch of the family. Dro o.: Well, you grew up then really in Norristown, Pennsylvaniao Dr. M.: I grew up in Norristown, Pennsylvania. I traveled very little outside of the eastern seaboard until I came to Madison. A visit to Washington in 1902 made an indelible impression on my youthful mind. At dinner in our home, a childhood friend of mother's, Cousin Zell Weaver, invited Rena and me to spend a week at their home in Washingtono We were naturally thrilled in the prospect that was made possible by the liquidation of a fund we had been saving for a pony! Every detail of that memorable adventure is most vivid to this dayo Boylike, I was impressed by the magnitude of our governmental buildingso The statuary in many public places received my close attention. We mounted Washing­ ton Monument to enjoy the expansive view. The Capitol itself held all of its traditional spell, which was somewhat blurred when we went into the galleries of the House and the Senate. The Chinese Inunigration Act was then under discussion. Interested as Rena and I were, we could not understand the lack of decorum among the Representativeso Some were eating bananas or peanuts; others drifted away from the floor. Perhaps most disconcerting was the warning of a guide who observed me writing. He said it was forbidden since visitors might drop notes to the floor. Mr. Weaver was on the staff of the Bureau of Engraving and we saw how paper money was made and disposed of. Naturally, this accustomed visits to the Smithsonian Institution, Mount Vernon, and Arlington rounded out our rewarding visito 14 Perhaps the timing of our visit and circumstances of our sponsoring friends made this sojourn one of the most profitable experiences of my life. During my Washington tour of duty with the Veterans' Administration (1955-63), I saw the annual visits of great nwnbers of American school youngsters and wished I might recapture for them some of the revelations the Weavers had made possible for Rena and me over a half century before. I graduated from Norristown High School in 1907. I think that my primary and secondary school education was a sound one for the time and period. I've often thought of some of the teachers of that period. One stands out preeminently: Miss Edmunds was a very strict disciplinar­ ian in what would correspond to the seventh grade. For the first time, she got the spark of education and direction into my makeup. She did so by challenging me. A youngster at that stage can be challenged. Undoubtedly, she had the capacity to bring it out of you, if you had it. She was responsible for my being skipped a grade. Hence, I graduated from Norristown High School at 17 rather than 18, the ordinary age for that period. Of all the teachers I had had to that time, she was outstanding. In high school there were certain teachers who had the capacity to stimulate. There was Mrs. Weaver, in English, who was a very enthusiastic and engaging teacher. She gave me my first insight into and a lasting fascination for English literature. There was Miss Jennie Roberts, strict disciplinarian, who instilled in all of her pupils a thirst for the knowledge of civil government and history. 15 From that early period came the interest in history. In Latin, Miss Anna Eisenhower, daughter of the principal of the high school, Alonzo D. Eisenhower--a remote kinsman of Dwight D. Eisenhower, was a very excellent classical scholar. I took four years of Latin and have never lost interest in languages. I would say that my high school background in Latin and German was really superior. Miss Woodmansee, in mathematics, gave life to higher algebra, plane and solid geometry by her insistence on the mastery of fundamentals and principles. In physics and chemistry, we had young instructors fresh from college who did stimulate, but did not have the sustained drive of these women. I went into medicine directly from high school. Dr. O.: Do you have any idea where, in this time period, you decided you wanted to go into medicine? Dr. M.: That's a very interesting question. When I was three years old, I said I wanted to be a physician. This circumstance is impossible for me to explain, since there's no physician in my family. Dr. c. z. Weber, a graduate of Jefferson, was our family physician. As I came to know him, I realized that he was the "rough and tumble" type of general practitioner. For example, he had his desk chair heaped with copies of the Journal of the American Medical Association that had not been opened! He was interested in sulky horse racing. He had his own racetrack--dirt track--with a grandstand. I can see it all still. He had a long moustache. He would put this moustache over his ears and would fold his cap over the same when he was in horse races. He 16 attended my sister who had a tuberculous cervical lymphadenitis. She would have been about six years old; I would have been ten. He took a curved bistoury and incised this abscess. When I returned home, I cut out a curved bistoury from cardboard and demonstrated how Dr. Weber had proceeded. When you come to family influence, you must raise such a situation as this: one, Billy Middleton, at three, said he wished to be a physician--kept saying that he wished to be a physician. ''What else do you want to be, is there something else?" "No, I want to be a physician." I'm certain that it was mother's logic and conviction that Billy wants to be a physician, he will be a physician. Whatever the sacrifices, this was to be my objective and I never waivered from it. My sister, Rena, said, "Yes, that's true up to a certain point. One time when you were nine years old, when you said you wanted to be President of the United States!" I never waivered and I never have regretted it. Dr. O.: When you entered medical school directly from high school, at that period there were still a number of individuals who did this. In other words, it was not rare. Dr. M.: No, it was not rare. As a matter of fact, if you have followed the development of medical education, the first school that had a pro­ gressive program of medical education was Northwestern (as Chicago Medical College, 1859). This was foll0wed in about twelve years by Syracuse and Harvard. The Hopkins was the first to require undergraduate college education as a requirement for medicine. That was extended and 17 it was catching up with us at Pennsylvania. In 1910, the Flexner Report was published. With it, the requirements of Pennsylvania were advancing. My matriculation in the medical school at the time was against the advice of my principal, A. D. Eisenhower, at Norristown High School. Expediency and actual necessity dictated my decision. I realized that this was going to be a tight pull for my folks, finan­ cially. If I were to go to college from high school, I might be caught in the growing medical school requirement and come to a point where there was no return from the academic standpoint. So that it was not truly a choice; it was a necessity. Dr. O.: You remarked yesterday that you have felt, you did at that time, and in a sense can still see evidence in your pattern of living and peripheral reading, the fact that you did not have this opportunity to get four years of college. I think it's rather interesting. Dr. M.: I've never ceased to regret my lack of college preparation for medicine because I know that I was working under a handicap. I was living, working, studying with men who had had the advantage--intimates of mine, who were college graduates or who had had at least two years of college. I realized the distinct discrepancy in my background. My habits of living, working, and reading since that time have largely been compensatory. I haven't been satisfied to let that gap remain un­ filled. Yet I have not, in the studied sense, worked on the subject requirements for medicine. I know very well what some of my gaps have been and which I would have remedied, might I have had the opportunity. 18 or. O.: That's really very interesting. Dr. M.: An interesting circumstance we may relate later when we get into medical school, but there were a series of us who graduated at a relatively young age--21. Obviously, they, too, had had some fore­ shortening of their preparation. Six* were of about the same vintage who, perforce, did not have advantage of college preparation. Three, still living, have attained some prominence in medicine without the advantage of the collegiate premedical preparation. Dr. O.: Really, when you stop to think of it, that the vast majority of physicians at one time, if not all physicians, had no college education. [Pause] Dr. M.: Although I was never physically the athletic type, I have always been interested in outdoor sports, and particularly competitive sports. I played basketball, baseball, and tenniso Swinming has been a very active outlet, but football was denied because of my size and weight; I did not weigh more than 105 pounds during the high school period. I did play basketball and was on the high school team which was in a rather unorganized state at that timeo My advantage was *Frank B. Block, Philadelphia, surgery - now retired after coronary; Conrad Berens, Jro, New York, eminent ophthalmologist - dead; David No Kremer, Philadelphia, internal medicine - dead; Harry c. Stein, New York, orthopedics - dead; Truman C. Terrell, Fort Worth, clinical pathology. 19 accuracy at the foul lineo Obviously, I couldn't compete with men who were a foot taller and a hundred pounds heavier, but I had an excellent record at the foul line. At that period, one individual shot all the fouls for the team. So they kept me on the team. Camping was a common outlet for the summerso With an uncle or uncles-­ our parents not being able to afford such holidays or to enjoy the same--we would camp on the Perkiomen Creek for a period of a week, two weeks, or more, and have full range of outdoor activities at that time. The camp site was opposite Mill Grove, the first home of John James Audubon in Americao Twice, relatively long canoe trips were taken with a high school classmate, Fred Wannero The first occasion was a shipment of a canoe to Hancock, New York and then coming down the Delaware and camping on its bankso There was some white water and some interesting passages hereo Obviously, conmerce and activities have made it a rather forbidden area at the present time. [End of Side I, Reel 1] [Side II, Reel 1] Dro Mo: The second long canoe trip with Fred Wanner was on the Schuylkill River, shipping a canoe to its headwaters and then coming down by river or canal to Norristowno Again, a very interesting trip that is not longer possible by reason of the closing of the Schuylkill Canal. A single sunnner before entrance to the medical school found me working with Will Reading, an unusual pharmacist, in a local drug store. 20 Mr. Reading was a skilled botanist and knew every plant, every tree in the countryside. From him I gained an abiding interest in these areas. He was quite interested in my projected plans and gave me every encouragement. However, there was no direct physician sponsor­ ship of my entrance to Pennsylvania. Dr. Oo: Was this still common in those days? In other words, when you say "sponsorship" you don't mean your preceptorshipo Dro Mo: No. I'm referring to an individual's advice or guidance to direct me towards the choice of Pennsylvaniao However, the faculty and the reputation of the University of Pennsylvania School of Medicine led to my choice as did its proximityo Throughout my medical course, I regularly commuted by train from Norristown to Philadelphiao Most of the time on trains was spent in visiting with schoolmates, but occa­ sionally there was an opportunity for study en routeo However, I was not a bookworm. The first courses in the medical school at that period were in anatomy, histology, and osteology. I shall never forget the course in osteology given by Drs. Cornell and Addisono These men attempted to make a very dry subject interesting. One episode indicates the serious purpose of certain of our classmates. One man who had repeated the course three times, was again taking it. A certified accountant, for some reason he felt that medicine should be his careero After having a question posed, he rose to his feet and a very exaggerated air of offense went out of 21 the room saying, "Sir, I came here not to impart information but to gain the same!" Needless to say, he was doomed to repeat the course, if he had still the same ambition. The occasional interchange in the classroom stands out vividlyo There were two Jewish lads--Abramovitz and Baradofsky--who answered portions of the same question. When the issue was passed, they both put up their hands and said, ''Who gets the credit, Professor?" Both of them were excellent studentso Our introduction to microscopy under Dr. Addison in histology, was interesting in the emphasis and the inordinate time spent in reproduc­ ing by drawing the image seen under the scope. The introduction to the dissecting room was, of course, traumatic to all of us. I was no ex­ ception, but I was heartened by the fact that our instructors, particu­ larly Dr. George Fetterof, had a very human interest and obviously was there for our advancement. The pattern meant that each individual dissected parts in the series of extremities, trunk, head, and necko Dr. O.: Were there four of you to a cadaver? Dr. M.: Four to a cadavero We were subjected to periodic examinations. Our professor of anatomy was Dr. George A. Piersol. My estimate of him as a teacher has not undergone any discount or depreciation in the inter­ vening yearso In my judgment, he was the most skilled of all lecturers that I have ever sat undero His command of English was remarkable; his diction perfect. He never embroidered his language and yet got his message across in solid order. His final examination was a test of merit 22 as well as memory, but it was never a stilted exercise. It was a very practical examination supplementing the written element. The course in physiologic chemistry would interest the modern student because it was so simple and so basic. Even with the limited expo- sure I had had in high school, I was able to get a high rating. Further­ more, blood chemistry had not yet come into its own. The period to follow the techniques of Folin and Wu would be about 1918. The simple Kjeldahl determination of blood nitrogen was demonstrated to groups of ten or twelve students and this was the depth of our knowledge of chemistry. The first studies of blood glucose were made while I was a house officer in the Philadelphia General Hospital--a gap of several yearso Dr. O.: And at that time, you probably took tremendous quantities of blood, I would imagine (for a blood glucose determination). Dro M.: The medical student of the period was a rather rough replica of his modern self. A little more profane, a little more given to tobacco chewing than to cigarette smoking, but by and large, he had most of the qualities and characteristics of the present-day medical student. The majority of the students of that period were not college men. A representative group had had very adequate background training, but only the exceptional ones had had a full college course and had attained an academic degreeo Of those with college exposure, a majority had not more than two or three years. A large group had had only the 23 high school or college preparatory school education. So that one did not feel at a disadvantage except that he recognized the distinct quality of the men who had had the greater advantages. Interesting was the transition to the second year with the introduction of physiology, bacteriology, pathology, applied anatomy. I would say a word about applied anatomy because it is not widely understood or followed in present-day curricula. Gwilym Davis, an orthopedic surgeon, was our teacher in applied anatomy. He was one of the soundest of teachers because he followed the implication of the course title. In­ stead of being purely surgical anatomy, it was applied anatomy, giving all organic and tissue relations. He was deeply interested in function. He never missed the opportunity of relating the parts to the function-­ the order of joints, the weight bearing of varying structures, the implied movement that arose from insertion of muscles--details that one never forgets when he is confronted with the problem of the actual appli­ cation of anatomy. Vividly I see the patient with a hip joint distur­ bance and the position of the foot under such circumstances, the rela­ tion of the adductor tubercle to the head of the femur--adductor tubercle up, head of femur up; adductor tubercle down, head of femur down. He would demonstrate this relation by taking a femur under his arm and dramatically say, "Adductor tubercle up, head of femur up; adductor tubercle down, head of femur down." The demonstration sticks with me to this day. If he had had the advantage of roentgenology at the time, he would have given the perfect demonstration of the functional iiiiiiiiiia 24 relationship of these several points that I've already made. The utilization of this approach was opposed by the Mall school, the Hopkins school, that taught anatomy as a science. When we come to the Wisconsin period, I shall stress this because I think it has its very definite place. As I have remarked in the past, the greater the assiduity with which the departmental chairman or the professor has attempted to isolate his skill from that of the clinic, the greater has been the necessity of bridging the gap at a later period without the advantage of an interchange between the two disciplines. We can make walls that are longer than the Chinese Wall and denser than the Iron Curtain right within our own faculty. This is a.n observation that becomes ever so clear in these days when we are attempting curric­ ulum changes. Bacteriology was taught by Alexander C. Abbott. Abbott was a very excellent man, a kinsman of William Osler as a matter of fact. With Bergey he presented the subject as an isolated field. However, he interested me so much that I did do a bit of research work in bacteri­ ology at an undergraduate level. I first studied the efficiency of typhoid vaccines prepared at various temperatures. That turned out very well. Then I tried to duplicate the study on the staphylococcus. It was unsuccessful because the concentrations were too low. 'When I set up the final experiment for Dr. Abbott's survey and Dr. Bergey's review, the bacterial suspensions were too inadequate to show precip­ itation. This fault in technique, of course, was a lesson in itself, but I always regretted that I stumbled on second base! i 25 A course in medical terminology was prescribed by Dr. Allen J. Smith in the first year. This exposure gave me at least a grasp of the new vocabulary. In the second year in pathology I came into closer contact with Dr. Smith. I was intensely interested in the subject. Howard Karsner was his first assistant and he became a close friend. Dr. Smith's human qualities made him an early counselor. His various foibles and interests I have touched on in my "Remembrancer". * I think that you can gather the substance of my estimate of Allen J. Smith from what I wrote many, many years ago. Dr. O.: Yes, it's very revealing. Dr. M.: In the period of my internship and after, I was regularly in Allen J. Smith's laboratory. I spent my summers in his laboratory the first years after I came to Wisconsin, so that this tie continued very closely. I remember one occasion that he put a slide under the micro­ scope and he said, ''William, what is this?" I said, ''Were it not a lung, I would say it was an epithelioma." He said, "It is epithelioma and it is lung." He said, "This is a patient with Paragonimus wester­ mani infestation--[lung fluke]. I suspect that there is some agent-­ carcinogen--produced by this fluke that induces the change in the epi­ thelium of this patient's lung." This observation has interested me in the years since; but I have never had either the time or the skill to *Dr. Middleton's "Remembrancer" is a document to which he kept add­ ing entries throughout his career. It is primarily personal reflections about people. It is preserved with his papers at the National Library of Medicine. 26 pursue it. However, in one of the southern provinces of China, there is a prevalence of the Clonorchis sinensis. In people coming from this province, there is a high incidence of primary carcinoma of the liver. How do these two tie together? There's something fascinating in it and I'm certain that there is a carcinogenic agent or propensity to explain the coincidence. The fact that Allen J. took me under his wing, and I was of the host that was so favored, meant that actually our relationship was closer than that of the ordinary student and teacher. He really was a father-adviser. Dr. O.: Yes, I gather he was one of the most important individuals perhaps in your medical school career. Dr. M.: Until Dr. Riesman came in, and that was to carry over, you see, and perpetuate because our interests were in the same direction. Dr. O.: Am I imagining things, or did I read this elsewhere, that there was something about Dr. Smith in later years, in fact perhaps after you had left--was he the one who was involved in sort of a conflict in some way and felt that he was sort of eased out? Dr. M.: Actually, he was eased out and Howard Ricketts was brought in as head of the department. In my "Remembrancer", I relate one of his most trying experiences. He said, "Billy, I have had a most unusual experience--real trying experience." Mrs. Ricketts had come to see where her husband was to have worked. He was a victim of Rocky Moun­ tain spotted fever or typhus fever while he was studying it. He was iiiiii 27 to have come to Pennsylvania as a professor of pathology and Dr. Smith was to have gone over to parasitology and tropical diseases. Yes, I relate that. Dr. O.: Yes, I remember that. But Smith apparently had a feeling that there were those on the faculty who were out to get him. Dr. M.: Well, you see, this was carried when Dr. Edsall had engineered many changes in the Medical School. There was this tremendous upheaval of the faculty. He brought in some powerful men. The best of them, of course, was A. N. Richards. He was a godsend to the university. Dr. O.: Oh yes, here you have "Dr. Edsall was the center of the clique which turned Pennsylvania upside doltln for a time in our junior year." But in spite of his faults, as you say, he did bring on some other out­ standing people who were to do fine things for Pennsylvania. Dr. M.: Right. Dr. O.: This is a very interesting comment about Edsall's leaving Pennsylvania and then staying at Harvard when he was expected at Wash­ ington U. Dr. M.: Yes. He stood Washington University up. Dr. O.: It's not the first time that sort of thing has been done, but you don't expect it sometimes when their names are rather familiar for a variety of things. iiiiii 28 Dr. M.: The Pennsylvania group were rather satisfied that Edsall was playing the game as he could play it, and that he was not always com­ pletely ethical in his activity. He had taken this sabbatical year from Washington University where he had been named the Professor of Medicine and then changed his allegiance to Harvard. Dr. O.: Well, I gather from what people say sometimes, Harvard can work that sort of a spell on you, though I would never use that for an excuse to forgive a man's breaking a commitment. Certainly you had contact with Dr. J. William White, who was Professor of Surgery, and again, it's a shame that I haven't had the opportunity really to go over more of these in more detail and get some of this chronology in line. But Dr. Deaver came along after---- Dr. M.: Yes, John B. Deaver, and an interesting phenomenon here, you are getting into the clinical years, and the clinical years, of course, are always a period of great leavening to the medical student, who has gone through the basic sciences under the old formula of Flexner with a sharp division from the clinical fields. Of course, the clinicians have a tremendous power over the medical student in that you find that for the first time the level and with a rapport that cannot occur any­ where else. It's the reason why I have always liked to teach physical diagnosis. You're really getting in on the ground floor. Dr. O.: And unfortunately perhaps at times, the clinician takes advan­ tage of this and says "Well, gentlemen,~ you're going to learn medicine. This is it. This stuff you've been learning you can forget. 29 Now you're going to become a doctor!" Dro MG: That is most infortunate because I think that if you have followed Wagner at the Hopkinso His analysis indicated the necessity of changing medicine to a biologic science, starting from fundamentals and getting away from this ideao This, after all, is the period in which you are training men in skills as technicians. Unless we modify our approach, very shortly we will not only turn into a trade school, we become a trade school. This transition was just as dramatic. We had had some professors as Reichert, internationally famed in physiol­ ogy, who were not good teachers. You had pharmacology with very good teaching and some indifferent teaching. Pathology had a very good staff. When we came into the clinical divisions we had an excellent faculty and I have cited them in the "Remembrancer" quite clearly. In medicine, Dr. Edsall was of the lesser group in the estimation of the contemporary student because he was competing with masters like Musser, Stengel, and Riesman. He wasn't in the same class with these men. Dr. Oo: Not in the same leagueo Dro M.: No. He may have had administrative capacities that were far beyond their ken or interest; but when it came to the problem of the hour of the day, it was just that. So different today, I think. Musser, a rather pompous individual--John Herr Musser, Sr.--but John Herr Musser, Jr. was three years before me. We were together in many activities, 3U the American College of Physicians and the American Board of Internal Medicine particularly. I will have something to say about both of those relations, particularly the latter. Rather pompous, the senior Musser, who must marshal all facts--every bit of data, clinical and laboratory, including the bacterial content of the stool--and then come to the final conclusion. The character of the man I recall very vividly. Dr. Henry Pancoast was the first Professor of Roentgenology in this country. He had a laboratory under a stairwell. It was not much larger than two or three times the size of this room. You see, the X ray was only dis­ covered in 1895. In this particular demonstration of a patient with a mediastinal mass, Dr. Musser had gone into infinite detail, the history, and the physical findings. Henry Pancoast came in and demon­ strated that it was an aneurysm of the thoracic aorta. Dr. Musser drew himself up to his very slight height and said, "Gentlemen, there goes all the romance out of the physical diagnosis of tumors of the mediastinum." And it was literally true; but it was spoken in pique. Dr. Musser was a very able individual. The most dogmatic of our clinical teachers in medicine was Arthur A. Stevens. There were eight causes for pain, or there were fifteen explanations for dyspnea and you had to put these down. Very dramatic in all of his expositions but very dogmatic. "Quite wrong"; "In his revised edition, he says"--were his pithy responses to erroneous answers. Dr. Stevens would draw these details out with complete dogmatism on every issue. He was the type iiiiiiiiiiiia. 31 of teacher that the spoon-fed student likes. He craves these concrete attitudes and answers. In all fairness, periodically in my teaching I have to hold myself up and ask, "Is that one of Arthur A. Stevens' approaches?" His interest in students was quite sincere. He used the monaural stethoscope and he would put his ear to it. Many of the deductions we thought were snap diagnoses by Dr. Stevens, as I observed him on the wards when I became house officer at Blockley, came from a very profound knowledge. From his dramatic leaning, he was inclined to give most casual attention but he had a tremendous background, not only of experience, but of acute observation. Next, Dr. Stengel--! have given some account of Stengel (in the "Remembrancer"), but Alfred Stengel (we called "rat eyes" because he had beady eyes) was a brilliant teacher. Dr. Leopold Shumacher, who was on the staff of the Student Health Service when I came to Madison, was a graduate of Pennsylvania by way of the University of Mississippi, told an interesting exchange with Dr. Stengel. Shuey had coveted the internship, or they called it the residency, at the Hospital of the University of Pennsylvania where there had never been a Jew appointed. Shuey was interviewed by Dr. Stengel, and he opened the conference, "I wish you to know that I am Jewish and I'm proud of being a Jew." And Dr. Stengel said, ''That shouldn't be any handicap, you see, I'm a quarter Jew myself!" He was a very interesting individual from many standpoints. He would cross-examine the students in the "pit." A very acute observer, very sharp in his perception of any lag or lapse on the 32 student's part, he kept the student on his toes constantly. He brought the best out of us. We thought him rather cold. One of the secretaries of the American College of Physicians told me that he accused her of picking up one of his pencils that he had been using at her desk at the College. She knew she hadn't; but she said that he was a gentleman and when he got back to his office and found the pencil, he called her up and said that she hadn't after all taken his pencil! Indeed, I have a deep sense of gratitude to Dr. Stengel for two reasons. In 1938, as Vice President for Medical Affairs at Pennsylvania, he unofficially sounded me out for the Deanship of the School of Medicine. I had been Dean of the University of Wisconsin for only three years and I pled allegiance to that responsibility. Obviously Dr. Stengel re­ spected my position, for he shortly offered me the Directorship of the Study of Graduate Medical Education under the Commission on Graduate Medical Education. When I again felt committed to my obligations at the University of Wisconsin, Dr. Robin C. Buerki was named Director and under his leadership the splendid survey was accomplished. Dr. O.: I might, if I may, just read so I can get this down in the record, but this is the text we were referring to. Graduate Medical Education. It's a report by the Commission on Graduate Medical Educa­ tion, published in 1940, University of Chicago Press, and Robin Buerki was the Executive Secretary of this committee. Dr. M.: Then we come to the greatest of them all, Dr. David Riesman. 33 Dr. Riesman was working against a handicap in my person because all of my spare time had been spent in experimental dog surgery. I was try­ ing, unsuccessfully, to reconstruct the esophagus of the dog. Without antimicrobial agents, all dogs died of mediastinitis. My added spare moments were spent in the surgical clinics at the German Hospital watching John B. Deaver operate. Dr. O.: Were you really tending toward surgery? Dr. M.: Very strongly, as indicated by spending borrowed time in actual dog surgery or in Deaver's clinic at the German Hospital. I presume this meant that I was fascinated and drawn by the drama of sur­ gery. The fact that I have related in the "Remembrancer" of some of the circumstances, the brilliance of his surgery, "the X rays at the tips of my fingers," the skill and ambidextrous gallbladder incision starting with the right hand, transferring the scalpel to the left hand and continuing the incision as he clamped a bleeder with the right: "I'm going right down, you see, gentlemen, to the peritoneum"--he was the master showman! Then having him in that retrospect perform surgery after I had come of age and finished my internship and was removed from his spell for a few years, I returned to see whether the Old Man was really as good as I had thought him. He repeated his statement, but the incision went through the peritoneum and nicked the gut twice! So I said, "Perhaps you had not made the wrong decision when you de­ cided that surgery wasn't for you." When Plattsburgh was the order of the day in the preparation of officers for World War I, Dr. Deaver was 34 scheduled for a lecture elsewhere before one of the national surgical societies. He walked up the aisle with his paper in his hand. Then he thrust it into his pocket and said, "Gentlemen, I am scheduled to speak on the subject of chronic gallbladder disease. I have decided preparedness is the appropriate topic for this morning," and he gave them a talk on military preparedness! Dro Oo: Preparedness--with reference to the Waro Dr. M.: World War I. Dr. O.: This was at Plattsburgh? Dr. M.: I'm sorry, not at Plattsburgh. This was at a meeting and he was urging them to go to Plattsburgh and train. He had not only a drama in his performance because this was a day of the drama of the surgeon, but in his habit of speech and action was very extravagant. He would drop a series of gallstones into a basin and state that these gallstones were tombstones of buried typhoid bacilli that caused eructa­ tions, pain, and the indigestion for fats. "Gentlemen, I want to see you come on the wards not with stethoscopes around your necks, but stomach tubeso" And his whole touch was of that period. John B. Deaver was really a great man in his own right; but his greatness was in his knowledge of surgical anatomyo His textbook on that subject is still a classic. There's one story of Gwilym Davis' Applied Anatomy that I do not think 35 has ever been printed. He had worked on his manuscript for some time. He took it all under his arm, with the various photographs and drawings, to the publisher--! believe it was Lippincott--and said, "Gentlemen, I have here the labor of love of fifteen years. You can take it and publish it as it is. You may not delete a single line, a single illus­ tration. You take it or you leave it!" They published it and it is still one of the masterpieces of applied anatomy. But after this drama­ tism of the surgery, the calm erudition, judgment, and gentleness of David Riesman prevailed as an entirely new world. Dr. Oo: I can imagine the contrast is vivid. Dro M.: From the third year, I was beginning to weaken in the time spent in surgery. When I got into my internship--called residency in those days at Blockley, I traded every surgical residency, or anything else to which I was assigned, to get an extra period with Oro Riesman. Dr. Riesman was everything that an internist could pray for; cultured, balanced, profound, with a gentleness that transcended any man I have ever encountered in public or private medicine in his conduct of patients. Dr. O.: He was a superb internist. Dr. M.: I wrote the Foreword to this (a collection of essays written by Dr. Riesman). Dr. Christian wrote me that he wished he might have written such an appreciation of a great old friend. Dr. O.: My gracious! No, I wasn't aware of this. This is the 36 Foreword that you've written in this the single edition--1937-- Dr. Riesman's High Blood Pressure and Longevity and Other Essays selected from the Published Writings of David Riesman, published by Winston of Philadelphia. Here again, you see this interest in the history of medicine. I know you mention in your "Remembrancer", whether it was Dr. Riesman--I can't remember who, in your training you felt contributed a lot to the further development of your interest in history. I would imagine it would be Riesman because of his great interest. Dr. Mo: Yes, it was Dr. Riesman. Dr. Clark, in gynecology, was the first one of our teachers at Pennsylvania who stressed history. So that the surgery begins to shrink in the picture. Obstetrics, except for the peculiarities of the brothers Hirst--Barton Cooke Hirst and John Hirst--did not leave a lasting impression. I recall clearly the period of the Southeastern Dispensary, where we went for our practical service in obstetrics. We delivered a certain number of babies in the slums of Philadelphia. Home deliveries afforded some very interesting experiences among Negro and other underprivileged patients. The circum­ stance of our service from the Phipps Institute in tuberculosis was also revealing. I recall a social worker who was on call with me to one of these homes. As we walked up the street, "What do you think of prostitutes, Mr. Middleton?" I said, "They have my sympathy.'! "No such thing," she exclaimed, "they are nothing but spoiled girls who try to find an easy living." A bolt out of clear sky to an innocent young medical student! 37 The vacations of my medical school--the first year, first sunmer--I spent working in a truck garden, Tyson's, which was about a mile or two from home. The crops were peaches, small fruit, and garden vege­ tables--largely tomatoes. Cabbage planting and tomato picking gave me a strong back. Between my second and third years I got typhoid fever swimming in the Schuylkill River, which was literally an open sewer. Upon recovery, I went to the State Hospital for the Insane to work in pathology under Dr. J. Earle Ash. Dr. Allen J. Smith was the active force in my assignment. Dr. Ash entered the Regular Army and eventually became prominent on the staff of the Armed Forces Institute of Pathology. Dr. O.: I saw him less than a year ago when I was at the Washington Academy of Medicine. Dr. M.: Yes. On the second turn at the State Hospital for the Insane, between my third and fourth years, I was the acting pathologist while Dr. Ash went abroad with Dr. Howard Karsner. The timing of this Euro­ pean trip (1910) was determined by the discovery of newer serologic methods. The Wassermann had come into the picture (1906). Dr. Karsner, instead of returning to Pennsylvania, went to Harvard and then to Western Reserve, where he had a long and distinguished career in pathol­ ogy. So I spent my summer vacations from medical school largely in pathology. Dr. Allen J. Smith was the consultant in pathology to the State Hospital. Whenever I had any problems, I took the tissue or specimen to him. After I came to Madison, I returned each sununer and worked in his laboratory in some direction of my personal interest. 38 After receiving my doctoral degree in 1911, I went to Philadelphia General Hospital. That in itself is a story that requires a separate explanation. I had ranked fairly in my class of 152. I was not in the first 25. I had been in this group through the third year and then some of the fellows, who were stronger on the stretch, caught up with me! I had a grade point average in the high fair to good range (upper sixth of the class). I took the examination for Philadelphia General Hospital, the only internship I wanted. I did not qualify in the first group; I was an alternate. Allen J. Smith called me in and said, "Now, we have these openings for you." I said, "I'm going to Philadelphia General Hospital." He said, "I'm sorry; but it doesn't look promising." He continued, ''The Hospital of the University of Pennsylvania has an opening. There's a choice spot for your top men even though it's not my hospital." I responded, "I'm sorry, Dr. Smith, I want Philadelphia General Hospital. I' 11 wait for it." So I got Philadelphia General Hospital after a few weeks delay. There I regu­ larly took the services where I would get Dr. Riesman. As I have said, I would trade services to get on Dr. Riesman's wards. The days and weeks and months I spent with him are the most cogent recollections of my professional life. The patients I see still. All of the problems that we had. I admit that I spent long hours. I knew no hours and often I stayed on the wards into the nights. George Taggert, who was in charge of the post house, would point me out and say, ''When Dr. Middleton was here, he stayed on the wards until midnight every night!" which was not literally true. It was a most profitable year. 39 An internship in the large municipal general hospital with its world of pathological material, with its tremendous human interest, and with all of the dregs of humanity and with some less fortunate, I think is an overwhelming experience. [End of Side II, Reel 1] [Side I, Reel 2] Dro Mo: The group of young men of various origins, particularly of different schools, afforded an unusual opportunity for growth by imbibitiono The exchange of viewpoints with men from Texas, Kansas, the Carolinas, Virginia, New England, an occasional one from the Middle West, gave an entirely different outlook to one's approacho Then too, for the first time, the house officer had independent responsibility for sick patients. This was controlled and guided in no small measure by a highly respected visiting staff. Among them in medicine were Drso Ashton, Beardsley, Stevens, Sailer, Pepper (Perry), and Riesmano Dr. O.: Perry Pepper is the son of William Pepper? Dr. Mo: Yes. And many others of the outstanding clinicians of Phila­ delphia, for at that period a staff appointment to the Philadelphia General Hospital was the mark of distinction in the medical community. Within a short time, one's pattern had been laid; but it became clear that many of the accepted premises of the didactic classroom or confer­ ence were modified or rejected for the first time in one's own experi­ ence. On occasion, I discussed the situation with my intimate friend, 40 Fred Narr, who was serving an interim appointment at the Methodist Hospital. In concluding my comments, I said, "Fred, you are going to have to give up half of what you learned in the medical school." Whereupon he answered, ''Well, Bill, that's not the kind of internship I want." I believe that all of us will agree that, while this is a quantitation that cannot be verified, it is nonetheless a direction of readjustment that one undergoes in any internship, or upon entrance into clinical practice. The days and nights of exciting new revelations at the bedside and the laboratory or at the necropsy table, are indelibly imprinted in one's mind. The interchanges with students, with staff, and particularly with one's own contemporaries, either informally in quarters, about the dining table, or on the ward itself, meant a steady expansion of one's own viewpoint and a depth of appreciation of the ever recurring problems. To generations of students in the intervening years, I have attempted to impress that this will be the most important year of their professional life. In this period they will undoubtedly undergo the greatest growth of any similar period in their career. Lightly I have said that next to the choice of your wife in importance is the choice of your internshipo The routine of an intern of that day was not particularly different from the modern experience except that it was less monitored. Perhaps more was left to the initiative of the house man than it is true todayo The admitted patient was assigned to a given ward, where, with twenty to forty patients under his immediate control, a single intern was responsible for the history, physical and the routine laboratory examinations in medicine. Certain of these 41 details may appear rather arduous from present terms of reference; but the occasional opportunity to demonstrate the plasmodia of malaria for the first time in the blood of a febrile patient in your ward, is a rewarding one that will not soon be forgotteno The one time, like a hole-in-one, experience of finding and demonstrating pneumococci in the bloodstream of a patient with pneumococcus lobar pneumonia, again, is long recalled. In that day, pneumococcus pneumonia and typhoid fever were rife in the urban community; Philadelphia did not escape. During my period of internship, there were 120 patients with typhoid fever in the Philadelphia General Hospital. The number of patients with pneumococcus lobar pneumonia meant the daily opportunity to ob­ serve the physical signs, clinical course and complications which are frequently denied the present-day medical student and house officero The tuberculosis wards were literally death houses. In one term of a month, thirty patients died of pulmonary tuberculosis on my ward. The so-called Out Wards of the hospital were across the street in quarters that had been reserved for this purpose after the Commercial Expositiono From these Out Wards were recruited many of the acute and chronic prob­ lems of our medical and surgical wardso The neurologic service at Philadelphia General Hospital has traditionally been the best museum of neurologic disorders on the American Continent. Dr. O.: I didn't realize thato Dr. M.: Actually, the Salpetriere in Paris is the only counterpart that approaches it. The work of Charles K. Mills and William Spiller 42 made these wards famous. Added to these two neurologists should be such names as Dercum and Weisenburg. Weisenburg was the first man to utilize the motion picture in the demonstration of abnormal gaits. Some of his early efforts are rather crude in our present terms; but it discloses the progressive direction of thought. He was a very interesting individual, who had a facial paralysis and to cover the same, he grew a beard. A student in the pit was being cross-questioned by Dro Weisenburg, who asked the cause of Bell's palsy. Whereupon the student said, "Syphilis," quite properly. Then Dr. Weisenburg asked, "Is there no other cause?" He said, "No, sir, this is the only cause." I'm at a loss to tell you the standing of the student after that par­ ticular episode. The wards in Blockley had every manner of disorder, every order of disease. Dr. Riesman, to whom I was commonly responsible for the clinics, invariably called the evening before the clinic and asked what we might present the succeeding day. In general, we hoped to present contrasting conditions, as hyperthyroidism and hypothyroidism, and Dr. Riesman, with his fine erudition, would give a classical discussion. Always, his clinical presentations were introduced by a historical background and not infrequently, citations that he would advise the students to read. In the "Remembrancer" I have given a number of instances of his remark­ able qualities of observation. They'll never escape me. I have, in several sources, given sufficient reference to them. Always in his patient contact was the kindness, the compassionate quality that marked 43 the true physician. In my subsequent career, it unquestionably has been a factor in my insistence of the dignity of the human being and the student's observation of the rights and the sensitivity of the patient. On the completion of my internship, Dr. Riesman flattered me by asking me to join him in his office. As a traditional gesture and really the manner of settlement of the physician in an urban community as Philadelphia, such a relationship would have been invaluableo I was very much honored; but I did not accept this kind offer of Dro Riesman. However, our intimate contact was maintained throughout the intervening years to his death. After my internship at Blockley, I went to the Babies' Hospital at Wynnefield Avenue, Pennsylvania, a country branch of Children's Hospital for the care of "summer complaint," or gastroenteritis. The disorder in infants, of course, was devastating in a period when the cause was poorly recognized and control even less effective. Here I came in contact with two individuals who seriously influenced my subsequent career. Dr. Alfred Hand, a pediatrician of Philadelphia, famous for his description of the Hand-Christian-Schtlller disease, was a very warm, kindly individual, large of stature, and quite deaf. He used a binaural stethoscope, from which he had removed one of the arms and presumably had placed the other element into his better ear; but I thought he heard very little. He was, however, an eminent cliniciano Closer and warmer in our contacts was Dr. Charles Fifeo My indebtedness to Dro Fife takes a very personal incident into account. When Dr. Joseph 44 Spragg Evans was looking for a young assistant to come to Wisconsin in the Department of Student Health at the University, Dro Fife recommended me and the chain of continuity was established. Dr. Oo: That's how you got to Wisconsin. I'm just curiouso Were you interested, in any way, prior to this time of really staying in the Philadelphia area and making a career at the University of Pennsylvania? Dro Mo: No, I was noto I think that my inclination was to go to a newer area. I never thought of practicing in my home community, Norris­ towno Had I stayed in Philadelphia, perhaps pathology would have been my entree through Allen Jo Smitho Dro Riesman's approach to me opened this clinical opportunity and I was much more interested in clinical medicine than in the laboratoryo I have, however, never given up my interest in the laboratoryo On occasions, both in service and in the University, I've done necropsies when there has been no pathologist to perform them, or in emergencies when I was called upono I would gladly substitute in the necropsy room todayo Dro o.: I don't imagine there are too many internists or surgeons, for that matter, who would admit to this; I shouldn't say admit to this, but who would have the interest, as a matter of fact. Dro Mo: Well, I have a very profound interesto I have a standing order to my house officers that they will get the necropsy and if they cannot get permission, I wish to be called and have the last chance to approach the family in this regardo They are under explicit orders to call me 45 when a necropsy is performed on my patients. I make a special issue of the importance of necropsies in all deaths. In the first part, it is in the interest of information. In the next place, it's a measure of intellectual integrity. You wish to go to the last court of appeals for an answer to your clinical problems. Then, there are considerations from the family's standpoint. [End of first interview session--about 1/3 of Side I, Reel 2] This is a continuation of Side I, Reel 2, the date, November 11, 1968. This Dr. Olch visiting in the home of Dr. Williams. Middleton in Madison, Wisconsin. Dr. M.: Reverting to Blockley days, there are certain personalities among my associate interns that should be recordedo My closest friend was Frederick c. Narr, a classmate at Pennsylvania, who spent a period of time awaiting his Blockley internship at Methodist Hospital, to which I have previously referred. Fred was a studious and conscientious individual who had a quiet sense of humor and a very warm personality. As our period of association at Blockley continued our friendship grew deeper and he was a frequent visitor at our home. I was his best man when he was married, and, at a later date, he was my best man when I married. The children of his marriage were constant visitors at our home and have continued friends to the present time. Fred, after a period of private practice in south Philadelphia, became interested in pathology and as an instructor in this subject at the University of Pennsylvania under Professor Allen J. Smith, grew in stature. His 46 hospital association was in the St. Joseph's Hospital in Philadelphia. From there, he was called to become pathologist at Passavant Hospital, Pittsburgh. After his wife's death, he left Pittsburgh to become pathologist at the Research Hospital in Kansas City, Missouri. In this last named relation, his influence as a teacher was outstanding and we regularly recommended the internship at Research Hospital to Wisconsin graduates for the very reason of Fred Narr's outstanding personality and ability. His premature death in 1943 was the result of carcinoma­ tosis of the peritoneal contents from a primary lesion in the colon. This process had apparently evolved on the basis of an ulcerative colitis which had been misdiagnosed, in our internship days, as amoebic dysen­ tery. We were always aware of Fred's sensitivity and insisted that his failure to give us the tropical fruits that had been sent in from Puerto Rico was responsible for his initial diarrhea. Another of the group at Blockley with whom I was closely associated, was George Wilson, president of our class in the senior year at Pennsyl­ vania, who became an outstanding neuropsychiatrist in Philadelphia. Of his personal characteristics, there are many stories, some apocryphal but many just as classical, that really developed during this period. I recall in one instance George's attitude toward the administration when he requested a leave of absence for a week or ten days to buck for the Pennsylvania State Board examination. He was denied this privilege. He committed some minor infringement of regulations and was suspended for a period of a week. On his return from the successful completion of the examination, he went to the hospital superintendent's office and 47 thanked Dr. Sikes for the leave that had been granted him. Whereupon Dr. Sikes politely asked him to leave the office and said, "Get away, you flippant derelict, you're no end of trouble to me!" George testi­ fied in the Thaw trial for establishment of sanity. When the judge called his attention to certain conflicting evidence that indicated that Mr. Thaw was perhaps not entirely responsible (he was known to have spanked his pet rabbits), he turned to George and said, "What would you do in such a case?" George answered, "I would take the rabbits away from him!" I asked him what he had gotten out of the trial and I re­ ferred naturally to the professional aspect. He answered, "A Packard, Bill." Brilliant. George was very much given to the dramatic insofar as his teaching was concerned and used Arthur A. Stevens, one of our instruc­ tors at Pennsylvania, as a model. However, his professional activities were on a very high plane and his teaching was greatly appreciated by Pennsylvania students. He died prematurely of gout and its complications. But there's another incident on the personal side that I should like to record that relates to my trapping of George in tennis. He had developed quite an effective game and I invited him to Jeffersonville to play on my uncle's court, the while having framed a match with the uncle, who was a poultryman. Uncle George had a remarkably accurate service and was one of the best men at the net that I have ever se.en. He came to the court while we were playing. I feigned some reason to drop out of the match with George Wilson and Uncle George took my racket. 48 Bearded, dressed in working clothes with overalls but by a rare chance with sneakers, Uncle George took my place in opposition to George. Needless to say, he had not gone through many exchanges with George before the latter realized that he had been framedo When he was finally beaten, he upbraided me no end! He never forgave me for the substitution! John Gilmore was the third of a triumvirate that remained close through­ out the internship period at Blockleyo A West Virginian, large in heart as well as body, John became a very intimate friend and a very welcome guest in our home. I visited the Gilmores on the farm near Hundred, West Virginia. In the evenings we sang hymns at the organ when Aunt Minnie played. John's background as the son of a Union cavalryman in the Civil War, gave him a very warm feeling toward the veterans of that periodo I recall vividly the reverse reaction in the travels over the countryside. We met on one of the back roads another buckboard, with the man, in his late fifties, and his daughtero John and his father never made a sign of recognition of these folkso I was curious because in that country hospitality is open and greetings warmo As I queried, however, I had the answer, '~hey're Copperheads," which completely con­ founded me since the Civil War was so many years removed! And it turned out that the parents of this particular group that we had met had sided with the Southern causeo John was not exactly profound in his clinical approaches. I recall one instance when a later associate, Robert Drane, asked him what the 49 hemoglobin on a given patient assigned to him on the medical ward at Bleckley was, John turned back the lip and the eyelid and said, "Oh, about 80 percent!" The warmth of John Gilmore, however, was felt not only in this early association but throughout the years. We visited interchangeably in Pennsylvania, West Virginia, and Wisconsin after I had come to the Middle West. Incidentally, his son, William E. Gilmore, came to Wisconsin for his medical course and received his degree at the University. He is now a prominent surgeon in Parkersburg, West Virginiao There are many others of my associates of the Bleckley period, "Dale" (Kenneth Mo) Lynch, now of Charleston, South Carolina, prominent in affairs of the Medical College of South Carolina--Dean and Chancellor Extraordinaryo Dale was a meticulous individual in all of his activities and persono His roonunate, Rafferty, "Hercules" by nickname, was in the habit of picking up and using his personal items such as a pipe and the like. Dale took umbrage and said, "I suppose you would use my tooth­ brush if you could find that, Herc!" Whereupon Rafferty exclaimed, ''Well, do you have a new one?" One of the most interesting of our associates was Doyle Eastland, un­ timely dead in the influenza epidemic, who had come from Texas. After an internship at Bleckley, he went to University Hospital for further training. His early death was a tremendous shock. I think of Doyle always in terms of warm affection by reason of his outgoing personality, his fine ideals and his splendid progress until his untimely deatho Another of the Texans at Bleckley was my classmate, Truman Co Terrell, iii 50 who had interested himself in pathology at that early date and who later followed this line of endeavor in Texas. Dr. 0.: Is that T-e-r-r----- Dr. M.: T-e-r-r-e-1-1, Terrell. His background in medicine was not lengthy; but he had considerable financial support in the fact that the third oil well to come in in Texas was the Enma Terrell well, named for his mother. Accordingly, whenever ''Tex" meets me, even to this day, he asks, "How is business?" However, one incident at Blackley indicates some measure of his boundless energy. He had examined the stools of all of the patients from whom he could obtain specimens, but wished to establish one final point and did so by capturing one of the rambling cats in Blackley. Having the specimen in which he had demon­ strated the Endamoeba histolytica, Tex fixed the cat to a board and then, with a glass rod, inserted some of the fecal material of the patient into the cat's rectum. Needless to say, as soon as the cat was released, it went to further parts of Pennsylvania!--the experiment was to no avail. As I have explained in the previous meeting, the Wisconsin appointment came as a result of a series of circumstances. The Student Health Department at Wisconsin had followed a sequence of events that was quite disturbing to the administration. A typhoid epidemic in 1908 had been traced to a food handler. There were several fatalities among the students. This was followed shortly by a minor diphtheria epidemic. 51 The concurrence of these two events led Mazyck Ravenel to urge a Department of Student Health to protect against such occurrences. Dr. Ravenel, a close friend of Dr. Joseph Spragg Evans, in Philadel­ phia, induced him to consider this position. The background of Dr. Evans is exceedingly interesting in that, a son of a clergyman-­ Baptist clergyman, West Chester, Pennsylvania, he had completed his academic training at Haverford College and then medicine at the Uni­ versity of Pennsylvania. During his internship at the Hospital of the University of Pennsylvania, he had under his care a member of a wealthy Philadelphia family who indicated their appreciation by under­ writing his support for a period of training in Europe. This disci­ pline included work under Weichselbaum in Vienna, and under the staff at the Pasteur Institute, notably Metchnikoff, in Paris. On his return to Philadelphia, he continued his interest in bacteriologic research at the Pepper Laboratory of the Hospital of the University of Pennsyl­ vania, and engaged in private practice. With this background, Dr. Ravenel was successful in enlisting Dr. Evans' acceptance of the responsibility in student health. As I have previously noted, Dr. Charles Fife, a friend of Dr. Evans, was one of my attendings at Babies' Hospital, Wynnefield Avenue, Philadelphia, during the summer of 1912. He in turn reconmended me to Dr. Evans in July 1912. Dr. Evans invited me to a luncheon at the University Club in Philadelphia and proposed this appointment at Wisconsin. I was duly impressed by Dr. Evans' glow­ ing terms of opportunity; but, before giving him an answer I asked that I might confer with Dr. Allen J. Smith. In turn, Dr. Smith urged me to 52 go with Dr. Evans, in whom he had complete confidence. In Madison, I was met by Dr. Robert Van Valzah who had graduated from Pennsylvania in the Class of 1908, and had been a house officer at the Hospital of the University of Pennsylvania during my clinical years. My early impressions were notable in several respects. In the first place, the Northwestern train pulled into the station, that was under construction, and all luggage was stored in a baggage car on the sid­ ing. Streetcars were the mode of transportation and we passed the State Capitol, a wing of which was under construction. I was innnediately impressed by the lakes and their proximity to the city and particularly the University campus. The impressive Main Hall dominated the hill opposite to the State Capitol one mile removed from the same. The Lower Campus was bordered by several major structures: the Historical Library to the west, the student YMCA and the Armory to the north, the University Club and fraternity houses to the south, with indiscriminate buildings to the east. This Lower Campus was to be the scene of many activities of that period on the part of the student body. I was early introduced to the seat of the student health activities in the Cornelius House, a two-story frame building adjacent to the Administration Build­ ing of the University, close to the corner of Park and State Streets. This was to be my early home, and I was given a room on the second floor, while the outpatient activities were carried on on the first floor in very inadequate quarters. The first building for the permanent occupa­ tion of the Student Health Department, was the Olin House, 762 Langdon iii 53 Street, adjacent to the President's home on the corner of Langdon and Park Streets and across the street from the north end of the Historical Library. This private home had a newly constructed addi­ tion consisting of a ground floor and a first floor which were to house the offices of the staff and the laboratories for the student health functions. Terrazo was used for the first time, to my knowledge, as a floor covering in this building. The Van Valzahs invited me to dinner that evening and many of the student activities were obvious from the vantage point of their second floor apartment on Mendota Court. The fraternities across the street were quite noisy and boisterous, in my judgment. They were then facing on Lake Mendota which was at its late­ summer best. The student activities of the "rushing" period that early fall, or late sunnner are still vivid. I remember on one occasion a prospective pledge let himself out a second story window saying as he went that he didn't want to belong to that fraternity anyway. The "rushing" was rather physical, as you may recall. The encounter with Dean Bardeen, as I returned to the University Club, was a notable one, and I have related it elsewhere. I took my hat off to the Dean, and he smiled. From that time on I never took my hat off to an administrative officer in the Middle West! It was a custom of the effete east that I carried to this section of the country. The responsibilities of the Student Health Department began with the examination of the entering students. They were classified accorqing to physical handicaps and their activities--competive athletics, and 54 the actual required physical activities--were accordingly rated in each instance. The staff consisted of Dr. Evans, who had come in 1910, Dr. Van Valzah in 1910, Dr. Leopold Shumaker, 1911, and Dr. Sarah I. Morris, 1911. The laboratory was in charge of Chris Rouse, a rather stilted German whom I found to be a nihilist under charge from the Baltic provinces, a price on his head in German hands. There was no X-ray department. Accordingly, all requirements for X-ray had to be filled by referral to the Madison General Hospital. At a later date, but before World War I, Dr. Robert Drane was added to the staff and he took charge of X-ray under the rather strenuous strictures of the Dean, Charles R. Bardeen. Frederick C. Rinker, a Virginian of very warm personality, came to the staff in 1913. The Medical School at this time had a two-year status. There had been courses antecedent to Medicine afforded from the early 1890's. Among the members of the faculty who participated in these courses were Dean Birge, Professor Marshall, and Dr. William Snow Miller. Not until 1907 was the two-year course authorized by Legislature and officially offered in the University of Wisconsin Bulletin. The Medical School of this period was in a rather compromised position in that all degrees were granted from the College of Letters and Science. Dr. 0.: I was going to ask you about this. I noticed some conunents about this in your letters. Dr. M.: This was a rather trying situation for the then Dean, Charles R. 55 Bardeen, since he was dominated by Dean Birge of the College of Letters and Science. This led to some trials and tribulations, but really no handicap that the students appreciated. The faculty of the Medical School was an interesting one. Dean Bardeen, the Professor and Chairman of the Department of Anatomy, was Dean, the first graduate from the Johns Hopkins University Medical School, by alphabetical accident. He always maintained that his degree was granted under the condition that he would never practice medicineo William Snow Miller anticipated the arrival of Dr. Bardeen by twelve yearso A graduate of Yale, he had had a broad training not only in this country but abroad. His intimates included men of the caliber of Spalteholtz and Mallo As Associate Professor of Anatomy, we always claimed that his one rivalry was with Dean Birge, insofar as their hair was concerned. Both had shocks of snow-white hair, and they never quite saw eye to eye. A very meticulous technician, his work on the lung, of course, is still a classico My relationship with the Millers was a very intimate oneo Not only was I their professional adviser, I was a regular attendant and participant in the Medical History Seminar and a warm friend of the family. Dr. Miller was a rather paradoxical individual. His external austerity contrasted sharply with his personal warmth. The deafness, which had led to his withdrawal from the practice of medicine, was really a barrier in many ways; but it gave him an opportunity to retreat into his own shelter and to do the work to which he was dedicated. I recall one incident that shows the manner of his reaction. Going up the steps in Science Hall, anatomy being on the third floor, he slipped 56 and lost his balance. The student behind him, depending on his deaf­ ness to get away his light comment, said, "I wish he had fallen and broken his neck!" Whereupon Dr. Miller, who had a convenient sense of hearing, turned and said, "Thank you for your compliments!" [Pause to turn reel over] Dr. o.: This is Side II, Reel 2, recorded November 11, 1968. Dr. Mo: In the Bulletin of the History of Medicine, July 1940, I have written my personal evaluation of Dro Miller and his seminar. In my experience there has been no individual more dedicated to a single objective than Dr. Miller and none in whom the fruits of his labor were so concentrated in the same degree. I recall his profound regret that the physiology of respiration had not attracted the attention of the Wisconsin group which gave so much to the study of physiology in other fields. The Department of Clinical Medicine was headed, as I have indicated, by Dro Evanso In pathology, Charles Henry Bunting had come to the University from Pennsylvania after graduating from Hopkins and having periods of training in that institution under Osler and Welch, and at Pennsylvania under Flexnero He was recruited from the University of Virginia to be Professor of Pathology at Wisconsino He early--1914-­ enlisted the support of Paul Fa Clark who had done conspicuous work in poliomyelitis at the Rockefeller Institute. In pharmacology, we find Dro Arthur Solomon Loevenhart as the Professor coming to the University 57 from Hopkins in 1908. J. A. E. Eyster was, at this time--1912, Pro­ fessor of Physiology, having come from Hopkins by way of the University of Virginia in 1910. This department is interesting in that the first man invited to the Chair of Physiology was A. J. Carlson who declined. In 1906, Dr. Erlanger toot the place, to be succeeded four years later by Dr. Eyster. Dr. Walter J. Meek had anticipated Dr. Eyster's arrival by two years--1908--and was Associate Professor. Harold C. Bradley came to Wisconsin in 1906 from Yale and headed the Department of Physio­ logical Chemistry when it was separated from the Department of Physiology. The faculty, as constituted at this point, was then largely a Hopkins oriented group--Bardeen, Bunting, Loevenhart, Eyster--with the two departures from Yale, Miller and Bradley; Dr. Meek was a product of Kansas with graduate work at Chicago. In my judgment, it was an extremely strong faculty to Dr. Bardeen's credit. He later gave me the dictum, ''When you choose a faculty, do not choose a faculty of names. These men are usually over the hump. Take men on the make." I think that this particular faculty clearly demonstrated his philosophy. If I were to turn to their contributions, Dr. Bunting had great strength in hematology, diseases of the blood and blood-forming organs. He was a cytologist and, unquestionably, one of the finest teachers in the organization of his material that I have ever encountered. However, he followed the lure of a cause for Hodgkin's disease and the Corynebacterium hodgkini, which proved not to be a true etiologic agent. Dr. Loevenhart had been interested in the various enzymes, the knowledge at that time quite 58 limited. His work on lipase was outstanding. The later work on the stimulating action of cyanide in respiration and on tryparsamide in the treatment of syphilis would be considered outstandingo The team, Eyster and Meek, was and is still conspicuous for its contribution to the conductivity of heart muscle and some of the basic work done by this team was to be outstanding in our present analysis. As a matter of fact, Dr. Eyster was the most brilliant of the entire faculty and one of the most brilliant individuals with whom I have come in contact in medicineo When Dr. Meek was elected to the National Academy of Science, I congratulated him and he said, "Bill, you know that you're congratulating the wrong man. English Eyster has more brains in his little finger than I have in my head! The fact of the matter is that he never presents well. He goes to a stated meeting, presents some profoundly interesting work by muttering it up his sleeve. He then goes off in a cornero Maybe two or three individuals who can under­ stand what he's reporting, will come around and talk to him, but he never gets his message acrosso" Of Dr. Meek, I shall have more to say later in another respect. Harold Bradley was interested in autolysis and coming from the Yale school had a great deal of weight. His greatest influence on the Wisconsin scene was in his support of outdoor life and activities. He not only entered into the student affairs in the Medical School, but the University at large. He was very active in the establishment of the Wisconsin Union and· in the Roofers, a group interested in all iiia 59 outdoor sports as skiing, hiking, canoeing, iceboating, and so forth. Returning to the Student Health Department, it was admittedly the forerunner of the clinical division of a four-year course. It was obvious that this was the design of its instigators. Dr. Bardeen was very strongly behind this movement. To me it has always been interest­ ing that when the clinical division was established, Dr. Bardeen insisted that it be a Pennsylvania-strong and not a Hopkins-strong division. And in his judgment Pennsylvania had a much stronger clinical division. Dr. O.: He chose Hopkins for the basic sciences---- Dra M.: ----and Pennsylvania for the clinical. This was done advisedly with a very definite design. I have indicated tmt the first function of the Student Health Department was the physical examination and the attendance of the staff on students on an outpatient basis and in the home. At the earliest stage, we had a ward at the Madison General Hospital where we could admit our very sick patients. As a rule, we referred them to physicians in the city or to surgeons in the city where surgery was indicated. The connnunicable diseases were referred to an isolation hospital, really a pest house, on East Washington Avenuea Dr. Ibnovan was the physician in charge there and I had very close contact with him. Then there was a small house in the area innnediately below the College of Agriculture, where we later sent our patients with communicable diseases. The house calls gave one a very 60 clear insight into the manner of living of these students. Those who were on marginal financial income, commonly lived in attics and might have a coal-burning stove in these stuffy rooms up in the attics of these frame buildings. You would pray there would be no fire. Condi­ tions were very marginal and, of course, the dormitory system had not yet been developed at Wisconsin. Fraternities took care of a small portion of the students. Only the two women's dormitories were avail­ able when I came here in 1912, Chadbourne Hall and Barnard Hall. They took care of only a few hundred of the women and the men shifted for themselves, aside from the fraternity associations. This, naturally gave fraternities a very strong position in this community. The Infirmary that was first acquired by the University, was the Raymer House on Langdon Street next to the Student Clinic. The Raymer House was developed into an Infirmary quarters for students in 1915. It was a frame building, certainly not adapted in any true sense for the care of patients. We had a good nursing staff and immediate proximity to the Student Health Clinic gave ready attention to students. I was given charge of this unit and in return had a room on the second floor of the Student Clinic Building. My quarters were immediately next to a comfortable room that was used as a make-shift library, the overflow of the faculty books, as a matter of fact. The Dean's Office was innnediately next to this library, so that the Dean and I had considerable interchange at this time, to which I shall refer in relation to further developments. 61 The World War I would interrupt this status in a period of the devel­ opment of the further physical facilities for the Medical School, to which I will refer. The Bradley Memorial Hospital was built as a memorial to Cornelia Bradley, the daughter of Professor and Mrs. Harold Bradley, who died of pneumococcus meningitis. The Infirmary was built at the same time through contributions from the Brittinghams and John­ sons, friends of the Medical School. These hospital units were built on the opposite side of the Hill from the existing Clinic and Infirmary. When I returned from service in World War I, I was very critical of the Dean and asked why he placed these buildings in that location. He had apparently overlooked the higher elevation behind these sites that would have given a much better prospect over the Lake and would have given him a much wider expanse for the development of the Medical School. In fact, I envisioned an extension of this preempted area to Lake Mendota on the north and Johnson or Dayton Street on the south. Dr. Bardeen spoke without moving his lips and said, "Middleton, if you had to fight as hard as I did to get this ground, you would be satis­ fied with what you've got." I still insisted that it was shortsighted and that we did not have area for expansion as the development of the Medical School would require. He said, "But you overlook the fact, Middleton, too, that the streetcars come right past your front door." That was 1919! The construction of a hospital for the Medical School was authorized in a special session of Legislature (1920) after the four-year course 62 had been approved by legislative action April 25, 1919. The excess sums from the Veterans Recognition Fund were assigned to the construc­ tion of the Wisconsin General Hospital as a memorial to the veterans. The plans were completed and the concrete foundation had been poured by December, 1920. However, the then Governor, John Blaine, was not certain of the adequacy of the funds for the completion of this project and delayed the continuance of the work until 1922. However, the building was completed in 1924. Meanwhile, the opposition to a four­ year course which is encountered by every state-supported University in this direction, was mounting. It took particular form in the profes­ sional reaction to the encroachment upon their presumed private domain. However, the opposition did not stop here as there had early in the history of the movement--as far back as 1850--been an effort to locate the Medical School in Milwaukee. The personalities involved were rather strong and the advantage only gained by the political maneuver­ ing of Dr. Joseph S. Evans and his friends. One of the strongest advocates for the Medical School was Professor Smith, better known as "Red Eric," of the Law School, whose devastating logic put to rout most of the arguments in opposition. The behind scenes activity was led largely by Mr. Fred Holmes, a newspaperman and later lawyer, and Sol Levitan, active in State affairs, who for some time was State Treasurer. Mr. Levitan, then advanced in years, in one of his later campaigns was accused of favoring free love. He said, "Sixty-eight years old? [He probably was over 70!] Free love? I wish to God it were true!" 63 The four-year program prevailed in spite of the opposition and twenty­ five students were enrolled in 1925, the hospital having been completed in the previous year. The tradition of excellence that had been ob­ tained in the earlier history of the medical school was the objective of the clinical yearso As a matter of fact, in the experience of the students transferred from the two-year course at Wisconsin to the schools for their clinical years, there was a remarkable record of performance that redounded to the credit of their training at Madison. In one particular year that I recall, the first man at Washington University, Hopkins, Pennsylvania, and Harvard had had their preclinical work at Wisconsin. The faculty in the clinical divisions was headed by Evans, who now moved from Clinical Medicine to Medicineo William F. Lorenz, who had directed the Wisconsin Psychiatric Institute, became the dynamic leader of neuropsychiatry in the Medical School. Carl Hedbloom was recruited from the Mayo Clinic in Surgeryo Temporarily Carl Harper and Edward Schneiders led obstetrics until John Harris, of Hopkins' origin, came to Wisconsin from Yale. Pediatrics was represented by John Eo Gonce and Ho Kent Tenney. The specialties found the eye covered by Frederick Allison Davis, the nose and throat by Wellwood Nesbit, the plastic sur­ gery by G. Vo Io Brown, orthopedics by Frederick Gaenslen, and urology by Ira Sisko It will be noted that the representation in these latter subspecialties was on a part time basis, whereas the so-called geo­ graphic full-time staff covered the major fields of medicine, surgery, psychiatry, pediatrics and obstetrics (latterly). 64 This situation of geographic full-time status was subjected to consid­ erable criticism throughout the tenure of Dean Bardeen, because these men eventually moved to downtown offices and were in direct competition with the physicians of the community. The patients admitted to the Wisconsin General Hospital were derived from several sources. The major portion were public patients, for whom, up to a given quota, the state paid half and the county half of the per diem cost. The Clinic ~atients represented a group who were able to afford the cost of hospitalization but for whom physicians' fees were a burden. The private patients constituted a minority. In this direction, there is a principle that has applied through the years that private patients, or the privilege of private patients is assigned to a staff member on the recommendation of the Departmental Chairman, sub­ ject to a review by the Administrative Committee of the Hospital. Their number is obviously limited by the facilities of the Hospital. The basis of selection of students is obviously one of continuing con­ cern to the administrators of a medical school. In the instance of Wisconsin, the first selection was on the basis of a vertical division of the class. At that time we had approximately 100 students in the preclinical years. On a vertical division it meant that men of varying grades of excellence would be selected, a half staying with us and a half going away. On one occasion, Dr. Bardeen felt that we could better our position if we made a horizontal division. He had the prompt response of the schools that had been accepting Wisconsin men to advanced iiiiiiia 65 standing, that for obvious reasons this was not an acceptable principleo After Dr. Bardeen's death, the situation was becoming increasingly· tenuous in our ability to place men advantageously in other medical schools aft~r their completion of the first two years. The ultimate crisis came when Rush Medical College, which had been accepting anywhere from ten to sixteen of our men into their clinical years, gave word that in 1940 they were going to go into another phase which would deny their acceptance of students to advanced standing. This was the time at which they were planning the graduate school at Rush, so that it became neces­ sary for Wisconsin to make a change and accept students only for the complete four years. The Regents acceded to the recommendation that we accept only 75 students for the complete four-year course. The curriculum is always a matter of serious study, as you know, and we are now in a period when it is even more involved. Dr. Bardeen as early as 1912 on my arrival had projected a Preceptor plano Now bear in mind, Dr. Bardeen was an anatomist and had never had a day of clinical medicine. I recall innumerable discussions with him in the evenings of our visits together in this makeshift library on the second floor of the old Student Clinic. He would try to drive home this argument. I was adamant that it just would not work. I would return to Pennsylvania and I would talk to my old teachers. They would say, "You are right; stick by your guns. It can never be an equal function and never have anything in the pattern of a University conmunityo The unequal expo­ sures will mean that you will have a very poor expenditure of time on 66 the part of the students." Of course, the Dean prevailed. When the four-year program was put into effect, the senior year was extended from the conventional 36 weeks to 48 weeks, which gave an added quarter. In this added quarter of 12 weeks, the students were assigned to prac­ titioners who were selected from the state at large. In 1926, Dean Bardeen called together a group of men, to whom were to be assigned the students for a revival of the preceptorial plan. His introductory statement was, "With your help we are about to try a new experiment in medical education, a combined academic and preceptor system." The thought in his mind was that students in the academic atmosphere of a university hospital were far removed from the forces that acted within the home and the connnunity to affect disease expres­ sion. Were they given the opportunity to view the practice of medicine over the shoulder of a tried clinician, they would undoubtedly feel some of the impact of these socioeconomic factors on disease. They would have a much broader viewpoint insofar as the actual practice of medicine was concerned. The men who were invited to this meeting were chosen largely on the representations of Dr. Evans. His qualities of personality and presence inspired the confidence of the profession and enlisted the support of a remarkably representative group of Wisconsin physicians. They included Dr. John M. Dodd, of Ashland, Dr. H. Christian u. Midelfart, of Eau Claire, Dr. Hartwig M. Stang, of Eau Claire, Dr. Adolph Gundersen, of La Crosse, Dr. Sigurd Gundersen, of La Crosse, 67 Dr. Edward Evans, of La Crosse; Dr. James A. Evans, of La Crosse; Dr. Karl V. Doege, of Marshfield; Dr. Walter Sexton, of Marshfield; Dro J.B. Vedder, of Marshfield; Dr. F. Gregory Connell, of Oshkosh; Dr. Neil Andrews, of Oshkosh; Dr. Merritt L. Jones, of Wausau. The success of the program emanated in no small measure from the careful selection of the pioneers for which Dr. Evans was primarily responsible. The success that I have cited, was so conspicuous that in its second year Dr. Bardeen felt that doubling the length of the preceptorships to 24 weeks would be of greater advantage, which almost proved the undoing of the entire program. The detachment of the students from the Medical School for one half of their Seminar year proved most dev­ astating. The succeeding year saw a return to the original 12-week preceptorial term. So the conversion of one of the opponents to the movement by its obvious success marks my interest in the field which has gone forward with continued by-products of interest not only of the preceptors but of the preceptees. The students have felt that this was the most important element of their clinical years. We have regularly monitored the program by visits to the site, going over the ground, problems, suggestions of the preceptor, the annual or semiannual meet­ ings of preceptors at the University, where attention is given to the several methods of approach and the interchange among the preceptors with such guidance as we might lend in formulating plans and solving problems. The students regularly report their reaction. If there be recurring fault cited by the students, we attempt to correct the same. Usually 68 this has been by infiltration and not by direction. I think that moral suasion has prevailed in the vast majority of instances. A by-product that we had not foreseen, occurs in this respect. The natural result of this reciprocal student-teacher relationship is the improved medical practice of the community. Singularly, this reaction has been remarked by many observations of Wisconsin to the credit of all participants of the program. I cannot tell you how frequently citizens of conmunities, in which there are preceptors, have asked that we under no circumstance change this relation which means so much to them. They regularly comment on the quality of care at the hands of the physicians who are participating in the program. From a period when I was an open opponent, I have come to be a convert to this extremely strong element in our teaching process. As a matter of fact, there are now some 25 other schools that have preceptor plans in some form. There is no discipline that will substitute for it, in my judgment. Just where it belongs and in what magnitude, I am not free to say, but I have my own opinion. These students who have the advantage of preceptorship, whether here or at other medical schools, are at least six months ahead of their fellow interns who enter upon a university hospital internship without such exposures. They have a "feel" of the patient, "feel" of the situation that does not come fresh from the benches and the classroom. So that I think that Dean Bardeen made a major contribution in his insistence on the preceptor plan. Immediately after the four-year program was announced and cleared, I went to Dr. Bardeen and said that I had an idea that should have some 69 consideration. "I'm very fearful, Dr. Bardeen, that the specialization that we are encountering, is of such order that exposing the students to specialists is simply going to fragment their approach. When a patient comes into the office or is seen in the hospital, he is the host of disease. There are many factors--physical, psychological-- that are being thrown into the total picture that the student or physi­ cian does not appreciate if he is taking a mere segment--the eye, the ear, gastrointestinal tract, or what you will." ''Well, what do you have in mind, Middleton?" he asked. I said, "I think that the patient viewed as the whole as a host of disease, whatever may be the factors involved, should, wherever possible, be presented in that light. If there is a pooling of the time--the hours assigned to the different courses--so that wherever possible we take the patient as the host of a given disease, viz. pneumonia. Lobar pneumonia is a specific infec­ tious process in which you can bring first, the bacteriologist, the pathologist, the pediatrician, the internist, and the surgeon, if there be complications. If their approach is consolidated, the student will leave that particular exercise with a composite and coordinated picture. Whereas, if one week or one month removed he has dealt with several other subjects, he will have a definitely detached attitude and no cohesive grasp insofar as the respective presentations are concerned." ''Well," he said, "you know, Middleton, I have never been opposed to new ideas. Try it out." So that we initiated this integrated course of medicine and surgery, we termed it. We pooled all hours wherever correlative matters could possibly be brought together. 70 Of course, the clinical pathologic conference has been a traditional stronghold of this coordinate type of teaching. It was, again, an important element in our approach. We had a further extension of this principle to clinical physiologic conferences--clinical physiologic­ physiologic chemical conferences. Then one of my most rewarding experiences; here's where personalities come into the picture very strongly, the question of the pharmacologic-clinical therapeutic con­ ference. To give you a formula, a given disease was under consideration. I would list on the board the recommended drugs. Dr. Loevenhart, who was a pride and joy from a pharmacologic standpoint, would tear these drugs to pieces. I would then discuss their clinical indications and render my opinion as to their use. To the great satisfaction of the students, the two of us would then argue our relative positions. The students had great satisfaction in these discussions. If we could come to a conclusion, we would so indicate on the board at the end of the period. This exercise was so effective that on Dr. Loevenhart's death, Dr. Arthur L. Tatum, his successor, and I undertook the same type of dialogue before the students. It fell flat! Dr. Tatum couldn't give, or I couldn't move him--it was a dismal failure. I cite this experience because it shows that in coordinate efforts the participants must pull together. A little bit later, a~d anticipating what is happening now rather broadly in the curricula, we offered a combined course in neuroanatomy, neurophysiology, neuropathology, and organic neurology. There were thus four individuals who carried the students through a given system in a carefully coordinated manner. 71 The organ system approach is having increasing audience in the new curricula. Our students were selected broadly. When I came to Wisconsin the medical students did not have an honor system. Dr. Van Valzah had come up under an honor system at Princeton and Pennsylvania. Dr. Shumacher had come to respect the honor system at Mississippi and Pennsylvania, and Fred Rinker came in 1915 out of Virginia where this plan was traditional. We proposed to the medical students that they inaugurate the honor system. As a matter of fact, I abhored the proctoring of examinations. In any event, we had a very interesting development; students accepted our suggestions and it was quite suc­ cessful. Then, after a period of years, the competition for places in transfer became so strong and rating meant so much that the honor system began to fall apart. The students came to us and asked that it be discontinued, because they were not willing to inform on the individuals who were abusing it. Dr. Bradley made the motion at a faculty meeting that the honor system should never again be accepted at Wisconsin unless at the instigation of the students. The students would have to initiate its proposal, which is as it should be, I think. Honor can be forced on no man. The adviser system was in effect. It was useful just insofar as the intimacy of contacts. I think that no period of my academic career that was as happy or as rewarding as when we had few students and easy interchange. The coming into your home or going to joint social affairs, 72 joint professional interchanges, meant a great deal insofar as this close rapport which has been a very important part of the total Wisconsin pictureo I'm afraid with the increasing size of classes that it is lost. I'm anticipating; but when I find a student who has not met and doesn't know the professor of medicine and who has had no close contact, I have serious misgivings for our future. I have had a very happy exchange. I have nicknamed practically every student I had in the early days! Dr. Oo: You're famous for that! Dr. M.: Well, that's bado But it has meant that he had an ease of contact. He had an ease of access; the door was always open. It was one of the most rewarding details of this Wisconsin period. At this early stage, and we were still a two-year school, there was encouragement of a break between the second and third years. Students of unusual promise were invited to stay over as student assistants or to work toward a master's; of course then perhaps even longer, for three years, to get their Ph.Ds. So out of that particular issue came men like Herbert Gasser, who went on to win the Nobel Prize; Leland McKittrick, an outstanding surgeon in Boston; Dick TeLinde, Professor of Gynecology at Hopkins. Dr. O.: For heaven's sakes, yeso Dr. M.: I mean to say that it was that type of men who would take advantage of the opportunity. Obviously, they were a selected group; 73 but they have paid dividends tremendously in their subsequent careers. I think that this is an area that ought to be encouraged and to be extended much more widely than it is. The tremendous urge for special­ ization, I'm afraid, is calling it off. Then early after I came here, the faculty-student ball games, then eventually a Field Day evolved. Eventually Student Field Day was established. The morning was given to special presentations, student's research projects; they had demonstrations of these efforts, and an invited guest would give a lecture. This followed the prototype of the Undergraduate Medical Association at Pennsylvaniao Several of the Pennsylvania men had participated and it was carried overo Then in the afternoon they went out and they had their baseball game or whatever might have been the sporto Usually it was baseball; and, unfortunately, a keg of beer at home plate, you know! You may have seen some of those pictures! [Laughter] Dr. O.: Yes, that sort of does things to the game. [Laughter] Dro M.: You have to keep winning! Well, they were happy times and I recall coming back from one of those occasions with Dean Bardeen and I said, ''Well, one thing I hope that Wisconsin can maintain and that is this close rapport between faculty and studentso" He said, "I hope we never lose those close ties." It went just that far. Aside from the preceptor plan and the integrated program of teaching 74 medicine and surgery, one of the interesting departures that we insisted upon at an early stage was a thesis, a subject of the student's own choice. If he was engaged in research, well and good. If he was not in research, a clinical problem that he might choose or we might assign, if he did not have a choice, was required, then the doctoral examination. A doctoral examination was given by five faculty members, three clinicians and two preclinical meno These tests were very serious occasions. I think they were soul-searchingo I've always maintained that an examination has a primary purpose to see how well you have taught and not so much what the student had learnedo In another relation I cited that at one of our faculty meetings when they were considering grades, a new member of the staff boasted that he had failed 35. I said, "I'll see you after the meetingo" So I met him after the meeting and said, "Do you know what you demonstrated?" and he answered, "No." I said, "That your teaching was inadequate!" He said, ''Well, how do you mean, I failed 35." ''That's it o You miss the point." I said, ''They did not fail the examination; you failed them!" I feel that position very keenly. I mean to say that if the examina­ tion, an ordinary perfunctory examination I'm speaking about, has any real depth of meaning, it is that measure of your teachingo The question naturally arises as to the function of the examinationo I think that the National Board of Medical Examiners is coming closer to its answer now than any other group. Of course, their examinations are being used by a number of different agencies, academic and other­ wise, to establish the objective and the approach to the objective in 75 examinations. There are a number of interesting details, and I think in the Remembrancer I have cited some of them in these examinations; but I use them as a very interesting "whipping boy" at times! The matter of the student's participation in the undergraduate period, of course, has been subjected to considerable discussion. I think that it serves as an interesting period for the development and evolu­ tion of the men and I have indicated certain outstanding exampleso When you consider the total story, much of the opportunity to evolve this sort of a system depends on the independent interchange--the close interchange--between a faculty member and a studento You can't do it en masse. You have to do it individuallyo The impact of the teacher is inevitably one of close contact. I do not believe that it can ever be replaced by a computer or other type of machineo Dr. Oo: Or a closed circuit television set! Dro M.: No, and these are things that are very close to my heart, as you knowo It occurs to me that this is a matter of great importance from the standpoint of the future of medicine when perforce we are going to have greater and greater application of computers, mechaniza­ tion and other electronic devices. You can never measure the output of the understanding heart! The question of internships naturally comes up at this timeo We have gone through two phases at Wisconsino The early phase was really very paternalistic and largely engendered by Dr. Evans who you will have 76 gathered in my judgment was the heart of the Medical School. He had-­ with the support of the rest of the staff--enlisted an exchange among eighteen medical schools who would take into their university hospital a Wisconsin man in exchange for one of their graduates on our repre­ sentation. We furthermore had some 58 hospitals the country over that, simply upon cognizance, would take our men. So that it meant we had a very easy exchange for the fitting of a man into a local scene. My thoughts, naturally, as I was counseling students this morning, recurred to that period when it was so simple. You have a certain quality, you have a certain reserve, you have a certain outlet that would definitely fit into this particular scene. To go into this large city hospital, it would be very difficult for another student to make adjustments. I wouldn't recommend such for a given graduate. I know the staff in this particular hospital, and I know they are interested in the young staff and the resident. The intern is literally a fifth wheel and receives no educational guidance. So you see what I mean, you can fit a given man into a very definite pattern. [End of Side II, Reel 2] [Side I, Reel 3] Recorded November 11, 1968. Dr. M.: Obviously, this pattern enabled Wisconsin to place its grad­ uates, personally, to extreme advantage. However, the Matching Plan put this plan into the discard. However, frankly, the present student has a two-to-one chance against the field to place advantageously. On the other hand, the personal element is considerably diminished. iiiiiiiiiiiiiii 77 The efforts on the part of our staff has been uniformly that of detachment of the student from the University of Wisconsin atmosphere to broaden his base. We have purposely opposed our students remaining at Wisconsin for their internship, because, for the last time in the lives of a vast majority, they have the opportunity for a different exposure. While it is a pattern of many medical schools to recruit their intern-resident staff by continuity from the senior class, we have arbitrarily opposed this position and have openly resisted it in every quarter because of the above circumstanceo In the interest of the graduate, it is to his advantage to seek another viewpoint, another outlet, and then to return or to continue his training in a specialty with the advantage of an extended base. Dr. Oo: This was something, frankly, I found la~king in Baltimore. There was a great deal of inbreeding and you have instructors and junior men in the Department of Medicine who had gone to undergraduate school, medical school, etc., at Johns Hopkins and knew nothing but the Johns Hopkins' way. It was very shortsighted, I think in the long run. Dro Mo: I would agree totally, and I have encountered the same situa­ tion in many areas in my own medical school. I have opposed the Pennsylvania attitude of inbreeding which is, frankly, an Eastern faulto Dr. Oo: I think so too. Dr. M.: And I have, in more recent years in interchanges at Oklahoma, 78 run head-on into the same proposition. The intense desire to strengthen a department is often done to the oversight of the advantage of the oncoming generation. I think that we have been sound in our insistence that the only students who remained for their internship at the University Hospital in Madison, are marginal students. They are retained in the thought that with an added year they may so improve their grasp as to become acceptable physicians. Dr. 0.: Have you had the opportunity to--well, I'm sure you have-­ but has this philosophy taken hold elsewhere? I mean particularly this last statement you made where you purposely keep the marginal student here an extra year as the intern group----- Dr. M.: I couldn't tell you, I'm sorry. I do not knowo But this man who has completed this year, if he stands his doctoral examination well, we give him not only his degree, but the credit for his year of internship; so that he has not lost time. In my experience, perhaps once in every three or four years we have reclaimed a man who might have been lost, had he been dropped at that timeo May I interpolate just a single thought. To me it's unthinkable that a medical faculty with an opportunity to observe a student for a period of four years should at the final examination--the doctoral examina­ tion--say that he is not adequate. If they cannot form a judgment before that time, they have been remiss somewhere along the line. I think that it's extremely important. Then you say, how does one assure the proper flow of residents? I can only answer for the Department of 79 Medicine in the University of Wisconsin Medical Schoolo Here we have men of the senior class who are interested in medical residency, whom we would like to holdo We say, "Splendid, we'd like to have you back; but get out and away from under our skirts and see what you can do for yourself elsewhereo If you wish to return, we're certainly most anxious to have you." Second--those men who have come from other schools who made good with us--"All right we'd like to have you"; and the third was the field at large. We rarely had a place for the third group. We had three chances and usually a majority were men whom we had sent away. As such concrete examples, I don't hesitate to cite them: Dr. Ovid Meyer, who was the recent Chairman of the Department of Medicine, had his first two years of medicine here, finished at Columbia, came back for his internship and residency, and I said, "Ovid, get out of here; get some broadening." So we sent him to Boston with Dro Aub and Dro Minot. Then when we wanted him back, on the death of Dr. Ray Blankinship, he had had a broadened baseo Dro Robert Schilling--Bob took his medicine here, graduated, took his internship at the Philadelphia General Hospital, incidentally, the best hospital in the country (laughter), came back here for his residency and met exactly the same situation. We sent him away from us, "You go to the Thorndike for a broader base.'' Dro Oo: This is Schilling of the Schilling test? Dr. M.: That's right. So that when we had a place for him, we brought him backo It's exactly with the same design, to give these men a 80 chance for a broadened base. I think that it's utterly selfish to keep a man, as you indicated, for his undergraduate college work, his undergraduate medical work, for his graduate medical work and then on the staff. Dr. Oo: He can't offer as much to the students as the man with a broader base. Dro M.: So that I think that it has paid dividends; but I give these two concrete examples which I might multiply. I feel that definitely it is truly an advantage to the staff as a whole and infinitely to the advantage of the individual. The Service Memorial Institutes were a design to bring the physical medical plant into one complex. Before its erection, all of the basic sciences were over the Hill in the attics and basements of Science Hall and the Chemical Engineering Building, in the main. From the excess of this same fund that built the Wisconsin General Hospital--that was the original name for the University Hospitals--the money was available to build all the departments except Anatomyo So Anatomy stayed in Science Hall until the Bardeen Building was completed in the recent past. The library, I must have a word in passing there, had an area that was designed for the physical medicine because, as this was a recognition of veterans' service, they wanted to include some element of a clinical order. So physical medicine was brought in and took the library space. The Dean gave up his quarters to afford a very crowded and inadequate 81 library for a period of years after 1928. He took a separate house on Charter Street for the Medical School Office. Later it was moved from Charter Street to North Randall to make way for the McArdle Memorial Laboratory, on which I'll speak. The Orthopedic Hospital was built for the children in the maino At that time--1930--there was tremendous demand for the children, ortho­ pedic subjects, as a result of poliomyelitis. One of the most interesting acquisitions, physically, was the Michael McArdle Memorial Laboratory. I've shown you the 11-story building for cancer research. Mike McArdle graduated in law from Wisconsin and I am sure in the Remembrancer I have gone into this in detail. He was dying of cancer and wished to leave $10,000 for cancer research. He left a thousand shares of Flexible Shaft Drive which he had bought for $5000 a share and we sold for $840000 In addition, he had some equity in real estate up in Door County, Wisconsin. In all, there was a sum of $132,578 realized from his estate. The utilization of this was in some question. Having gone over the will repeatedly and having had legal advice, I had very definite reservations as to whether it could be used for a building because it was strictly for cancer research, you seeo President Dykstra thought it could; so that we said that the only way we could get an answer was by going to the attorney for the McArdle family to obtain his reactiono Mr. Mccaffery, the Fiscal Officer of the University, drove me up to Sturgeon Bay, and I think you've read in the Remembrancer how all the way up he was coaching me. iiiiiii 82 When we got to Sturgeon Bay I said, "Well now, who's going to present it?" He said, ''What do you think I have been talking to you about all the way?" I said, "I gather that I have to do it." Well, we had a very splendid audience in Mr. Wagner, the attorney for the McArdles. When I was through he said, "Doctor, if Mike McArdle thought that he could have his name on a building on the University campus, only $10,000 represented, he'd be the happiest man in kingdom come!" He added, "I'll have to have each one of the McArdle heirs sign off. I'll give you my word there'll be no trouble." With this money from the McArdle's and the $107,000 from PWA, the McArdle was built--a very substantial building, originally, of the basement and four stories, joined to the Hospital on one side and the Medical School on the other. From the outset, the McArdle was a very successful venture. We had had the Jonathan Bowman Fund of $420,000 from a wealthy citizen of the state of Wisconsin. This Fund had been used as a nucleus for cancer research, and there's one article of that interchange that you should record. I brought the matter to the attention of the staff at a faculty meeting in 1935. I said, "This sum, the interest, could be dissipated and the corpus completely wiped out in a very short period of time if we give it to patient care." The ordinary sympathy of the layman is to turn to the patient through his ills; but I said, "I would indicate that to me it would be a rather ridiculous gesture because it would be so short-lived in its effect." They voted unani­ mously that it should go for research, and it has continued a very healthy source of income through the years. The first fellows named 83 under the Bowman Fund were Harold Rusch, Fred Mohs, and Mead Burke. Mead Burke went into pathology and then into the practice of allergy, Fred Mohs into chemotherapy---- Dr. O.: Chemosurgery. Dr. M.: Chemosurgery, excuse me. Fred would correct me too! (Laughter) Chemosurgery of superficial cancer; and the one who has gone farthest and been the most conspicuous in cancer research has been Harold Rusch. Dr. O.: Well, he's one of the names in the country. Dr. M.: Right. Therein you see a very definite tendency for a capitalization on an area that had the appeal of unusual order. I don't know whether I told you that one time a doctoral examination was being given in the College of Agriculture. Twenty-five candidates in fields removed from medicine were asked the _same question, just at the conclusion of the examination: If you had a million dollars now, what would you do with it? These people were in the various branches in the College of Agriculture; but 23 of the 25 said they would put it into cancer research. Dr. O.: For heaven's sakes! Dr. M.: And if they'd ask me, I think cancer research would be in third or fourth place, but it is rather singular that a group of laymen, medically speaking, largely chemists, should have selected cancer research as the area of their primary approach. 84 Dr. Bardeen, who had been Dean from 1904, died in 1935. His terminal illness was a very devastating carcinoma of the pancreas with metas­ tasis to the liver. Dr. Van Valzah attended him; but I would see him in substitution from time to time. He would say, "Middleton, put your hand on my belly and see what you feel"; it was an enormous nodular liver. He said, "Do you think that could be gas?" "Well," I said, "it could be. Has Dr. Van spoken to you about it?" Whether he was simply deluding himself or whether he really didn't know, I can't say. At his death there was, of course, a great deal of discussion as to succession. Dr. Evans, my chief, advocated the appointment of Dr. Stovall. Dr. William D. Stovall was the Director of the State Hygienic Laboratory------ Dr. O.: Successor to Ravenel. Dr. M.: Yes, and a very dynamic, driving Mississippian; Bill never had things half way there, he went all the way. His position in the state was unquestionably very strong, a very dominant leader. Dr. Evans talked to me about it and I was very, very strong for Bill as the successor to Dr. Bardeen. I was called to Glenn Frank's office-­ President Frank's office--and he talked to me about the deanship. I said, "Glenn, I thought Stovall was next candidate for succession." He said, ''That isn't what I brought you up for, Bill," he said, "I want you to be dean!" Nothing under the sun that I wanted as little as the Deanship. I never wished to be Dean. I never sought power as a matter of fact. Actually, I wanted to stay with the patients. 85 Dr. o.: You weren't actually chairman of the Department of Medicine, I imagine, for this very reason, that you perhaps avoided this because you wanted bedside medicineo Dr. Mo: Right. And he said, "Are you totally opposed?" I said, "Yes, I am totally opposed. I want no part of it. I'll do anything I can for any successor to Dr. Bardeen but please let me out of this." "Well," he said,"the real situation is that if you do not take the Deanship, I am going to select a man from outside." This position gave me another pause; I didn't know whether a cat in the poke was a wise move or not o I said, "Do you mind if I talk to the Chief?" He said, "You mean Dr. Evans?" I said, "Yes." I think he got on the phone before I saw Dr. Evans. At least when I talked to Dr. Evans, he said, "By all means." I said, "Have you been advocating this?" He said, "I had no thought that you were even being considered; so that I cer­ tainly would choose you." I said, ''Well, that makes my decision easier." We went over the details, three days, parrying back and forth, talking the situation over with some of my confidants on the staff, and I accepted. And then I told the story of Glenn Frank's asking me if I knew what a dean was. I told him I'd been trying for three days to find out! He said, "He's a man who's too dumb to teach and too bright to be president!"--which I thought was a good characterization. Dr. O.: Yes. One hears all sorts of commentary, I fear, about the qualities of a dean; fortunately, there are many exceptions. Dr. M.: Yes. Well, fortunately I found a very sound faculty, a faculty 86 that was behind me body and soul, basic sciences and clinicians. The response my appointment received from outside was hearteningo In other T; words, I think that I was a popular choice in some measure, if I may be modest enough to claim it, for the position which I did not crave. I was a reluctant deano The faculty, if I can go into it in some detail, of course was one that would have invited the interest of anyone. I thought I would defer that for a moment because I think that they represented strongly the several elements of the Medical School interests, the hackneyed education, research and serviceo You might say that my interchange in respect to these details raised some questions because I think that few people realized that the service element was really only an inci­ dent to the education of physicians. When I appeared before the Joint Committee on Finance of the Legislature and told them that I was there primarily in the interest of education. We did have a hospital, that the hospital was the largest laboratory on the campus, and it was so located for the purpose of the clinical training of physicians and nurses for their professional careers and not primarily for the care of patients as such. It's not a very popular approach. Dro O.: No, it certainly isn't. I'm sure there were many eyes that were open and their mouths dropped! Dr. M.: And it did not downgrade the quality of care; but I did want them to keep our primary mission of education in perspective • • 87 The first objective that I had, was a conference with the clinical staff. I was deeply troubled by the reaction of the state's medical profession that had crept out from the local scene in Madison to the state at large. The idea had been spread that here was a group exploit­ ing their positions as members of the staff of the medical faculty in competition with the practicing physicians and literally taking the bread out of their mouths. I know of one individual who, in an open discussion, said, "Bill, your University physicians have taken $10,000 out of my pocket this past year!" I went to the records of all the patients from any area from which this doctor could draw, not only his local community but the surrounding country. We didn't find a fraction of $10,000 that could have come out of any pocket! So that I had to answer him that the evidence could not be drawn from the actual records. The first crucial session, then, was with the clinical staff. This was a faculty meeting limited to the clinical staff to resolve the points of difference with the local physicians o "Will you now take with me the position that I have maintained throughout my Wisconsin career? At times I have felt as though I was pariah in that I never would accept a patient except in consultation and upon reference. I never wished to build up a private practice; I never wished it to be pointed out that here, Bill Middleton, subsidized by the state, is in competition with me trying to get my living by practicing medicine in Madison." ''What would you wish then?" they statedo "Simply that you follow this par­ ticular formula: that no patient will be accepted by you directly. He 88 must come to you on reference or in consultation with a physician. You will return him immediately to the referring physician after you have completed the requested study or such investigation as you have been requested to make." They voted unanimously to do so. I added, ''We will try this plan for six months. If it doesn't work, then we will go to another system at least." They applied it immediately. The questions of the University relationship were resolved. What was a grievance committee, called the University Relations Committee, the second time they met after our session in the Medical School, they said, ''Why are we meeting? We don't have any complaints!" So that the plan was effective and there was absolutely no question from that time. Its resolution is just that simple, in my judgment. Dr. O.: Was it at this point, Dr. Middleton, that it was agreed that one could supplement one's----- Dr. M.: I was coming to that next. Yes. That one might supplement his salary from outside sources to a point not to exceed his University salary. In this relation, the staff avoided the participation of the University in corporate practice. This was simply an arrangement be­ tween the individual and the patient. It never came to a point where a University element was injected into it, so that you could not accuse us of being in the corporate practice of medicine which existed in other states. Your question as to the sums involved. There are individuals who collected more than this limit. Every dollar they collected over it, iii 89 was put into a fund for uses within their department--fellowships and things of that type. The medical schools of certain neighboring states operated under other patterns with certain hazardso For example, one state gave the professor the privilege of outside income equivalent to his salary from the university; associate professor, 75 percent; assistant professor, 50 percent, and the instructor, 25. I said, "Now, it's obviously unfair, it ought to be exactly the reverse; it ought to be the instructor 100 percent and the professor 25 percent!" Certain other neighbors resented the diversion of some of their funds to the beautification of grounds, things that were entirely unrelated to the medical outlets. Dro Oo: They weren't held for the department, necessarily. Dro M.: Noo So that these were some of the things that occurred. The second point that I made in this first session of the clinical staff was that we should attempt to make our influence on the medical practice of the State centrifugal rather than centripetal. In other words, the natural impulse is to draw everything to a center. This is, I think, human nature. I think that we had an important function in attempting to disseminate the information of a center to the periphery. By this effort we could hope to improve the practice to the limits of the state or at least to the limits of communication. In this respect I have a fixed habit. When I pick up the State Medical Journal, I turn to the county society notes. Of course, one of my 90 tremendous trials of the present moment is the deterioriation of the county medical society meetings which, of course, is almost nationwide. There are a number of contributory factors that we need not go into here; but for the purpose of our present discussion my habit arose from the fact that I insisted that our men get out into the county society meetings. We not only invited the State Medical Society to take notice of the availability of our faculty in this relation, as a matter of fact, we drew up a list of available speakers and subjects and indicated that we could attend in continuity or we could attend detachedlyo In other words, by continuity we could, over the period of a year, cover a given field, or we could definitely come on notice to present new subjects of their own choice, provided we had the man to meet it. My first general faculty meeting was the occasion of my proposal to introduce a nonscience elective into the curriculum. If a man had a keen interest in art, history, music, I would encourage him to culti­ vate and continue that avocation. There have been too many men that I have known who were expert pianists or violinists who had given it up. I thought this surrender of talents and interests greatly to their detriment. Certainly they had narrowed their vision and perspective. I was fighting a losing fight; but Dro Meek, the Assistant Dean at that time, came to my rescue and he said, "Well, why not make this nonscience elective a choice? He could take either a science or a nonscience at the discretion of the faculty." This compromise prevailed, which brought me to the Dean of Letters and Science, Dean George Sellery. 91 I said to the Dean, "Our faculty has cleared this particular hurdle; it wasn't too easy, not all of them were agreeable." And he said, "Well, I agree with the minorityo I don't see why after the students enter the Medical School, Letters and Science shouldn't shed all responsibility. I don't see any useful purpose in keeping any tags on themo" I was quite surprised at Dean Sellery. I said, "You know there's a chance that one of these students might be interested in history." "Oh, you said history, did you?" and right away I had a friend, of course; so we won our case. Now, it is very interesting, Dr. Olch, that over the many intervening years--! was Dean for 20 years--only the exceptional student would take an elective in a nonscience; but it would usually be a conspicuous student. It might be music, art, history, literature; but such a student had a definite cultural leaning or breadth--! still think that it was a good idea, even though it was not overwhelmingly popular in the subsequent yearso I have in the Remembrancer given analyses of the various presidents and I think that in such detail that there is not point in going over them further. You have been through these? Dr. Oo: Yes, I haveo Dr. M.: Are there any questions? You can take them off. Dro O.: Not specifically about the presidents, I must admito As far 92 as the University of Wisconsin material goes, I found not a great deal of your early period mirrored in your correspondence. It was really the later period that you haven't come to yet, with the excep­ tion of one or two items. Should I interject that? Dr. M.: Please. Dr. Oo: All right. One of the things I was quite interested in what the reaction, locally, was and I suppose nationally, too, but you would certainly be aware, locally, of the reaction to the work of Dr. Mohs and his chemosurgery. I know there have been groups that have somewhat looked askance at his efforts, particularly surgeons. Dro Mo: Righto I'm glad you bring it up, because I'm coming to cer­ tain other elements later on insofar as research is concerned. Fred Mohs' work is in the use of a caustic, zinc chlorideo The menstruum is immaterial; but apparently he feels that it has certain virtues in the penetrability of the escharotico The tremendous virtue is his meticulous care in technique. In other words, each layer of coagulated tissue (eschar) is removed. We'll say that we are dealing with a basal cell carcinoma (or squamous cell) and these various projections pene­ trate to different levelso He will have taken off and microscopically controlled each one of these layers or these sections, until he has maybe five projections and then he has two and then he has one and then he goes all the way down to normal tissue. Only a man with infinite patience and with scrupulous technique could get the results that he getso He does get the results; of that there's no question. When 93 this group of three men was selected, his godfather, the head of zoology, Professor Michael Guyer, said, "Bill, don't you know that there'll be 50 to 75 people here, physicians, to study this technique at all times and all the years to come. You're giving him such meager facility?" I don't think Fred has had more than 25 in the intervening years, since 1935, which means, of course, that the method has never taken hold generally. Yet I think that if I had a neoplasm of such order that was accessible to his method, his would be the one I would request. He takes some of the most difficult subjects that have failed of X ray control, surgical removal and establishes results with chemo­ surgery. The one notable case is a local physician who had a mixed tumor of the parotid. He went to a recognized clinic in a nearby state and they said, "Impossible. We can do nothing." He came back and one of our own graduates naturally thought of Fred Mohs, who proceeded with his meticulous technique and got a complete removal. You can scarcely see the scar on the left side of his neck! And the facial nerve was spared. The scar is soft and has none of the details shown in the encounters with surgery or X ray. I think chemosurgery has a real place in the treatment of accessible cancer. It's limited and the amazing part of it has been that so few people have had either the interest or patience to learn the technique. My interest in the history of medicine as a cultural outlet undoubtedly had its inception solidly in the approach of Dr. David Riesman to every problem of clinical medicine. I can recall no clinical presentation 94 that did not have at least a few historical preludes. Dro Riesman built his story largely on the background of the history of medicine. Therefore, when I came to Madison Dr. Miller was deeply engrossed in the history of medicine. Heeding my natural inclination, I was very happy to be taken into Dr. Miller's seminar. You, of course, have studied Dr. Miller's seminar plan. His discipline was a very strict one. The members of the seminar had to participate in them; it wasn't the question of mere regular attendance, even delightful as it might beo You participated annually in an area of your own interest; I think that made for more ready and happy cooperation. You did not have to follow any fixed subject or any bent that the mentor might have; you followed your own leaning. Insofar as this was concerned at an early period, mine was practically entirely Philadelphia medicineo This predilection pleased Dr. Miller no end and, of course, gave substance to my own studies in that fieldo Very attractive, the library, I pictured in that article on Dr. William Snow Miller and his medical history seminar. And the Anatomy, as his subject, every few years he would give these forty feet of anatomy-­ some of his priceless texto You've seen the Vesalian items that have come to our Library as a very splendid collection. The Medical History Seminar lapsed in the period that I was away from Madison, perhaps from disinterest or the detachment of some of the older stalwarts of the Seminar. It has revived. With Ackerknecht here before I left, and then Dr. Mani returning, the interest will be sustained, I am sure. 95 Dr. O.: I have a few little notes in here that really are still early on. I was quite interested by the fact that you were--in the late 1920s, 1928 and thereafter--treating patients with pernicious anemia here with liver fractions that you had obtained from Dr. Castle---- Dr. M.: Dr. Minot. Dr. O.: Dr. Minot, yes. In a sense it was like a field study and you were a part of an overall study. Was there a distribution to a number of hospitals? Dr. M.: There are two of those areas that will interest you. I will probably touch on them again in another relation. When insulin was isolated, we had connections with the Eli Lilly people through Dr. Bradley in physiological chemistry which gave us access to Iletin, the first named product. We did some of the original clinical studies on Iletin. Then liver was announced as a treatment for pernicious anemia in 1926. Whipple and Robscheit-Robbins had reported its obvious advantage in treatment of standard anemia, dog (1925). The following year Minot and Murphy reported their remarkable results upon its use in patients with pernicious anemia. I immediately went to Boston (1926). I indicated to Dr. Minot that we, of course, had followed the same lines; but we had not had the pernicious anemia patients. Dr. Minot was very much interested in our efforts. He was a friend of Dr. Bunting which was my point of entree. We sent our technician, Miss Ethel Thewlis, to Boston where she worked for about two years with Dr. Minot; a superb technician, an English girl. We were in close contact with Minot from 96 1926 on. That is the basis of the several contributions and studies in hematology. The lot of a dean is not always a simple one. The administrative attitudes varied among the several presidents under whom I served. Interestingly, they started with President Van Hise in 1912, then Birge, Frank, Dykstra, Sellery, and Fred. Beyond question of doubt, Van Hise was the broadest and ablest of this group. Dean Birge was a perennial acting President. Scholarly and austere, his qualities have been well-covered in the Remembrancer. Although my initiation to administrative responsibilities was at the hands of President Glenn Frank, the subsequent contacts with Presidents Dykstra, Sellery, and Fred partook of very different attitudes. In effect, Glenn Frank was the permissive administrator who supported his subordinates on the advice of the several deans and regents. President Dykstra had two strikes on him when first he came to the University of Wisconsin. He had had the important position of city administrator at Cincinnati but limited academic experience. Furthermore, on advices he was rather antimedical. In my experience, this particular issue never emerged and I found him rather superficially involved in the affairs of the Medical School and more interested in the broad relationships of the University. In the Remembrancer I have covered his particular failings along with the general considerations of other presidents. Dean George Sellery was an interval president who answered the requirements of the situation from the academician standpoint, but was somewhat less than interested in the broader responsibilities. Incidentally, one might 97 have anticipated the greatest strength in President Edwin B. Fred, a close friend of long years. However, he was, as indicated by Dr. Evans, my chief, too swayed by the currents of opposition that might arise. Always the Medical School had friends in the Board of Regents. Important among these during my tenure in administrative responsibilities were the President of the Board, Mro Frank Sensenbrenner, and Regent Daniel Grady. As long as their influence prevailed, the Medical School did not suffer. On the death of both of the~, the Medical School lost stout friends in court and it was obvious that we could not expect the forthright advocacy of policies that had obtained in their lifetime of devotion to the cause of better medicineo The attitude prevailed that the Medical School operated independently of the University as a wholeo Certainly this was never the case except in the endeavor to obtain material support for construction purposes. Then with the knowledge that the Medical School could, by channels that were not open to the University at large, receive favorable consideration for their projects, independent efforts were made with the full cognizance of the adminis­ tration. Then, too, when the University administration required support that they could not engender through their own efforts, the influences active in the Medical School were enlisted to further general University ends as witnessed, first, the construction of the Memorial Library through the efforts of Dro Anthony Ro Curreri, abetted by Mr. John Walsh, and the obvious erection of a Biology building addi- tion by the sacrifice of monies that had been assigned to the completion of the Service Memorial Institutes. The latter device was largely the 98 result of pressure from Governor Walter Kohler who indicated that it would be impossible to get two separate appropriations for the Univer­ sity construction program. Already monies had been set aside for the extension of buildings within the medical complex. The sacrifice of one half this amount that had been engineered by Assemblyman Graass, lost to the Medical School the long vouchsafed support of a good friend in his person. The Medical School was rarely subjected to political pressure. Minor details arose from time to time. For example, one Mr. Padway, of Milwaukee, took up the cudgels for a student who had been dropped from the Medical School for adequate academic and personal reasons. These circumstances, although privileged, were made known to Mr. Padway; but he insisted that the action had been made by reason of ethnic preju­ dice. Realizing the case that was being built against the Medical School in general and me in person, I approached my good friend, Mr. Sol Levitan, who immediately took up the issue on a personal basis and so berated Mr. Padway with evidences that completely disproved his contention that he took to flight without question. Mr. Levitan, in relating the situation to me, said that had he made accusations about any member of the faculty except me, he would have listened patiently; but there was no basis whatever for consideration of prejudice on the part of Dr. Middleton. A most interesting incident occurred in the person of an assemblyman who was at the same time a member of the University faculty. Mr. Harold 99 Groves approached me in the interest of a student who was seeking admission to the Medical School. The circumstances were interesting in that this particular lad fell just below our acceptance levelo After listening to Mr. Groves for a time, I indicated that it would be possible, but at a price, to advance a student to the acceptance level. If I did so, I would have to indicate to each one of the students between him and our acceptance exactly the basis of the decision. Mr. Groves said, "Dean, you would under no circumstance do this!" I answered, "Just try me!" Whereupon he dropped the caseo The ranks of the medical faculty remained intact, particularly in the clinical division, until the death of Dr. Ray Blankinship in 1932 when Dr. Evans approached me relative to the policy of appointment. The Chief's position was that at this time we were at a crossroad and we could either start building in the specialties or we could strengthen general medicine. Dr. Blankinship had specialized in gastroenterologyo Should we recruit another gastroenterologist or should we seek a strong general internist? My vote was in the latter direction and, accordingly, Dr. Ovid O. Meyer was recalled from the Thorndike Memorial where he had been sent for a period of broadening experience. One of the most serious losses in the clinical staff was that of Dro Robert Van Valzah, who in 1936 withdrew by reason of ill health. Van was a superb clini­ cian; in my judgment, the most finished bedside clinician whom I had ever encountered. With over 24 years of continued contact with Van, I had come not only to respect him as a physician but to hold him in the warmest affection as a friendo There was no sick room that he entered 100 that was not refreshed by his presence; no consultation given that was not rewarding. Yet, as a teacher, he was rather mediocre. [End of Side I, Reel 3] [Side II, Reel 3] Dr. M.: His lectures were written out in completeness and read in the same fashion. The succeeding years followed completely those of the preceding. At the bedside, in diagnosis, he was unsurpassedo Still he could not give you the bases for his diagnosis. Not infre­ quently he said, ''Well now, I remember, oh five, ten years ago, I saw a patient that looked just like this!'' Or there was something about the smell or the attitude of the patient that had led him to an unusual diagnosis. His withdrawal from the Wisconsin scene was followed by a period of gradual physical deterioration and he died in 1946 on his farm at the Great Bend of the Potomac in Virginia. The chief, Dr. Joseph S. Evans, continued active in the Medical School until the appointment of Dr. Ovid Meyer as Chairman of the Department in 1946, when he became quite inactive and died two years later after a period of complete lack of communication through a cerebral vascular accident that preceded his death by many monthso For an individual as gregarious as Dr. Evans, this was a terrific cross. His contribution, rather than to scientific medicine as his background and training would have anticipated, was primarily in the area of medical statesman­ ship. Largely through his skill and good offices, the clinical 101 development at Wisconsin had a sound footing and a successful course. Undoubtedly, his personality leveled many rough spots in this evolu­ tion. His vision and idealism gave substance to a dream that Dean Charles R. Bardeen had envisioned from 1904. When World War II broke out, as Dean I was called upon by Surgeon General James Magee to form an affiliated unit; it was the 44th General Hospital. I selected Dr. Joseph W. Gale as Chief of Medicine and---- Dr. O.: Medicine? Dr. M.: Chief of Surgery, excuse me, and Dr. Frank L. Weston as Chief of Medicine. On their recommendation, Miss Ida Bechtold was made Chief of the Nursing Service. This foundation set, recruitment was quite ready and the 44th General found some eight members of the staff in active military service. In all, with the 32nd Division Medical Services including the 135th Medical Regiment, 19 further members of the staff engaged in active military service. After the 44th General Hospital was organized, I withdrew, indicating that I hoped to return as Dean of the Medical School and did not care to assume corrunand of the unit. My active duty, which began April 27, 1942, was to continue through December 16, 1945, although I had returned to the Medical School early in August 1945. The conspicuous service of the 44th General Hospital has been recorded elsewhere. It did outstanding duty in the Southwest Pacific. Actually, 102 on Leyte, it came into the first line when the Japanese decided that they wished to reclaim the perimeter of the airfield that was occupied by the hospitalo In this action, there were two casualties--Birge and Bingham--both of whose wounds were fortunately of less serious order (Bingham was shot in the head--just creased, and Birge through the forearm)o The casualties of the enemy before our lines that had been armed at Colonel Weston's insistence, were materialo During the period of active participation in the war effort, the Associate Dean Walter Jo Meek was Acting Dean, and the remarkable effort of the residual staff under an accelerated schedule was quite outstand­ ingo The return of the members of the staff from active military duty found the faculty most eager for a complete resumption of teamwork. From a teaching standpoint, there was a rewarding experience in the reaction of students. The avidity and maturity of the veterans con­ trasted with the 4-F and other students who had not had military serviceo In my unorthodox method of approach, it was not unusual to sense a lack of resilience in the men who had not been in serviceo Whereas, if one clipped a veteran, he was on his feet immediately looking for more. Quite striking was the academic attainment of this immediate post-World War II group of studentso For several years, no student with an average of less than good plus--virtually 90--was accepted in the Medical Schoolo This situation had never occurred previously and I doubt whether it will ever occur again. There appeared at this period the crying need for expansion of the 103 physical facilities. The areas of our confinement in space were obvious. The library facilities were pathetic in their inadequacy and treasured collections of medical volumes were in serious jeopardy of irreparable loss. The plan to incorporate the library in the com­ pletion of the Service Memorial Institutes received favorable consider­ ation at the hands of the Regents, particularly President Sensenbrenner. At that time, it was estimated that a cost of $300,000 would be required to build this unit into the completed Service Memorial Institutes. When funds, as cited before, were available for the addition, circum­ stances compelled us to turn one-half over to Biology. Thereby, the library facilities were for the time lost. This circumstance led to the approach to Mr. Alexander Horlick for support. Mr. Horlick had been an earlier regent of the Universityo Dean Arthur Uhl, of the School of Pharmacy, and I were given an interview with Mr. Horlick; but the very circumstances of its setting led to doubt as to ultimate success. My conception at that time was of a General Science Library at the corner of Charter Street and Linden Drive to serve medicine, pharmacy, and the biologic scienceso Even the chemical and physical sciences could have been included in this strategic site. Certainly the need of such facilities in all of the elements cited was granted. The appoint­ ment was held in the lobby of the Hotel Pfister in Milwaukee. Instead of a quiet conference under private conditions, we had the turmoil of passing patrons and interruption of the various calls and paging! In a brief statement, Dean Uhl and I outlined the deplorable conditions under which our respective libraries operated. We took Mr. Horlick to 104 the high mountains of service to humanity. I thought that Dean Uhl did a particularly good job. Obviously, Mr. Horlick was not impressed and merely gave us an audience with scant courtesy and little time. Perhaps my judgment of the man is unfair; but his most telling connnent was, "Your Medical School is so small!"--presumably an argument to end arguments. The north wing of the Hospital was an addition long overdue. When Dr. Bardeen and his advisers constructed the original Wisconsin General Hospital, there was thought largely of bed space and the number that could be contained within the limitations of the appropriated funds. Obviously, there was shortchanging on all of the supporting facilities, service, laboratory, X ray and physical therapy in particular. The north wing addition to the Hospital afforded adequate surgical suites plus these elements that had been deleted from the original plans. Then came the addition to the Hospital. The addition to the Hospital on the east and west wings were to afford added bed space. The func­ tions of the Hospital continued throughout the period of construction. The Hospital addition for cancer had been underwritten by a $900,000 grant from the Public Health Service (U. S.). Regent William Campbell had initiated the negotiations through Representative Frank Keefe. The reclaiming of certain of the areas that had been given to the architectural design of the logia, afforded classrooms within the Hospital that had been denied in earlier planning, even though there were sacrificed certain details of design. Movement was steadily _, 105 forward. The influence of the Medical School in post-World War II period was greatly extended through the medium of the State and County Medical Society meetings. Then, too, members of the staff participated in regional medical meetings. Extension courses had varying periods of activity, both in degree and depth. The radio was utilized to excel­ lent effect by Dr. Llewellyn Cole, and after his death by Dr. Robert Parkin. Interestingly, our design to utilize television was denied by reason of a ruling of the communication authorities. This particular effort, effective though it promised, was not available until a later date. All through this period, the activities in organized medicine were not overlooked. The Central Society for Clinical Research was one of the most fruitful of these. The organization of this group was the out­ growth of an apparent sectional handicap for placement in national societies. The parent society, in general terms, was the Association of American Physicians. Its limited membership was granted to only a few of our associates in the Middle West. Even more trying was the difficulty of placement of our men of the Middle West, who had proven their mettle, in the American Society for Clinical Investigation--the Young Turks. In meetings of the Central Interurban Clinical Club, free discussion of these circumstances was had and it was decided to develop a regional society to be known as the Central Society for Clinical Research. I well recall the meeting of the Central Interurban at Rochester when the final details were discussed and resolved. The in­ tent of this movement was not to weaken the national organization, but 106 to afford opportunity, both geographic and professional, for the outlet of our younger, rising generation. The membership was drawn sharply on performance and promise. The first president was Dr. Frank Billings and I was the first treasurer. The first paper given for the Central Society for Clinical Research was '~he Effect of Respiration on the Venous Pressure" by Dr. Ovid O. Meyer and William S. Middleton; I pre­ sented our joint effort. The success of this movement exceeded all anticipation. Later developments should be of some interest. When Dr. Henry Christian communicated his design for a federated society of research, I tried to prevail upon him to develop regional societies of clinical research after the pattern of the Central Society. I indicated that a northeastern, southeastern, southern, and western group might follow in line with what had happened in the Middle West. Dr. Christian resisted this suggestion and the success of the Federation is a matter of record. The fact remains that from my advices, the Southern Society of Clinical Research is growing in stature by leaps and bounds, and I have no doubt that both of these movements will have had their place in the ultimate development. The presidency of the Central Society for Clinical Research came to me and I have maintained a sustained interest in this area. Dr. O.: Was Henry Christian's view shared by others? I mean the eastern compliment. Dr. M.: It must have been. I think so. They also have regional units and I think that they both had their place; but I mean to say that the • 107 central theme of a regional Society for Clinical Research presently holds at least in several areas. At the time of which we're speaking certainly the second group has taken a lot of the youngsters into the Federationo The American Association of the History of Medicine would naturally be an area of personal interesto I was not only active in its proceedings and in participating by periodic papers, but I was its president for a year. The American College of Physicians, I became a fellow in 1929, and president in 1951. In the interval, I had served as a regent for a term and as vice-president. The details of my membership include participation, not only in the scientific meetings, but in the adminis­ trative details of the organization, the qualifications for fellowship, and the insistence on certain standards. The meeting in Boston under Reg Fitz's presidency found me inducted into the presidency. In my acceptance speech, I made a serious proposal that the College cast the moneychangers out of the temple. I referred to the fact that the com­ mercial exhibits had, in my judgement, deteriorated to a level that was not in keeping with the dignity of the College. Ed Loveland, Executive Secretary, told me that I had cut the throat of the supporters of the annual meeting by this approacho I had no qualms in the matter. I felt that they might have a little blood-letting without any real sacrificeo However, he raised the question as to whether I did not believe a sensing of the reaction of the College might be in order. I willingly accededo To my great surprise, from the two hundred inquiries that were circular­ ized among fellows of the College, only three supported my position! 108 I still do not know the exact wording of Ed's corrmunication; but the fact remains that I had few very staunch supporters to my reaction. It was my contention:that, if we were to admit the various commercial concerns for advertising purposes, each and every one, aside from the publishers, should have an exhibit that was educational in depth and not purely promotional. I lost my case, but not my conscience! Membership in the Association of American Physicians is a coveted recognition for any physician in this countryo I had been a member of the American Society for Clinical Investigation and had regularly attended without great contribution. The Association, in its joint meetings with the Young Turks, afforded interchange with men that I have treasured over the years. The only paper that I have given before the Association was the one on "Dissecting Aneurism of the Aorta." The heart and blood vessels have been a subject of considerable interest through the years and this represented one aspect of the total fieldo I was invited, after World War II, to give an address before the dinner meeting of the Association. I spoke on the subject, ''The Impact of World War II on British Medicineo" In it, I related my remarks first to the physical evidence of war and then to the change in the pattern of practice that was to follow upon the implementation of the White Paper in the National Health Act of Great Britain. I have often felt that I fell short of the mark in not publishing my discussion which was heavily loaded with material evidences of the trauma afforded by photographs that had been given to me by British friends, and followed up by the clear implications of the state-controlled medicine that the I 109 intervening years have witnessed. After World War II, the activities in the Association of American Medical Colleges gave me my second vice-presidency. It's one of two organizations in which I have twice been vice-president and, in fact, the •~ridesmaid," never the president! There's one amusing episode in relation to my association here. I was approached by the Secretary of the Association (Dr. Zappfe) with the statement that they had had some evidences of a transfer of the student from Wisconsin to Arkansas. When the letter of transfer that was being considered by the Association staff, came into the secretary's hands he said, '~hat's a forgery. The letterhead may be that from the dean's office but that's never Bill Middleton's signature; he never wrote that well!" So it was an occa­ sion of a forger tripped because he wrote too good a hand! (Laughter) I have a feeling that the Association of American Medical Colleges has come of age with better insight into its mission through the active participation of faculty other than deans. The mission is still one that has to be followed through. I am not certain that the curricular tangles of the present period are going to be an answer. Naturally, because of my participation, I had increasing activities in the military assignments after World War II. I was consultant to the Department of the Army from August 1946 to April 1950. This entailed occasional visits to Washington at least once a year, sometimes more frequently, for the advice of the Surgeon General of the Army. The most important function of this immediate post-World War period was 110 Chairmanship of the Task Force in the Medical Reserve Corps, the Department of Defense, in May and June 1949. I cite this because one's first reaction was that they were building on very feeble grounds. There was so much "deadwood" that they could not count upon in an emer­ gencyo The first recommendation was that they bring the picture into sharper relief by determining the availability of these officers. There was a Ready Reserve that would be called in with organized units innne­ diately. There was a Stand-by Reserve that could be depended upon to fill in the gaps or to extend the bridgehead, if you please, medically speaking. Now this was a circumstance that we felt was extremely impor­ tant. We had a very strong committee and this was a formula that you might desire to look into a little bit further, that we establish a Reserve Corps that had its established mission. You had the first line, this would be the active young medical officerso You had, then, men who were professionally qualified that you would put into specialties in the back-up units, the evacuation hospitals or the base hospitals. You would have the individuals who were administratively trained, so that they could be put into a slot for administrative func­ tions that perhaps had never occurred to them in their civilian activityo And fourth, the preventive medicine; now, I might better have put it in the reverse order. However, these several elements came to a point where they could be called in function rather than just in body and then try to fit them into notcheso In a word, the Task Force sought a Reserve that was functionally strong. I did not think that we made as strong a point of the use of the affiliated units as we might have made. Now, 111 I shall discuss this situation in World War II. Affiliated units pro­ vide a source of highly skilled personnel that will be sorely needed in event of a war. These were some of the problems that we were sifting. We invited the various chiefs of staff of the several services--! remem­ ber them vividly. General Collins represented the Army; I had known General Collins overseas in World War II. Develop a good Reserve, just so that they would back us up. We just want the support of the military and the military wants the support of the medical when they are in a fight, was his position. Admiral Sherman was a gentleman of the old school. He said, "It's a very interesting situation that you outline to us, Colonel; but after all is said and done, after medical officers get to be lieutenant commanders, we have to take their stethoscopes away and they become administrators." General Vandenberg came in last. I had the preconceived idea that here was a young man who had been advanced beyond his capabilities probably--a lieutenant general--because he was a nephew of the Senator from Michigan. Actually, he was the only man with the real zest. He listened to what we had to say. He appreciated our objectives, where we were going, what we had planned, and said, "Gentlemen, we're the young service. We're brand new at this game. If you have any ideas, use us as guinea pigs!" This Task Force made a number of recommendations and you will probably find them in the archives somewhere. Some of them have been implemented in part. It was a very strong committee (Wink Craig, Randy Lovelace, Jim Mason, Charles R. Wells) * and its sound recommenda- tions, in my judgment, merited more expeditious and incisive action. *This committee and its deliberations are further discussed in detail on pages 399-409. 112 As a member of the Civilian Health and Medical Advisory Council, Department of Defense, April 1952 to March 1955, the situation was one in which first, Mel Casberg and then Frank Berry occupied the position of the Assistant Secretary of Defense Health and Medical. Dr. O.: Yes. That's where Pete Rousselot is now. Dro Mo: Yes, Pete's there nowo And the one vivid recollection, again the record may give you more of these details; but the one vivid recol­ lection has to do with my insistence in the development of the depen­ dent care program, namely, that the individual have the choice of the Armed Forces medical support or outside. In other words, my insistence was that you ought to make this relationship so competitive, the medical staff so strong within the Armed Forces that dependents would elect the military. We drove that point very hard. I was intereste~ that the "Regulars" at first fought me and then I think that I shamed them a bit, because it was so obviously a point that you wanted to get across to the dependentso What dependent would want to come to an inferior Armed Forces physician. If you could put it up on another basis; then your argument comes homeo The next door neighbor, the daughter is in Germany with her husband who's an artilleryman. The mother came to me and she said, "Agnes is going to have a baby; what if she has the baby over in Germany?" I said, "I can assure you, Mrs. Domini, that the obstetrician in the Armed Forces over there will be the equivalent of anything she'd get in Madison. I am perfectly certain she will have excellent care." The mother came to me later and said, "Agnes has had - 113 her baby and she's very happy!" I think that is a very important element. When Frank Berry was in this Assistant Secretary position, Health and Medical, he invited me to go as chief consultant to the Third Medical Planning Conference of NATO in Paris, May, 1954. And it was a very active one. I have some papers in the file to which you can refer. I was a member of the Special Medical Advisory Group of the Veterans Administration from 1946 to 1950, that's the first Special Medical Advisory Group. I presume I was so named because I had been General Hawley's Chief Consultant in Medicine in the European Theater of Operations. It's rather an interesting situation that I shall enter upon when I get into VA, because it has a very definite tie-in with Paul Magnusono The research developments in the Medical School--now I am repeating what we have said educationally, from the standpoint of service, and have indicated to you the relative position of service to education as the essential element. The McArdle group developed by leaps and bounds under Dr. Rusch; I've nicknamed him "Benny." Even though he spells his name R-u-s-c-h, he's "Benny" to me. They have had a very strong group there; the Millers, their study in nutrition and its influence upon the development of cancer of the liver; Van Potter, his studies in metabolism, especially enzymes, and then you come to Charlie Heidel­ berger and I have to tell you a story about Charlie; it has to do with his dad, Michael Heidelberger. Did you read that? 114 Dr. O.: In your Remembrancer, yes, God forbid! (Laughter) My, what small threads some fates hang by. Dr. M.: Well, in the Remembrancer I have cited the way we lost Michael when we tried to get him as a University professor. Dr. Heidelberger seemed quite impressed; but no apartment would accept their dog. Just upon this small detail we presumably lost Michael; but we got Charlie. I think we got the better part of the bargain. Dr. O.: Well, you got somebody who has more active years ahead of him, certainly. Dr. M.: And his SFU, of course, has come through. You see, it was developed on sound scientific grounds with the displacement of cellular functions. In clinical research, Tony Curreri has been a tower of strength. He, at present, is the Chairman of the Department of Surgery, an area that I shall not get into because that was a feud that came after my period and in which Dr. Bowers was involved. Sometime, pri­ vately, I will tell you what actually happened; but this was after my period, and I've stayed entirely removed although interested, deeply. Fred Ansfield was brought out of the private practice of medicine to head the medical aspect of the clinical oncology. Fred has done a magnificent job; he's a splendid, keen internist; not young any longer. In neurophysiology, we had Brittingham money to develop what was really the Slichter Professorship in Neurophysiology. Slichter was a former Dean of the Graduate School and this was money that was given so that 115 we could get this under way. Woolsey has done an outstanding job. Clllinton Woolsey is a product of the Hopkins, by way of Albany, and he bad been elected to the National Academy of Sciences and has really an autstanding Department of Neurophysiology. In medicine, it's hard to single out individuals, but I shall attempt to do so with an indication of the areas where they have made major contributions; Meyer in hematology. If I were to select the outstand­ ing bit of work he's done, it is not in the use of anticoagulants where he has had international recognition with dicumarol, but basic work that he did on the relationship of the pituitary to hematopoiesis. Fred Pohle comes into the dicumarol picture very definitely. When Karl Paul Link was working on the hemorrhagic disease of cattle, particularly young heifers, he encountered the fact that, apparently, this arose when these young stock ate spoiled sweet clover. He came to me with the proposal that we underwrite this research. I said, ''Karl, we can hardly underwrite this when it has no clinical or medical application. If you come to the time when you feel that we have a place in the pro­ gram, I'll try to get the money. We're not so flushed with money as you are in Agriculture." Some time later he called me on the telephone and said, "Are you busy?" And I said, "You know, Karl, I'm a dean and deans are never busy!" He said, "I have something to show you." So it was just a walk of a few hundred yards from my office to his labor­ atory. He had blood in a bucket and asked, ''What's this?" I said, "Blood." He stated, ''Well, any damn fool could tell you that; but what's wrong with it?" I said, ''The only thing I can see wrong is that 116 it's fluid." He said, ''Well, that's what's wrong with ito This calf ate spoiled sweet clover and from that spoiled sweet clover I've gotten this." He shook the powder in a little vial and said, "I call it dicumarol." He asked, "Do you have anyone over in your department who is interested in coagulation?" I said, "Fred Pohle is just back from the Thorndike in Boston where he has been working with Laskey Taylor for a number of months on the coagulative systems. He's your man." Fred was over there within fifteen minutes. I simply cite this because of the easy interchange on the same campus within geographic toucho Fred Pohle was called into service after a time; but he had been work­ ing with Ovid Meyer who really carried the clinical ball after Fred Pohle initiated some of this interchange that I citeo It has always been an example to me of the importance of propinquity, when you want a job done. Next is Edgar Gordon, who has been interested in the endocrine system for some time. He is now most vitally interested in obesity. Edwin Albright, who has done some conspicuous work on the thyroid and the one piece of work that we did together. I had been waiting for years to prove whether the increased basal rate that one encounters in leukemia, was of thyroid origin. Of course, as soon as we had radioactive iodine we proved that it was not. The thyroid does not take up an increased amount of Iodine 131 in leukemiao Albright did that technical work. And Robert Schilling, of course, has been interested in hematology alsoo He did an outstanding piece of work with radioactive B which it is 12 - 117 ~ienerally applied for the diagnosis of pernicious anemia. Leroy Sims, in medicine, has been interested particularly in the liver; but I do not cite any original work in that area. Dr. Loevenhart and his assistants developed tryparsamide. Tryparsamide, of course, has all of the possibilities of potential eye injury that any of the other arsenicals have. Dr. Loevenhart had an idea that it might do a job on sleeping sickness, trypanosomiasis, in Africa. To meet this challenge, Dr. Loevenhart wanted to arrange a team of Dr. Lorenz, psychiatry, himself in pharmacology, and me in internal medicine (1922). His plan fell through. When they approached the British, they said that they had a laboratory at Stanleyville. Given the material, they would study it on their own. The Belgians were not as firm in their position, so that eventually it came to a point that Stratman-Thomas, one of his assistants, was sent over to do the job. It did not, apparently, pan out particularly well. Dr. Loevenhart de­ cided to go to Europe to intercede. While abroad he developed acute activity of his peptic ulcer and came back to this country. Dean Lewis did the surgery at the Hopkins and he died. Dr. Loevenhart's death was a serious loss to medicine. Dr. Tatum succeeded him. Dr. Loevenhart's work on tryparsamide, as you know, was followed on the clinical side by its use in central nervous syphilis. Cooper, in dermatology, Loeven~ hart, Lorenz, Hodges, and, I think at a somewhat later date, Reese and Bleckwenn, were the team that treated this group of patients with try­ parsamide. 118 The surgery, to continue---- Erwin Schmidt had succeeded Carl Hedblom before I became dean~-as a matter of fact, Hedblom was here only two years. He was a good clinical surgeon but no research came from thato Schmidt brought with him Alton Ochsner, who did some of the conspicuous work on first bronchographies in this country. He was here just short of two years. He went to Tulane as Professor of Surgery. Dr. Oo: Was it from Wisconsin that he went to Tulane? I don't know why, I thought he was somewhere in Chicago. Dr. Mo: Noo He went from here to there. Now there's one incident, I don't know if it has a place in history. Al was very seriously con­ sidered at Western Reserve. The one obstacle to his appointment, amazing, i.e. he wrote too many papers! Joseph Gale succeeded him in thoracic surgery and, of course, was very active in that areao He died within the last month. We did consider­ able work togethero One operation that we devised together was scalen­ ectomy, section of the scalenus muscles to reduce the activity of the movement of the upper thorax. I don't think it's too hot myself! That's the period, though, when we were having all sorts of interrup­ tions of the phrenic nerve and muscle sections. Dr. O.: In TB therapy? Dr. M.: That's right. Then to the specialties of medicine, as I have indicated, Cooper in dermatology contributed. Roscoe McIntosh was clinically active in supplementing the weekly visits of Otto Forster 119 from Milwaukee. In cardiology, Chester Kurtz was very active in ortho­ diascopy--establishing heart size by use of a single central X ray beam. He wrote a text on it (1937). None of the people in gastroenterology did research of moment. Elmer Sevringhaus and Edgar Gordon were respon­ sible for metabolic diseases. Sevringhaus was the first one to consol­ idate our work in diabetes on the introduction of iletin. His efforts in the general field were not original; but he was a splendid synthe­ sizer of literature and the efforts of others. Dr. O.: Certainly he's co-author of a very outstanding and very well­ recognized textbooko Dr. M.: Exactly. In pulmonary diseases--we've had great strength. Reuben Stiehm was the first one to do a concerted study of the incidence of tuberculosis among our students. He and William Oatway had a great deal of influence in introducing the BCG vaccine in students and student nurses. [End of Side II, Reel 3] [Side I, Reel 4] November 11, 1968 Dr. M.: After the initial surveys by Stiehm and Oatway, chest diseases in general have been very adequately covered by Dr. Helen A. Dickie. Her work has not only consisted of the careful evaluation of BCG vaccina­ tion but has extended to such interesting fields as the "farmer's lung." Pediatrics was very ably represented by Drs. John E. Gonce and H. Kent Tenney, and Dr. Kenneth McDonough with Harry Waisman coming at a some­ what later period. - 120 The specialties in surgery showed great strength clinically in Gaenslen, Burns, Wirka, and Okagaki for orthopedic surgery; but no outstanding research was done in this department. Dr. Frederick A. Davis did a classical study on primary tumors of the optic nerve. Elsewhere in this department the effort was largely clinical. Dr. O.: Dro Yates, of Milwaukee, had some connection with the Depart­ ment of Surgery, did he not? Dro M.: Not as such. He did some work with Dro Bunting on Hodgkins disease. Eye, Ear, Nose, and Throat, and Plastic Surgery were adequately repre­ sented in all details as was Urologyo The Chemosurgery has been outlined in some detail. Neurosurgery found Dro Crawford as a recruit of Dro Hedblom, but his succession by Dr. Erickson saw renewed effort and achievement from the basic standpoint. A product of Penfield's school, Erickson was an outstanding surgeono Gynecology and Obstetrics as indicated were first covered by local spe­ cialists, Carl Harper and Edward Schneiders, on a part time basis. Dr. John Harris, who presumably brought great promise in bacteriology to obstetrical complications, was more conspicuous as an effective teachero Interestingly three Professors of Obstetrics and Chairmen of Departments came out of his residencieso Dr. O.: John Parks at George Washington University being one? . ■ 121 Dr. M.: Right. The Department of Anesthesia is a phenomenon among similar departments in this country. Dr. Ralph Waters, who was recruited in the Department of Surgery before Anesthesiology was split off from this major depart­ ment, had little of the academic background that would have recorrnnended him. Coming on the Madison scene at 46 years of age, he was beyond the period when one would look for great development. Yet as a catalyst, he drew to himself, Chauncey D. Leake and Maurice Seevers in Pharma­ cology and Meek in Physiology, to constitute an incomparable team for the intimate study of the action, experimental and clinical, of anes­ thetic agents. Their efforts were backed by careful records evolved by Noel Gillespie. The result was that this group attracted to Madison students from virtually every country on the globe. To come into their sessions was to sense an international meeting. Dr. Waters' untimely retirement found the administration in some difficulty regarding his replacement. The succession of Dr. MacKay was entirely to our liking, but he had no taste for administration and begged to be relieved. Fortunately Dr. Sidney Orth moved over from Pharmacology to Anesthesia and filled the post admirably before his untimely death. Dr. O.: Robert Dripps is a pupil of Dr. Waters, I believe. Dr. M.: Yes, he is. Only the high spots insofar as research have been touched. The various agents that were used in anesthesia had their careful analysis at the hands of this team and the tbtal effort unquestionably attracted more 122 attention to the University of Wisconsin Medical School than any other department. A word should be said about the Department of Clinical Laboratories (Surgical Pathology). With Dr. Stovall's guidance, Surgical Pathology was taken over from the Department of Pathology when Dr. Medlar found it impossible to arrange his schedule to meet the time and the tastes of the surgeons. As a wheel horse in an organiza­ tional system, Dr. Stovall assumed this responsibility in addition to his Directorship of the State Hygienic Laboratory. This is not an unusual experience for him since at one period for two years, he was the acting superintendent of the University Hospitals in the absence of Dr. Robin Buerki, who was surveying graduate medical education in the country. One other member of the staff requires special attention because of an unusual quality. Dr. Walter Jaeschke is the "teacher born" who contri­ butes little to the literature, but much to the training of residents. His value is beyond measurement in the information as well as the con­ fidence given to this rising generation of young medical men. Patiently he spends hours with the surgical residents in familiarizing them with histological pathology--a priceless asset to any hospital. Now the period of the Deanship cannot be concluded without reference to the conspicuous contribution of the Associate Dean, Walter J. Meek, a physiologist by training. Dr. Meek came to Wisconsin in 1908 from the laboratories of Professor A. J. Carlson in Chicago. Regardless of the circumstance or call, Dr. Meek delivered on every occasion. In a 123 period when most physiologists were specializing, he welcomed the opportunity to give the lectures on general physiology to the students in the College of Letters and Science, an assignment that was eschewed by most physiologists. As a matter of fact, when readjustments became necessary, the younger members of the staff were very critical of their former chief for having assumed this responsibility. Yet Dr. Meek felt that this was one of the most important assignments that a physiologist could haveo So well were his lectures and conferences organized, that President Conrad Ao Elvehjem said that he was the best teacher under which he had ever sato A high compliment from a competent judgeo From a professional as well as an administrative standpoint, I can bear witness to his selfless devotion to duty. Only on one occasion was he critical of me. I had been in the habit of taking my nonuniversity papers to his secretary, Miss Josephine Maher, for transcription or typing. When he saw me do so, in his sharp manner he once said, "Bill, I do not see why you cannot have that work done in your own office." I said, "Oh, that will be all right, Dr. Meeko If Miss Maher doesn't want to do it, it is up to hero" When I left the room, Miss Maher told him that this was one of her sources of outside income and she wished that he would not interfere. Whereupon he apologized profusely to me for his breach. He was a student adviser to premedical students par excellence. Though he was not a medical man, he sensed the strength and weaknesses of students and gave the counsel that could not have been improved upon by any physician. Insofar as his scientific contribution, I have already alluded to his election to 124 the National Academy of Sciences. He was interested not only in the tirculatory system, but also in the gastrointestinal tracto With Ray Herrin, he did some conspicuous work on the influence of dilatation of the gut on secretion. In a word, he was a most able associate from a professional as well as personal standpoint. He was interested in the history of medicine and was a very active member of the Medical History ~eminar. His most fascinating paper was on "The Gentle Art of Poison­ ingo" A paper that was perhaps of greater professional interest was his study of the early physiologists of this countryo The war period with its burden found a lapse of the integrated course in medicine and surgery. I always regretted this sacrifice because I felt that it was a very strong element and obviously an introductory phase to what is now happening to medical curricula. The number of graduate and postgraduate students increased apace after World War IL The quality I would say had likewise improved generally. Not the least element, I have already cited, was in the maturation of the young men who had been in service. What was the schedule of a Dean who presumed to have some function in this particular period? My working day began quite early in the morn­ ing. From Memorial Day to Labor Day I had a swim at 5:30 each morning in Lake Mendota with the only company, a few mallards. At 7:30 I would be at the office in the Hospital and rounds started promptly at 8:00. These ward rounds for teaching with consultations might last till noono At noon I played handball or tennis three to five noondays 125 t weeko Some of these tennis matches I don't think I have told you Dr. O.: No, I have seen reference to your handball games with Park. Dro M.: Well, of course tennis was a summer gameo Eddie Gordon was one of my favorite opponentso Our contests were really, in a manner, psychic warfare, not gamesmanship. I never talked on the court. I strictly observed all the rules; but Eddie would drive his car up and I would get in and say, "Well, Eddie, it's a strange situation. You're thirty years younger? Perfect coordination and better physical shape than I am in, too, Eddie. Isn't it a strange circumstance that you have never been able to beat me? Oh, I remember one time you tied me." By the time we would get out of the car, Eddie was as taut as a drum and I wouldn't say another word from that time. For some of my rivals, I wasn't quite so impressive. Chubby Poser, who had been a star basket­ ball player and my resident in medicine, used both hands for his backhand. He had very quick reactions. This was a very hot day and I thought that I would get him. I took salt tablets. When I got out on the court, I puked my head off! On another occasion, Chub and I were playing. Each of us had a set and the deciding set was on. I had him 5 to 2 and set point, 40 - 15. I went to the net and said, "Chub, come here." He giggled as he did when excited. I said, ''May I see your tongue?" He said, ''What's all this about?" I said, "I don't want you to have any alibis when I beat you!" And he beat me! Beat me 7 - 5! After I had him 5 - 2, set point, 40 - 15. Well, as • 126 I say, I have had my days! (Laughter) He never let me forget that eithero Then from 1:30 to 4:00 I was in the Dean's Office. I said that if the Dean's Office can't run on two and a half hours, it is just too bad. Meetings from four to fiveo That was my ordinary schedule. Do you want something about Wisconsin? Dr. Oo: Yes. Dr. M.: The University life in 1912 was as follows. I came here a young man 22 years old. I found the professional life most stimulat­ ing. Young associates, the ambition ahead with the assurance that in five years time we would be a four year school. Of course, that frankly was the occasion of my coming to Madison. Dr. O.: I was earlier going to ask this because I was sure that it must have been the caseo Dr o M.: The Dean told me, "In five years, Middleton, you will have your four year schooL" There was not a particularly active social life. There were many outlets for the young folks of whom I was one. I was physician for the football team and the first year I was here we had a Big Ten (Western Conference) championship team. They won all of their games. They had had a championship team in baseball and in track and later in basketball. I had come to the right spot and at the right time! 127 What did a young man do for recreation at that period? Well, fortu­ ftately I was interested in hiking. I regularly walked around the big iake, the Fourth Lake, they call it here. That's Lake Mendota. It is about a 25 mile hike around ito I would do this twice a year. I walked practically every weekend. Then with one of the Forest Products men, Norman Betts, who was an authority on birds and had written the definitive text on the birds of Colorado, I would go out practically every Sunday, bird-watchingo The other fellows at the University Club where I ate when we returned to the dining room made derisive gestures at the "Peewees," as they termed uso Unfortunately, Jim Walton, Profes­ sor of Chemistry, who deviled us most--his daughter later became a student of mine--upon mention of the llama said that there wasn't any such thing. "Llama? And you have never heard of it, Jim?" "No," he saido From that time on, whenever we would see Jim, we made llama-like motions of the hand at the wrist. So we gained our revenge. It was an idyllic life, really. I swamo I was a very poor skater. I got shin splits whenever I tried. After a short turn on skates, I would sometimes be laid up for dayso So tennis and handball were my physical outletso I liked contact sports; but I couldn't play football in high school or anywhere else because I was too lighto They still talk about the blocks I threw in handball; if you see "Captain" Parks, you ask himo You could put a block on before the ball hit the front wall; but after the ball hit the front wall, it was a foul to block your opponent. I used to place it so it would come off the side and I would have to get over the top of him. 128 With Dr. Shumacher when I came to Wisconsin, I was urged to make a study of the heart of athletes. This is not an easy task as you know. It has been a controversial situation until recent years. The athletic heart was really an unknown affairo Our results indicated that the oarsmen were having some trouble with cardiac hypertrophyo What hap­ pened to this condition after discontinuance of rowing, we proposed to establish by continued observations. When our publication came out, they abolished crew. When Dr. Evans returned from his holiday in the East in 1913, he said, "Bill, you're in a hell of a mess!" I said, "What do you mean?" He said, "Well, certainly you won't have much standing with these athletes around here." He hadn't been back very long when he learned that the team had asked me to be their team physi­ cian again. Of course, I had had no academic college work as you recall before I went to Medical School. When I came here, I found that there was a sharp division between what they called "the barbarians" and fra­ ternity men. It entered into many of their discussions in these sessions; but they had a very free interchange. They respected each other. I was taken into two fraternities, the Alpha Tau Omega--a social fraternity, and the medical fraternity, Phi Beta Pio I don't think Phi Beta Pi took me in for social reasons. They had a little epidemic and I quarantined themo When I visited them one day, they had a keg of beer in the back room! I didn't report them so I think they took me in! They had bag rush on the lower campus. If it hadn't rained, they soaked it down so it would be heavy with mud. A bag rush usually meant that a lot of clothes were torn off, nothing very serious. 129 Dr. O.: This was part of fraternity rush week? Dr. M.: No, this was part of the class rivalry between freshmen and sophomores. There was not a row between the "barbarians" and the fra­ ternity men. Of course, the sorority women didn't get into it at all. When there were radicals here on the campus, the treatment was rather direct and abrupt. It was hydrotherapy! The lake was very handy. I give you my word that I think they could break up any of this stuff around here at the present time if they used the same treatment. Dr. O.: Particularly this time of yearo Dr. M.: Oh, right now! This was a frequent occurrence and not just casual. When these fellows got out of bounds, they knew they were for it. They might as well get ready for it and get their clothes offo Speaking of student acceptance; in our clinic, the Student Health Clinic, we had the students who kept the records or the running files. One of the first was Robin Buerki. When I came here he was quite activeo As you know, he has gone high in hospital administration and just retired last year. Robin Buerki would come to work at 7 o'clock in the morning and would just tear through it as he did all through his life. If I couldn't find him around the Clinic, I would just call up the sorority because I knew where he was. They would say he wasn't there and I would say, '~here is a bench right underneath the stairway there. If you look, you will find him there with Louise!" And he would come to the phone and ask how I knew where he was. I told him I had been there myself. 130 Another one was John Currie Gibson. He was a little fellow with a very heavy voice, a very excellent bass baritone. Currie was making up these records and he found the abbreviated diagnosis on the records of a number of girls. He didn't know any medicine at this point, so that "DYS" meant dysentery. We got these records back and wondered where this epidemic of dysentery had started. All of them had been "Excused for dysmenorrhea!" Currie became a Professor in the School of Commerce and died just last year, a very eminent man. Fred Rinker, who came from Virginia in 1915, had an excellent tenor voice. These two would sing operatic selections, one at each end of the hall; nights you know when no one was there. Huck Newberry was one of the favorite student assistants around the Clinic. He was junior to Robin Buerki, but had also come from Waukesha, the same community Robin had come (born in Black Earth and raised in Waukesha, near Milwaukee). Dr. O.: I know the area, yes. Dr. M.: Huck Newberry was a powerful man. I was always riding him. He came into my office one evening, when I was doing some work in the Clinic and said he wouldn't leave me until I said Uncle or something to that effect--some penalty at least. He was leaning back in his chair like this and he had his feet off the floor. I simply hooked my toe under his chair and pulled the chair out from under him. Naturally I took to my heels. The Dean happened along at that time but merely smiled. I went upstairs after one of these encounters and heard the -,ater running in the bathtub. Huck came in and said, "You gettin' your 131 clothes off? You're taking a tubbing! Well, I got my clothes off in short order and in the tub I went! Those were childish things back in those days. I was 23 at that time. Huck was younger but such strength. Actually, a chap had a Ford, a Model T, stuck in the mud alongside of the Clinic. He went out and lifted it right up out of the mud by the front axle. Sigma Sigma was begun as a rather frivolous organization. Sigma was for skull and the other Sigma was for scrotum. It eventually became an honorary society. In the present day with the woman initates, they don't dare to tell the real story of the origin of Sigma Sigma. It is still a local honorary society. The "Yellow Helmets"--! have related this episode regarding Carl Russel Fish--where they only met to have some beer and to discuss whether to pay their rent. They weren't going to pay their rent; so they would have another meeting. We were all visited with summons and Carl Russel Fish was very much disturbed be­ cause I didn't take it seriously. The "Hard Dogs" was a very special society. It was made up of a very select group of athletes. Arlie Mucks was about 6' 5" and had placed third in the discus as a high school boy in the Olympic Games in Stockholm. He was built like an inverted pyramid from his shoulders down. In football the opponents knew that his knees were the target. They wouldn't try for his huge body; they would go for his knees. I would have him in casts up to his thighs after most of the games. He died about a year ago. He was a great character. His son is the Director of the Alumni Association of the University now, Arlie, Jr. Another, Tom Kennedy, had won letters - 132 in crew and football but was deprived of all of his honors and was dismissed dishonorably for cribbing. In any event, he went to bumming and tramped across the country. Then he returned to the University and won back all of his honors. Some of the tales he would tell about the experiences: the tramps getting thrown off the freight cars on the Continental Divide and finding their way back. They had a lap dog, the little fellow who had been coxswain on the crew. My only position in this crowd of roughnecks was as "patron saint." I bought them steaks down at Ben Stitgen'so His restaurant was the St. Nicholas Cafe and they give you a thick steak. One of the handball teams had beaten our team and I took them down to Ben's. After they had the first steak, I asked them if they would have another. Of course they said, "Yes!" And did! That's the kind of company I kepto Mother Matz's was a bar and restaurant at Pheasant Branch where they had their rough initiations. It was the only time that I ever witnessed paddling at a fraternity initiation and they did it royally! The holidays I invariably spent back home in Pennsylvania. My parents were still alive and I visited them. We had a small house on the Perkiomen Creek, "Crows Nest," near Arcolao It was just a three-room cabin with a loft, really. We had a tent pitched outside for the over­ flow. The men, if we had a group, slept in the tent; the womenfolks, indoors. I do not think I mentioned the occasion of my father's rent­ ing "Crows Nest." "Bunny" Marks, my classmate at Pennsylvania, asked me to coach him for his State Board examinations. You see, "Bunny" Marks was the athlete who was really responsible for my primary interest ■ 133 in teachingo I practically tutored him all the way through medical school. We were very good friends and we were in the same class sectiono "Bunny" was out for football and basketball and needed a little urging along the way. So that I think that riveted my attention on teaching. There followed this period when we studied for the State Boards at this quiet spot along the Perkiomen Creeko That is a picture of Perkiomen Creek right there (referring to a picture hanging on the wall of his study). That is K.aser's Mill and Dam which is just down the hill from the "Crows Nesto" It is about 25 miles from Philadelphia. The Perkio­ men Creek empties into the Schuylkill and this dam is about three miles from its moutho Whether subconsciously or otherwise, I think that this experience had some bearing on the formulation of my interest in teaching, which has been a consuming passion ever sinceo My folks had that cabin, the "Crows Nest," for about five years, from 1911 when we went up to study for the Board examinations until 1916. In the morning I would go to Philadelphia to work in the laboratory with Allen J. Smith to keep my hands in pathologyo I would make rounds with Perry Pepper at the Hospital of the University of Pennsylvania, go over to Blackley and see old friends in the morning and return to Arcola in the afternoono I think that it was a very helpful experience for meo Of course, the rest of the story on Madison was that Dory, who was a Clinic nurse--but I never really courted Dory when we were together in the Clinic. I went into the service in 1917, on May 24, 1917. I did 134 not see her until I was being discharged by way of Bordeaux, but that is another story. She was with the Base Hospital 22 in Beau Desert near Bordeaux. I had been up in Flanders with the British, then came back to the Americans, first in Dijon and then with the Field Hospitals. We will take that up in detail when we get to World War I. (Pause) Dr. O.: Would you feel that the three most important tangible or material things that you have accomplished at the University of Wiscon­ sin Medical School which are in a sense your legacy, would be your deep concern and final establishment of a Chair in the History of Medicine; the McArdle Cancer Laboratories; and of course the new medical library. Dr. M.: Of course, I consider that these are all vital and important. From a physical standpoint I should like to have my tenure as a Profes­ sor of Medicine and as a Dean of the Medical School marked by these several items and the physical consolidation of the Medical School in a single center. This, of course, is extremely important. In the next detail, I would attempt to dissociate these physical elements from something that to me is very much more important. The opportunities to teach and to observe the emerging mind of the young medical students have been the most important elements of my teaching career. In a word then, I admit that these matters are details that are not susceptible of complete dissociation. However, I think if there is any one thing a teacher leaves, it is of the spirit and not the material aspect of his contribution. 135 Dr. O.: Do you think that in that sense you have made your mark at the University of Wisconsin? Are you pleased with the style of the clinical teaching now in the Department of Medicine? Dr. M.: I'm never satisfied. Dr. O.: Is it a matter of increasing specialization? Dr. M.: This has been one of the most disturbing elements of recent developments. Of course, the old guard must attempt to hold the front. Not that they are able to see all or know all elements in medicine; but there are methods that can and should carry over into the future of any pattern of changeo It is not total gain simply to have the mechaniza­ tion of medicine supersede the qualities of compassionate understanding. [End of Side I, Reel 4] [Side II, Reel 4] The date is November 12, 1968. Again we are in the home of Dr. William S. Middleton in Madison, Wisconsin. Dr. Middleton is going to begin this morning with a discussion of his experiences in World War I. Dr. M.: World War I found the United States emotionally and sentimen­ tally involved long before its active participation in hostilities. The events leading to the actual declaration of war are a matter of record and shall not be enlarged upon. Personally, I had experienced an inherent abhorence of violence and of war from childhood. Only family tradition compromised any psychologic reaction that evolved from the current events of that period. For example, there was a 136 constant reminder that there was no war in which your country has been involved without participation of a member of your family. Then, too, my Grandfather Shainline constantly reminded me of the fact that actually I was a collateral relative of Mad Anthony Wayne. This cir­ cumstance subconsciously must have affected my thinkingo However, his very vocal brother, Uncle Jim Shainline, who had received a serious skull wound at the first Battle of Fredricksburg in December 1861 had not gained much favor by his lurid reminders of the violence of the Civil War Periodo His reaction to my friendships in the Medical School were particularly amusing. One of his sayings is recalled: ''Willum, never turn your back to a rebel; before you know it they will have a knife between your shoulder blades." The interest in medical history that had been fostered by the acquaint­ ances in the classroom at Pennsylvania and by the very stimulating recital of related events by Dr. David Riesman, then in the seminars at the home of William Snow Miller, in Madison, undoubtedly had their reflection in my interest in American history. I was quite familiar with all of the campaigns of the Revolutionary War and Civil War, for exampleo In biography, collateral readings had included particularly the lives of Abraham Lincoln and Robert E. Lee. Singularly, these colorful backgrounds had been supplemented by further reading of the lives of the latter's associates, as Stonewall Jackson and Jeb Stuarto Dr. O.: We might just add here for the record that here in your library you have a rather extensive collection of biographical studies of figures in the Civil Waro 137 Dr. M.: I believe that there is a fair indication of my interest in that period and singularly the military elements are conspicuous in my reading of the interval after coming to Madison and before World War I. The commission in the Medical Officers Reserve Corps was obtained in 1917; but I insist that I had been very critical of the propaganda that had been so much a part of the preparation of the American people for the declaration of war by President Wilson with the support of Congress. As an agent of the American Red Cross, Dr. John L. Yates, of Milwaukee, inquired of the availability of my associate, Robert Drane, and myself for early service with the British. Apparently from his story there was a very distinct shortage of medical support to the British Expeditionary Force by reason of the loss of many medical offi­ cers in the Sorrnne offensive of 1915. These deficits had not been repaired in the interval until the declaration of war by the United States. The first request of the British military was for the recruit­ ment of American medical officers to fill the gap. We were both willing to go to active service on this basis and orders were received to report to the Army Medical School in Washington. On May 24, 1917 we reported to Major Jones at this post and were given perfunctory directions. An interesting and amusing incident occurred while we were reporting. One officer, obviously not versed in military etiquette, presented himself with eagles on his shoulder. The major rose to his feet irrnnediately and in the course of the conversation in greeting the assumed "Colonel," inquired what background of training he had had. The officer stated ... 138 that he had had none and the major asked by what means he had arrived at his rank. The officer said, "Sir, when I was looking over the offi­ cer's equipment, these shoulder ornaments appeared to be most attrac­ tive; so I just bought them!" Whereupon the major took an entirely different attitude toward the First Lieutenant, who was assuming the elevated rank. After a period of several weeks, we were ordered to New York or Hoboken for embarkation with twelve other medical officers on the steamship St. Paul for duty in the British Expeditionary Forces, or rather with the British. The voyage was a very interesting one in several respects. Acquaintance among the American officers was promptly accomplished and certain of the friendships have lasted over the years. In general, we were informed that our duties could not be assigned until we arrived in Great Britain. However, the gun crews mounting the two guns with which the St. Paul was equipped, did not have sufficient personnel to handle the ammunition and volunteers were asked to serve as powder monkeys to bring the annnunition from the hold. On the arrival in the North Irish Sea, there was a submarine attack and we were called to our posts of duty. A torpedo apparently passed within twenty yards of the bow of our ship; but in firing upon the submarine the only damage done by the gun crews was to some of the rigging of the St. Paul. The passage to Liverpool, our port of call, was uneventful except for this detail. I vividly recall some of the sessions in the bar of the steamer in transit. Captain Hume and Captain Kennedy were leaders in certain of the songs that still ring in our ears. 139 From there, our movement to London was by easy stages with the British volunteer workers affording food and drink at the several stops en route. In London, wartime conditions prevailed. Although we were given excellent quarters in Mayfair, we_were informed by Major Lister, regular United States Army, that we were expected to see early duty with the British Expeditionary Force. Only a few of the Americans remained in Great Britain. Most of us were shipped to France without further delay. The transport from Folkestone to Boulogne was the usual stormy crossing. We were first housed in a hotel on the quay at Boulogne. My early recollections were the first horse meat steak for dinner and the early morning arousal by the tramp of the hobnailed boots of soldiers march­ ing on the cobblestones in the quay in front of the hotelo Shortly we were moved to another billet and our duties were assignment to the Base Hospital 13 outside of Boulogne. Here we did wound dressing and very little other professional work. We awaited anxiously our line assign­ ments. Two circumstances should be recalled, however. In the first place, the staff at Base Hospital 13 included Almoth Wright; but we overlooked one of his subordinates who was Alexander Flemingo The other detail of significance in our Boulogne stay was the first 4th of July celebration overseas. A proper gathering of Americans convened in the Hotel Burgoyne within the walled section of the city where a very excel­ lent repast was served and great festivities followed. However, the number who were sober, came down the hill to their billets to encounter the revelries of the Australians who were apparently on leave to this port. 140 July 11, 1919 orders arrived to scatter the small American group to the four winds. Robert Drane was assigned to the 17th Division and I was assigned to the 4th Division B. E. F. Of course, at this time we did not know the units to which we were to go. From Boulogne we went by train to Etaples and St. Pol on July 12. At the end of the rail at Savy, we were met by a British Colonel and a Scotch Lieutenant who took us to tea and treated us royally. Robert was assigned to the Field Ambulance 52 and I was assigned to Field Ambulance 11. When we reached our respective stations, we found that we were within a stone's throw of each other in the badly battered city of Arras. My conunanding offi­ cer was Lt. Col. David Ahern, a stout Irishman, of whom more will be heard later. There were two Australian Captains, Harvey and Ryan, and an Irishman, Captain Bridge. An Englishman was represented in this particular group in the person of Lto Laing. All had seen field service and were very helpful in instructing one as to his anticipated duties. The post at Arras was the rear element of the 4th Division from the medical standpoint (Main Dressing Station) and my early reactions were quite favorable to the immediate associations. The Colonel, the second day after my arrival took me to the headquarters of the 4th Division to meet the Conunanding General Lamson, who immediately rose to his feet and saluted me, saying "I greet the American Army!" That his spirit was more than skin deep was borne out by his order to the Division Band to play the American national anthem as I left his office. The occasional air fight that could be viewed from the second story of the billet where we had our mess, the periodic explosion of heavy 141 artillery fire in the city when the Germans fired on strategic points, kept one alert to the activities of the respective·armies. The con­ trast of the peace of poppy decked fields a few miles back of the line and the wreckage of the villages as well as the city, left no doubt as to the seriousness of the situation. The church parade was of particu­ lar interest to me in that on occasion when new recruits came in, Colonel Ahern sat with his adjutant to interview the men. When an individual indicated that he had no church of preference, the Colonel would say, "Give him all three!" which meant that the new arrival would be sent to the Church of England, the Catholic, and the Protestant (nonconformist) ceremonies. When this became voiced about, there were few who did not have a preference of church. The 10th Field Ambulance had its mess at Blangy, a village east of Arras. In their shelling the Germans hit the mess, killing one servant and wounding several of the men, so that relief was sought from the 11th Field Ambulance. I was assigned to duty in the Advanced Dressing Station of the 10th Field Ambulance at Feuchy. Here one of my asso­ ciates was Captain Boldero, of whom I was to learn much in the post­ World War period. The experiences here with more activity in the shell­ ing and in the treatment of the wounded was entirely revealing. On return to the 11th Field Ambulance, I was early assigned to the Advanced Dressing Station of the 11th Field Ambulance at Fampoux, which was in the lock house and a stable along the Scarpe River. The Scarpe, a canalized river, was used for evacuation by motor canal boat at night to the rear. The lock house along this canal or Scarpe River was 142 occupied only in the basement by the medical officers. My associate here was Captain Jock Campbell who entertained me in his monotone singing of Scotch balladso "Kind, kind and gentle is she; kind is my Mary" was one of his favorites but always off tune! The wounded were treated in the dressing post in the basement of the stable which was adjacent to the lock house. Dr. O.: What did this immediate treatment consist of primarily? Dr. M.: Practically only the simplest of dressings. We did not have transfusion or infusion facilities. Medication and dressings were practically all we had. We occasionally applied temporary splints. First aid was as much as we could give at that level. The patients were evacuated as I have indicated by canal at night, because this canalized stream was under direct observation of the German balloons. The treatment of a definitive order began at the Casualty Clearing Station in the British line of evacuation. The tour of duty at Fampoux lock was exceedingly interesting in an entirely different detail. One detachment of bearers across the stream apparently had come under the observation of the Germans and a 5.9 shell landing among them killed not only the patient upon the stretcher but the bearers, so that this was one of the first casualties that I witnessed at first sight. An amusing but serious incident was that of a Scottish soldier who had had a wound which had amputated the distal inch or two of the penis. When he asked me whether he would be all right again, I said, "Naturally, you are going to get well!" He said, "Doctor, you know just what I mean." 143 An eviscerated patient whom I kept over night in the dressing station, was still alive in the morningo Having replaced his viscera and applied the sterile dressing with nothing else to be afforded him except relief by morphine, he was evacuated. I always regretted that I could not follow his subsequent course. That he could have survived, of course, was in serious doubt. While we were in reserve in training, when the 4th Division was pulled out of the line, I was, of course, a mounted officero This was an interesting circumstance. With the British at that time, the Regimental medical officer had a batman, a servant who was one Private First Class Adams, the dirtiest soldier that I have ever known, and a groom for his horseo It would appear that these two men were superfluous insofar as striking strength was concerned; but in the event of combat or engagement, these two individuals who were armed, were called into a separate detach­ ment for tre divisional activityo My horse was named Sammy. I was never an expert ridero I never knew horses really; but Sammy had a very bad habit. Coming to a jump, he would stop almost stalk still and then make his effort. I had learned this idiosyncrasy and I was getting along reasonably well when Colonel Ahern observed the unusual behavior of Sammy and said, "Yank, let me take a turn." He was an expert rider. So he mounted Sammy and took off at a gallopo When he came to the obstacle Sammy did exactly the same thing. The difference in timing and inertia was something that Colonel Ahern had not taken into account; so he pitched over his head. 144 Whereupon I went into uproarious laughter and the Colonel said, "You know it's no damn fun!", which quieted me on the moment. He was a very interesting character. A devout Catholic, he had no end of jokes, earthy and otherwise; but if there were ever a woman's name or character drawn into a story, he would withdraw from the group immediately and have no part of it. The 4th Division was then on the Arras front which was relatively quiet as you will have gathered and only trench warfare with night raids for identification of troops or feeling out the enemy involvedo We realized when we were pulled out for training that there was something more serious aheado Names of trenches and of areas became commonplace to us with our close contacts in the line. The Triple Arch, the Chin Strap, Johnson Lane and other names, Deadhorse Corner and things of that type. Apparently the Germans continued to feel out the British as the British were feel­ ing out the Germans. The withdrawal for training, however, gave us an excellent opportunity to study the terrain and to give a better account­ ing of the effectiveness of gunfire and of our projections. When I returned to Blangy, the headquarters of the 10th Field Ambulance, I found Colonel Lewis in conmand and James Brash, a Captain who had had a very excellent record on the Somme and had been decorated with the Military Cross. He proved to be Professor of Anatomy at Edinburgh. The various other members of the staff were very congenial, although they realized I was simply a relief officer. Returning to Fampoux for 145 a further tour of duty, this time with the 10th Field Ambulance, I was rather more at ease in moving about in the trenches in the forward areao Our training period was out of Berles-au-Bois. We made the most of the freedom of open country to move and to ride at will. The interest­ ing circumstance of the attitude of the civilian population came out in several respects. On one occasion there was obviously an able-bodied individual, a Frenchman, who was not in complete military uniform though certain of the articles of his dress indicated that he had beeno The natives would whisper to you as he passed by, "Ambusquer," that he really was a slacker in a sense. We found that he was working very hard in the harvest field. Then he came into our mess the day before he left our community in full French Army uniform and all the decorations that could be carriedo He had just come home to help with the harvest and was reporting back to duty; but the French were very apt to be quite criticaL An injury to our Commanding General in September lost to the 4th Division one of the most respected soldiers in the area. General Lamson was thrown from his horse when he stepped into a shell hole. September 13 I was assigned to the 1st Battalion of the Rifle Brigade as relief to Captain Paschall, who was to go on leave. This Brigade was one of the select Army groups before World War I and they affected a peculiar short, jerky marching step. They were the only battalion permitted to trail arms on the march. Certain of these distinctive marks of the British regiments were carried over into their shoulder patches, of which they were extremely proud. The duty with this battalion then was my first 146 direct attachment to a line organization. The training continued. I had occasion to visit with Americans who were attached to other regi­ ments of the 4th Division, Davis, a urologist, particularly. One of the interesting circumstances was the open arrest of Captain Riley, a friend of mine, who had been charged with drunkenness. He wore the Military Cross and had been in the Northwest Mounted Police in civilian life for some time before the war. Interestingly, when we were out in the rest or taining, Captain Riley was under open arrest and he had requested me as his escort. Under the circumstances of open arrest, the individual could not leave quarters without an escort. I shall recall this circumstance at a later date. The detachment to a line battalion meant that my mail had some inter­ ruption and I regularly moved back to the 11th Field Ambulance to keep in contact. I realized that my detachment was not a temporary one; but that I would undoubtedly be permanently assigned to a battalion. We left our training area and I recall vividly a beautiful youngster in her late teens who came up to my horse and offered me, "Bon chance"-­ there was no romance I assure you. The British kept aloof in some respects from the French; but I judged it was largely a matter of igno­ rance of the language or their reticence in developing their contacts. With the Rifle Brigade we moved out of this training area to the north and realized when we passed through Doullens and St. Pol that we were going into the Ypres saliento This was a design on the part of the British to attack this area with the thought of freeing certain of the 147 channel portso The terrain was extremely flat. When trenches were dug beyond a few feet deep, they were flooded with water. Sandbags were largely the protective device. We were to go to the line in front of Poperinghe. We disembarked from our trains at Hopoutre, which I inter­ preted to be a British liberty with the French language. Poperinghe was a scene of great activity since the Australians had already engaged the Germans in the attempt to advance the salient. Farmland was still under cultivation, though we were not far behind the lines. We found the towns largely battered. Called to the A.D.M.S. at Headquarters in Proven for instruction and while waiting I went over to the 12th Casualty Clearing Station to see certain Americans and then to the 46th Casualty Clearing Station to see Major Harvey Cushing. With Lt. Horrax, of Boston, they formed a very distinguished operating team on head wounds. We were awaiting our assignment and the commanding officer of the Rifle Brigade brought all of us together and said, "Gentlemen, I have to inform you that you have the honor of leading the advance when we go over the top tomorrow." The Captain, who was seated alongside of me, said, ''Honor, hell!" An interesting circumstance, however, related to my relief from the Rifle Brigade the night before the battalion was to go over the topo Colonel Paschall returned from leave and took over the burdens that would have attended the advance. As a group of young officers, we had gone back to Poperinghe for dinner the day before. Of the eight officers who participated in this repast, five of them were casualties, either wounded or death in the attack. 148 The drum gunfire that preceded the advance was very impressiveo A rise and fall in the din as hundreds of guns were firing continuouslyo The advance was made against great odds. The 4th Division went over the top on October 4o By that time I had been assigned to a "walking wounded" post for the reception of lesser casualties. In one day there were some seven individuals who had through and through wounds of the neck and yet came walking to my post. From this position, I was assigned to the 46th Casualty Clearing Station at Mendringham and then came in close contact with Major Cushing and his team. The prisoners of war from the attack of the 4th amounted to 4500 and my assignment to the German ward gave me the opportunity to practice some of my meager German and some propagandao The Germans were always impressed by the fact that there were American officers present in the line at that time. I recall a single instance of a shrapnel wound. Now shrapnel, in the technical use of the term, refers to a round pellet enclosed in a thin shell case. These pellets are perhaps a centimeter and a half in diameter and are very much less devastating in their wound effect, ballistically speaking, than the modern high explosive shell fragmento At the present time, of course, the shell has a heavy explo­ sive inside with a very heavy shell casing which fragments into very irregular pieces which are very much more lacerating and traumatico The interchanges with Harvey Cushing are related in the Remembrancer and I shall not recount them hereo I was impressed by his lack of con­ sideration of his team; but his technique was superb and was attracting • 149 wide attentiono I reflected that he might at least have some thought of his fellows. Dr. Oo: Don't you think he really was a bit of a conceited ass? Dr. M.: Yeso I think soo I have had occasion to refer to that here, but this one trivial detail is very interestingo On one occasion we happened to be discussing some circumstance and I referred to the syndromeo He came over and said, ''Well, Bill, you are the only other educated man in Europe," which was rather expansive from my standpoint. On the 16th of October, leaving the German subdivision of the 46th Casualty Clearing Station, I rejoined the 11th Field Ambulance in Poperinghe. We then moved back by train to Arras, retracing the steps that brought us there. I was sent forward to select the billets for the 11th Field Ambulance in Arras. When I reported to Colonel Ahern, I indicated that I had found splendid billets for all the officers and he said, "Captain, what have you done for the men?" Of course, it gave me a lesson that I have never forgotten since that time. You take care of the enlisted men first. I had good quarters for the men. The training continued here. We lived in Nissen huts in the village of Tilloy in front of Arraso Then I was sent again to relieve Captain Paschall with the 1st Battalion Rifle Brigade, again expecting that this would be a permanent assignment since I had been brought back to the 11th Field Ambulance rather unexpectedlyo Walking in the open at times when the trenches were pretty muddy or water logged, was always a ... 150 temptation but with some risk. I soon learned of the difference between a near and a far miss of shellfire. One did not ordinarily take the risk of walking in the open but a near miss was warning enough. Dr. O.: May I interject one question here? It was in August of 1917 which was around this time that we are talking about now, that you apparently addressed a letter to Colonel Ireland inquiring as to what sort of observations one could make as an American medical officer assigned to the British. I gather he wrote back essentially that you don't say a word, keep your mouth shut! Dr. M.: This is a very important matter. After a period of time with a combat outfit, an individual who is on detached duty is naturally going to wonder just what utilization is going to be made, how far his inquiries should go, and just how he should transmit the cogent informa­ tion he may have to his own Army, since you are with a foreign group. The fact remains that Colonel Ireland indicated to me in his response that I was to do just that. Use my eyes, but be very careful about my conn:nunication and to keep my mouth shut. The question of rank; I had said Captain, but I was still a Lieutenant then. The return to the line was in November. Activities about Arras then included the preparation for an attack toward Cambrai. This attack went quite well; but the use of tanks was in the judgment of most of us premature as many of them were casualties of the advance and did not exert enough weight to carry the front. On November the 25th, after some exposure to gas, word came that Captain Harvey had been seriously 151 wounded and died this noono Interestingly, he was a very fastidious Australian. He had gone forward to see some patient at a field artillery post and heard the shell coming and instead of falling, he bent over and got the full charge through his buttocks that killed him. I was then attached to the 1st Battalion, King's Own Royal Lancaster Regiment at Achicourt. Colonel Summerville was in command and indicated that my attachment was temporary, which, of course, was always received with some reservation. My first recollection of this particular assign­ ment was the divisional bestowal of the Victoria Cross on Private Halton. When I saw Private Halton and congratulated him, I said, "Just how did this all happen? I know you were decorated for valor in the salient, but how did it come about?" He said, ''My matey and I were in a shell hole and they got himo I was so mad that I got up with some Mills bombs and blew up one pillbox. When I got back to the shell hole, my matey was still dead; so I got some more Mills bombs and I went out and blew up another." The day after this tremendous ceremonial of the bestowal of the Victoria Cross with the entire division drawn up for the parade, I met Private Halton on KPo He had just over-celebrated! [End of Side II, Reel 4] [Side I, Reel 5] November 12, 1968 Dr. Mo: The King's OWn assignment found very convivial associations. Colonel Cunningham was a splendid soldier, whose philosophy of war as a Regular officer interested me greatly. In one serious conversation, 152 he asked me, "Just why has America come into the war? If you had stayed out, we, of course, would have been beaten; but we would have just regrouped and when we were in shape again, we would have come back and would have beaten the Germans." I told him the basis; but he said, "I don't believe that you can get enough fire power on the Continent to win the decision. You simply protract the waro 11 I respected him because he was a very stout and thoughtful soldiero Interestingly, he was a pianist of some accomplishment as our quiet hours in periods of reserve or rest would indicate. The most impressive officer of the entire group was Lto Colo John Kennington, a very serious and competent soldier, who had come from Lincolnshire and who was to have a tremen­ dous impact on my entire life, not only while in service but thereaftero John would walk fearlessly in the open. He gave me some very trying moments, as I accompanied him on some of our tours of inspection. To give a single incident as typical--the German had gotten our range and was pounding our trenches very heavily. We had only an elephant iron over the post in which John and I were sitting in a reserve trench. They were coming a little close for comfort and I said, "I have had it, Johno I am going down in the dugout," which had about a 20-foot covero After a half hour of heavy bombardment, I came up and John was still looking over the London Illustrated News just as casually as if nothing had happenedo He was a devout Christian and I think that he had the Presbyterian philosophy which translated into the Tonnny's vernacular, "If a shell has your name and regimental number on it, it will go around a corner to get you." He was decorated with the Distinguished iiiiiiiia. 153 Service Cross and had the Military Cross as well. I think that he was the stoutest soldier that I have ever known. The occasion of line duty involved a number of circumstances and inci­ dences that occur to you just casually. My Aid Post Sergeant was Sergeant Stanley. He was an up county man (Yorkshire) and a very stout individual, for whom I got the Military Cross because of some very conspicuous bravery. I never knew him to be fearful. Corporal Barnes was a Cockney Englishmano He was an unpaid Lance Corporal--a nominal rank given to men in the British Army who were under­ paid to begin with; but this meant that he got the title and the respect and nothing more. There were very few nights that he didn't cry from the dugout where he had been posted, "Gas, gas!" Sergeant Stanley would have to quiet himo One instance of a raid that the King's Own made-­ Wilkinson, a very stout Sergeant came into the dugout after this raid, dragging a dead German. I asked him why he had brought the Boche in and he said, "In coming back through the wire he must have tripped and as he stumbled along I thought he was trying to get away and jabbed the bayonet into him." Well, he had jabbed the bayonet into the back and whether he got the kidney or the aorta, he was a dead German when I saw him. This very stout Sergeant whom I had observed for months came on sick call when he next got out of the lineo He was complaining about his hearto His heart at rest had a rate of 130 or 140. I would run him 25 stationary steps and it would drop down to 80. He was com­ pletely shaken and it dated entirely to this episode when he had inad­ vertently killed the German, without any intent I am sure. 154 The strafing of the lines by the German planes who would come swooping down with their machine guns blazing, of course not particularly effec­ tive, but from a psychological standpoint, adequately. I was in about eight gas attackso These attacks were of varying orders, but I never really got a heavy gassing because of the protection of the mask. The morale of the troops in the line was quite variedo I recall one instance of a "stand to" at 4 o'clock in the morningo They would give the men a bit of grog before they stood muster at alert. They would man the parapets, you see, and be prepared at a given hour. The rum, of course, bucked some of them up and some of them got the rations that was supposed to go to several. On one occasion a sergeant who had received extra rum rations, tried to climb the parapet to attack the Germans single-handed. I caught him by the coattail and dragged him back into the trencho The incident of Private Conneally is quite vivid. I had assured myself that the German barrage was on the line of trench a hundred yards in advance of us; but as I turned a corner in the trench, I ran headlong into Private Conneally who was on sanitary detail, in charge of the forward latrineso I asked him why he was running along this wayo He said, "Sir, in case of gunfire, distance is better than cover!" Trench foot began to give us considerable trouble. The British had a technique we might well have copied had we been so inclined in later wars. They had details that afforded at given stations in the trenches a change of socks after the men had rubbed their feet well with oil in 155 which there was some mild counterirritant. I cannot tell you the counterirritant. In any event, we had much less trench foot injury than the Americans had frost or cold injury in World War II. The morale of the British troops, as I have indicated, was quite goodo They were obviously fed up with the war that continued so long and particularly stalemated where they might anticipate very little movement, very little advance. Where you have war of movement, it is always better tolerated by troops whether they are moving forward or backward. This is a cir­ cumstance that we learned very earlyo Good Friday, 1918 found the 1st Battalion King's Own Lancaster Regiment in reserve before Arras, on the north of the river Scarpe, with the elevation going to Monchy le Prieux to the southeast, and Vimy Ridge to the northeast. We (King's Own) were shortly the front line after the third wave of the German advance overwhelmed the Essex and other regiments in front of uso My post in reserve was behind a railroad bank in a shack, rather fragile. I felt steadily that I was being pressed and that I might have to find other cover. I had gone out to meet a party of walking wounded, and addressed one of the sergeants whom I knew quite well in the Regiment. He had been wounded once and he said that this was about enough when a shell burst about twenty yards away. So that I gave orders to my squad at the post to move forward. This was not an act of bravery, but our line was beyond the railroad track and I wanted to keep in contact with the Battalion. Making contact, we had to clear the wounded of the remnants of the battalions that had been badly shattered. In this movement I was going over rather 156 elevated lands where I could watch the advance of the German line to our south on the other side of the river Scarpe. I could also see the inroads that machine gunfire was making, as the ranks would break in their advance. Speaking of the warfare, of course, I have indicated that gas was a potent weapon and shellfire was one of their most effective offenses. Of course, we did not have a great deal of bomb­ ing from the air. At this time it was just developing. Machine gun fire was depended upon a great dealo There was one element that had been used in the Battle of Arras that we had occasion to remember. Dead Horse Corner, just behind Monchy le Prieux had piled up horses that had been killed in the last cavalry attack of the British that had occurred about two years before in the Battle of Arraso They called it Dead Horse Corner because of the accumulation. As we estab­ lished contact and had consolidated the line, the King's Own held firm and with Scottish regiments to our right, the Germans were contained and did not break througho The design of this attack of Good Friday and Easter in 1918, was to take Amiens, a rail center in France that controlled considerable terraino Two things happened when we were heavily engaged in this particular battleo The first was that the 10th Field Ambulance had cleared out when we were obviously in a compromised position and in chance of being captured. They left everything behind. Of course, being a field soldier at that time, I told my aid post men to take anything they found and could useo When things stabilized in a few days, one of their captains came back and said, ''Middleton, what happened to all 157 the things we left here?" I said, "You'll have to hunt them for yourselves because I think my men have been using them." In the height of this battle, when things were really very hot, a runner came into my aid post--dugout--breathless and totally fatigued. He handed me a chit from the divisional surgeon. It read, "Your vaccination returns are not available. Kindly expedite the same!" It was the least thing--a man had risked his life to come through! Expedition was on different termso Just at this time came my recall to the American Expeditionary Forceso I can say with all candor, even these 51 years removed, that it was with sincere regret that I parted company from a British combat battalion with which I was associated. You will appreciate my attitude when you realize the ·circumstances under which we had lived, the intimacy, the knowledge that it was a close team. For the first time in World War I, I felt that I was really contributing to the war effort. It's very much like the situation that exists in sportso A man can be on the sidelines, or a spectator, and have a feeling that the closer he gets to the heat of the action, the more involved he is, and emotionally the more a part of the affair. My transfer to the Americans was then determined by Dr. Yates' commit­ ment to Robert Drane and myself that when there was a place for us with the American Expeditionary Forces that he would see that we had orders for recall. By this time I had been given my Captaincy. When we came to Dijon, we found that there had been set up in the Central 158 Medical Laboratories facilities for research in chest surgery. The team was John Lawrence Yates, then a major, Major James Gwathmey in anesthesia, Robert Drane in X ray and Miss Barnard, nurse, Miss Fitz­ gerald, anesthetist and nurse. My particular function was in internal medicineo We had as immediate neighbors in this laboratory Drs. Walter B. Cannon and Hans Zinsser. They were obviously most convivial and they requested that Drane and I, who had the most comfortable billet-­ I would say two rooms, one room for sleeping and the other for living-­ form a breakfast mess. I'm going into this in a little detail because I think that it has a very charming background. The very nature of the individuals involved, the two young medical officers who were really interested bystanders and a rather dramatic interchange among three outstanding characters. John Lawrence Yates was a very stimulating, scintillating individual, not too stable so far as ability to carry through on a given patterno I cite this circumstance because it came to pass that I would have to set up the schedule for what was to be done in the laboratory or what we were to do so far as other contacts were concerned. Dro Cannon was the soul of compassion, gentility, who never thought of a vulgar incident except the associations that he had found in Dijon, and who wrote this very charming book that you will recall, The Way of An Investigatoro It's almost impossible to conceive that this gentle soul, born in Prairie du Chien and early educated in Milwaukee, through his own abilities, one of the outstanding physiolo­ gists in the country, stooping as low as to have given that couplet I mentioned to the breakfast mess. When he heard the burst of applause, 159 I think it quite overwhelmed him. Bad company I call it! Dr. Hans Zinsser, a charming individual, the most artistic of all scientists whom I have ever known. Dr. O.: You describe him in your notes in one of your diaries as brilliant and temperamental and that he and Cannon are like two chil- dren. Dr. M.: Yes. I mean to say the play between the two of them is almost unbelievable in two adults. I think that Hans Zinsser, as I have pictured him, coming up this gravel walk from the gate to the mess at Madame Chabrat's with the weight of the world on his shoulders one day, you know, as things had gone against us in the field. Then the next day singing at the top of his lungs, "It was Christmas Night in the Harem!" "Sing that again, Hans. I've never heard that before." Well, it was an interplay that I shall never forget and I shall never regret. Dr. Cannon was always interested in what you were doing. "Bill, when you go back to Madison what will be the most serious problem that you encounter?" I said, "The differentiation between 'effort syndrome', you know, neurocircu,latory asthenia and hyperthyroidism." "Oh," he said, "that's going to be resolved out of hand. I think that you'll find that they'll be using basal metabolism determinations when you get home." "Have you ever taken a piece of paper and rolled it up like this, Bill, and looked at an object? And what are the optics that are involved in the change that that gives you? Why do you lather your face?" Well, he said, "Of course, you say it softens your beard; but .. 160 doesn't it show you where you have been when you shave?" The most trivial things to which he would direct your attention that you've been doing all your life, not stopping to think that there's something behind it. I have made note in the Remembrancer of another detail. Of course, we were so close that we observed all the work that was going on. We knew what Dr. Cannon was doing; what Dr. Zinsser was doing. We knew what other members of the staff under Colonel Siler, whom Dr. Yates characterized as the ''whitest officer" in the American Army. Dr. O.: The whitest? Dr. M.: The ''whitest officer." He was really a very splendid charac­ ter. I recall that his assistant was a very fiery Colonel Foster. Colonel Foster and Jack Yates got into an argument that I thought was going to come to fisticuffs, so violent were their denunciations of each other. When Dr. Cannon was unable to give lectures at Langres which was a training point for the American medical officers, he asked me to substi­ tute. When he was preparing papers, as he did on occasion, I was flattered to be asked to check them from an editorial standpoint. I was thoroughly incompetent to criticize the Harvard physiologist; but nonetheless I did my best. The close relationship at Dijon has meant a great deal to me in intervening years. I think that the intimacy was most helpful. The study of thirst which was to be the subject of one of Dr. Cannon's lectures in England led him to ask Robert Drane and me 161 to move to the hospital, the only hospital in Dijon and to put rubber ground sheets around ourselves and to see how much weight we had lost in sweat in two hours time. All sorts of details of this order would be imposed on us. There was, of course, the need for dogs and it was the imagination of Dr. Cannon that manufactured a nonexistent epidemic of rabies among the dogs; but, in any event, it did bring us a full crop of animals. He wasn't above such subterfuge on occasion. The later period, before the break-up, I'll mention in greater detail, but Jack Yates was the brother-in-law of General John M. T. Finney---- Dr. o.: Oh my goodness, I didn't realize that. Dr. M.: ---- who was Chief Consultant in surgery for the American Expeditionary Forces. Dr. O.: I didn't realize he married a Finney. Dr. M.: They married sisters. Dr. O.: I see. Dr. M.: The intimacy there--! shall have occasion to touch upon in another relation because it was to affect the entire picture. Dr. O.: May I ask, I realize that you were assigned to this laboratory of surgical research--Cannon being the chief, and Yates his---- Dr. M.: No, I mean to say that they were different groups. 162 Dr. O.: Well, this is what I was wondering. It's what I gathered from your diary, and yet they have been listed here which must be in error. It has "Lt. Walter C. Cannon, Chief" and Yates is second in comm.and in the Laboratory of Surgical Research. Dr. M.: Yes, well I think that that is perfectly correct, that Dr. Cannon was in charge of Shock, and Dr. Yates in charge of the chest surgery. Dr. o.: I see. Dr. M.: They were only related, I should say, if you were to draw the table of organization in parallel because Dr. Cannon never had any comm.and over Yates. Insofar as Dr. Yates was concerned, he was as much interested in what these other men were doing and what he was supposed to do so that was part of my charge--to see that Jack stayed in line! The progress then was material. We had a life in Dijon which was greatly enriched by this association I mentioned. Another circumstance that was a little bit out of the ordinary. They had a Mess uptown that was patronized irregularly by American medical officers in which the French, British, and any other Allies who happened to be there. They had an orchestra that was led by a sergeant--second violin--the first violin was Spaulding, the American artist, and they had a pianist and a violist. This sergeant, the second violin, dominated all of them regardless of rank and he would stop them right in the middle of a selection. They would start all over again at his order--perfectly delightful man--of course, superb artistry. There was not enough of it, but at least it 163 gave us a diversion. We had visitors at the First General Medical Laboratory. One of Robert Drane's intimates was John Walker Moore who became quite famous in the post-World War I period as the Dean of the Medical School at Louisvilleo "Farmer" Moore was a very interest­ ing character--there are many stories I can tell of him, but one of the amusing ones was relative to the effort of Robert Drane to see that he got off to the right starto He bought the most expensive Burgundy wines for him. Finally he decided that maybe "Farmer" didn't realize what he was getting; so he bought him pinard (vin ordinaire) and he said, "Robert, why didn't you buy me this to begin with? This is the best wine I've had yet!" Dr. O.: Was this the table wine of the area? Dro M.: Yes, that's right. A sparkling Burgundy. The Special Surgical Team with which we were associated then had the composition that I mentioned to begin with and we were called into activity and line duty with the advance in the Aisne-Marne affair. And this meant that we were attached to field hospitals with our complete complement for the express duty that I have cited. We moved with the divisions. As they were relieved our team would be taken over by other divisionso We first went with the 26th Division from New England and then went with the 42nd Division--the Rainbow Division--the 4th 164 Division, and in this movement, of course, had the experience of a tremendous volume of casualties. Dro O.: You were there as a shock team, is that correct? Dr. M.: When they had no shock team, I functioned as a shock officer in all of these units. Each time we would move, I would take over the shock functions---- Dro O.: But you were also involved in the pulmonary study and in the pulmonary surgery. Dr. M.: Yes, in other words, the judgment as to the availability of surgery, and this I'm glad you bring up because Jack Yates had no sense of the statistical significance of surgery. We'd have a man admitted in grave shock and he would say, "How's he coming?" I said, ''He's not ready." Again we'd see him together; "What do you think now?" I said, ''He's better, more stable, pressure's holding up under transfusion or infusiono" "What is his chance?" "Well," I said, "I don't think it's even." "Well, does he have 1 in 10?" "Oh yes, he has 1 in 10." "Does he have 2 in 10?" "Well, perhaps." He said, "If there's a chance and he is not gaining ground, we'll take him." In other words, he was very, very conscious of the physiologic component of the subject and always looked back to this element in projecting_the availability of surgery but never as a protective device. If there were a better chance for his getting well with the surgery, he would take that chanceo He was, not so far as hands were concerned, an adept surgeon; but he did have 165 the feeling of the patient and his prospect of survival with or without surgery as one of his first targets. He was intellectually honest. One of the interesting circumstances was, of course, the anesthesia. I was responsible for the shock, preoperative and postoperative care of these seriously wounded patients and I indicated that the chest surgical patients were ones that were diverted to this team. I never saw a man who was more clumsy--less adept--with dogs than Jim Gwathmey. Yet when he had a human subject, he was most skillful. I don't know what there was about ito I can't conceive of the mortality he had with dogs that did not find some reflection in the humano Yet he was most skillful in manipulating anesthesia in his patient by the use of pres­ sure bags for keeping the oxygen at a level that he wanted and other details. This man so skillful and attuned to the human economy could do nothing with dogs. Robert Drane did the X ray work. There are scores of episodes that come to mind too. ''My Home on the Field of Honor," was the chateau that apparently had been used as a hunting lodge in the peaceful times; but it was the headquarters for the 168th Field Hospital of the 42nd Division. And I say there are a number of episodes, but one that will amuse you greatly I know, Major Goodman was in charge of ~he instruments, and Fred Rankin was detailed to meet a convoy of woundedo When he could not locate the instruments, he was told that these were in charge of Major Goodmano When he went to Major Goodman's room in the chateau, the door was locked and he told his mission. Major Goodman said that he had gone to bed and couldn't be disturbedo Whereupon Freddie said, 166 "Bring the instruments out or I'll break the damned door down and take them!" Another incident refers to a personal exchange with a seriously wounded Alabaman. The Alabama Regiment of the 42nd Division had already gained an enviable reputation by an exchange that occurred on their first appearance in the trenches. The Germans had a large sign over the top of their trenches saying, "Welcome 168th Regiment to the front." The next morning in front of the Alabama trenches was a sign, "Pray to God for your soul; the Alabams got your ass!" (Laughter) This particular soldier required transfusion. Lacking walking wounded or gas subjects for donors, it was found that my blood matched his and I gave a unit for self-transfusion. The next morning, the word had leakedo The soldier was in much better condition, and I asked him how he felt, he said he felt fine; but he asked, "Captain, what is this I hear about your giving your blood to me?" I tried to pass it off casually and finally said, ''Well, it was the only blood that was avail­ able; so I gave it." He said, "Sir, I want you to bleed me right away. I don't want any damn Yankee blood in me!" So, regionalism prevailed! The movement on the Aisne-Marne front was active. From time to time I did necropsies on the dead soldiers--American or German--and had an oppor­ tunity to view the local scene since an epidemic of dysentery was abroado It is an important observation that, although we had many patients with dysentery, there was little typhoid--a circumstance that I have directed to the attention of epidemiologists since typhoid vaccination had been under fireo The circumstance on the Marne was that of rapid movement 167 with little attention to sanitation. The only spread that we had for our bread, was molasses. It was a common contest between the plate and the mouth with the flies that had recently left the latrine or the dead soldiers or animals, and the ingestion of foodo Undoubtedly this is the explanation for the occurrence of the dysentery, and the vaccination, in my judgment, the explanation for the lack of typhoid fever in our troops. The movement that next involved us was the Saint Mihiel drive, a wonderfully executed---- Dro Oo: All this time now you're still just sort of allocated from the Central Medical Laboratory. Dr. M.: We went back, yes, that's right. And the policy was to return us to Dijon between offensives. On this occasion we had a short respite, but there was still the necessity for preparation and movement. We retained our billets in Dijon, but were on call for any offensive. Dr. O.: I would gather from reading through your diary that you actually were rather "delighted," I mean that you were not at all un­ happy at these assignments because there seems to be a fair amount of evidence that you were getting fairly "antsy" after your exposure to front line duty with the British that you were sitting around Dijon really almost depressed on occasion because you thought you were sit­ ting by while everybody else was seeing actiono 168 Dr. M.: I'm glad that you bring that up because at this particular period, after exposure on the Aisne-Marne front, I made overtures to Jack Yates to be moved to a combat unit; and if not to a combat unit, to be trained in aviationo An interesting result of one of these conferences was his comparison of the training of the medical officer and of an aviator. He said, "Just how much do you think you're going to waste if you go into the air and are bumped off, for your years of training experience in medicine?" So that reason even­ tually prevailed and I did not get back to a combat unit, nor was I detached for training in aviation. The Saint Mihiel drive was a well-conceived and executed attack that resulted in the obliteration of a salient that threatened the area of advance that had been gained by the Aisne-Marne offensiveo From the standpoint of the Chest Surgical Team to which I was attached, it was fraught with some frustrations in that Mobile Hospital 5 in command of Colonel Donald McCrea, of Council Bluffs, Iowa. A very proud organization in that they had had some experience in the level of evacuation handling at Coulommierso We were constantly confronted with this achievement. However, he bought no part of the plan that had been developed at the request of General Finney in the hands of Major Yates, namely, that our unit would work to the limit of its capacity but that there should be channeled all of the chest surgical patients. Without a meeting of the minds, this Special Chest Surgical Team was broken up. To me befell functions of a ward medical officer 169 plus the supervision of any chest surgical patients as might be assigned, plus shock work. So that I was at least busy. Dr. O.: You referred to him, as a matter of fact in your diary, as unreasoning and bombastic! Dr. M.: Unreasoning ahd bombastic is still qualified, I would say. I had only one occasion to bring him to tasko We were walking along a road nearby this post of Apremont, and there was a German bomber coming over the ridge. He dropped his three bombs and the colonel who was just ahead of us dropped into the ditcho We continued walking along the road and he said, ''Why, get out of there, don't you hear the bombs?" "Oh," we said, "Colonel, he's dropped his three eggs; he hasn't anymore." Whereupon in great chagrin, he got up and walked along with us. The band of the 26th Division came through our post and was invited to play. Thereupon the officers and nurses danced as it was a lull period. There was no offense meant and certainly there was no intent to neglect duties; but the Colonel came barging in and dismissed the band preemptorily. Then at the officers' call he said he would like to recall for us a story that he felt had some point here, to wit: the stallion that did not have its mind on the race! But in any event, we were happy to see the end of him. Meanwhile we---- Dr. O.: Was he any relation to J.M. T. Finney? 170 Dr. M.: None, none. Meanwhile, we were joined by two very interesting individuals, Major Verdi, from Yale, an outstanding surgeon and with all of the manual skill that Jack Yates lacked, and with a splendid personality to work into the team; and Marion Blankenhorn who was an internist of C. Ho Hoover's training. Blank had been with the British surgical team of Gask and who would naturally, in my own calculation, have filled the position that I occupied~ Thereupon I again made overtures to get active field service only to be denied by Jack Yates on the same grounds that he had outlined before. Marion Blankenhorn fitted in extremely well; never intruded on my particular prerogatives and viewed the functions and the position of the internist much in the same light as I had operated in the pasto He stayed with us through most of the succeeding Meuse-Argonne offen­ sive when he was recalled to the headquarters to serve under Swift. Dr. O.: Homer Swift? Dr. M.: Homer Swift. Meqtion of Homer Swift recalls another circum­ stance of our transfusion experience. On a visit to our unit, in his duty as consultant, I pointed out to him that I had repeatedly given blood for transfusion and he took me aside and said, "No heroics, Middleton!", which put me again properly where I belonged. The Meuse-Argonne offensive was a dogged, grisly affair in that we were fighting over terrain that was very difficult, against odds that were tremendous, and elements that were beginning to take their effect 171 in the early winter of 1918. The German forces were giving ground very reluctantly and taking advantage of every opening to exact the toll of our advancing troops. The tenacity of the command, the definite objective with an end in view meant that the cost was not discounted but at least was kept within bounds of reason so far as reserves were concerned. The weight of American arms undoubtedly was swinging the balance and on other fronts the Germans, in repeated efforts to break through and divert the American effort, were unsuc­ cessfulo Reports were coming in of the British and French successes to our north and this gave added heart to the troopso The armistice came on the eleventh of November after a false alarm on the eighth and ninth of November. I recall this clearly because I was at the checkpoint in front of Montfancon when the French troops in a camion, singing hilariously, came along the road and were stopped by the American guard who told them to put out the lights, and they said, "Finis la guerre, finis la guerre!" The American sentry said, "Finis, hell!" Put out the lights or I'll blow them out!" The jubilation on the conclusion of hostilities was perfectly natural; but perhaps the most vivid recollection I have of that day was the appearance of lights, fires lit by the soldiers at many points over the countryside, and lights on the automobiles and in the houses. Strange that this circumstance should impress you after all of the period of darkness. The unit was in Cheppy at the time and I was one of the group sent back to get some of the contraband liquor that might be available. Nancy was the nearest large city; and when we brought 172 back the champagne and other drinks, I was a very popular man. Popular, I might say, only insofar as I could deliver. Then when I was through, they had other objectives. We returned to Paris on the 19th of November and from that time on it was a matter of effort to establish cause and reason for the return to the United States. Naturally, my University connections made matters much more simple than would have been the case otherwise. Visits to Paris, attendance on the Opera Comique with Perry Pepper to see Louise, Samson and Delilah, the opera, will give some idea of the change of front. It was a period of jubilation on a very somber basis in the main, but renewal of acquaintances, extension of social contacts. We had the serious project of attempting to establish some method of eval­ uation of the results of the surgery that had been performed by Yates and Verdi. The interchange with the authorities, the conferences with General Finney, are a matter of record in the Remembrancer and I shall not enlarge upon the same. [End Side I, Reel 5] [Side II, Reel 5] Dr. M.: Naturally in this period there was concern as to my future in Wisconsin. There had been an interchange of correspondence with the Chief, Dr. Evans, in which he had expressed his clear design on my services. I had had no response to my letters to Dean Bardeen. The letter from Bob Van Valzah indicating that English Eyster was being iiiiiiit. 173 forwarded as a clinician was disturbing because in spite of my high respect for Dro Eyster's brilliance, I realized that he was not a clinician and could not, without further training, take an important place in the development of our clinical division. Obviously, at this time my attitude was ambivalent and I could have been swayed to move elsewhere, had there been such an opening. My position otherwise was very definitely leaning toward a resumption of my professional activ­ ities at Wisconsin. On the evening of December 25, orders came to return to the United States--a wonderful Christmas present! The attitude of the Executive Officer in his unwillingness to route me through Paris where all of my belongings had been deposited, was resented and I took that route not­ withstanding the objection of the commando I protected my flank, how­ ever, by leaving the train in Paris through the railroad yards and not presenting myself to the military police at the normal exit. The dinner for Wisconsin men at the University Union, found a number of old friends and it was a splendid reunion. On December 26--follow­ ing day--I continued, after collecting my belongings, to Angers. This was merely a point in transit and several of the Dijon group had pre­ ceeded me there--Drs. Cannon, Aub, Cattell, and Robinson; Robert Drane and Jack Yates came later. One of the vivid recollections of the period was the seeing in of the New Year. Jack Yates and Dean Lewis got on opposite sides of the table consuming liquor between them and indulged in profanity that would have done credit to cab drivers. 174 From Angers we were routed to Bordeaux (Camp Gerricourt). This was not a prearranged route; but it did afford the opportunity to visit Base Hospital 22 at Beau Desert where the Wisconsin group from Milwaukee, in the main, was stationed. Among the group there was Maude Webster, in whom I was naturally most interested. The first visit to this unit and call on Miss Stella Matthews, the chief nurse, apprised me of Maude's leave of absence. At that time she and Miss Merseth were on the Riviera. A peculiar circumstance, again over which I had no control, was the arrest of one of the other casual officers in our camp for the theft of some several hundred dollars. It appears that he had engaged in a crap game and had lost heavilyo He was tempted to take the wallet of a fellow officer and was seen to throw the wallet away in a latrine after he had taken the money from the same. The officer who witnessed this incident took another officer with him to recover the wallet, so that he would not be incriminated and then the original thief was taken into custody. When he was placed under open arrest, by chance he selected me as his escort which meant that I was kept in the camp for a period beyond that that I would ordinarily have been. Dr. Oo: That was the second time that you had been asked to do this. Dr. M.: Yes. Once with the British and once here at Gerricourt with the A.E.F. It was an interesting experience in that I had to explain by devious methods why I was held and then the opportunity to do Arthur Curtis, a former Wisconsin great in football and worldwide renown for 175 his work in gynecology, a favor by affording him my place when I was denied transportation at an earlier date. The return of Maude Webster to the Base Hospital 22 was the occasion of a happy reunion. We saw considerable of each other in Bordeaux and in the neighborhood about the Base Hospital. And then I was ordered to Marseilles for transpor­ tation to the United States. We shipped on the grey, tiny and uncom­ fortable Steamship Caserta, by way of Gibraltar where we stopped for coaling for two days. This gave me the opportunity to visit and enjoy the garrison town that is famous through history. Passage over the wintry Atlantic was rather uncomfortable and the monotony was broken by the ridiculous strictures placed by the senior officer and relieved only by the amusing gambling of the soldiers who at the rail would bet on the time and the order of the seasickness and vomiting of their fellows! (Laughter) Dr. O.: How to pass the time! Dr. M.: Righto Well, we were then at Camp Dix and ready for dischargeo My discharge, in this instance, was expedited by the request for my return to duty at the University of Wisconsin. Dr. O.: May I ask you some specific questions? Dr. M.: You got me through World War I. Dr. O.: I wanted to inquire whether or not Oswald Robertson who was with you at the Central Medical Labo was the Oswald Robertson of the refrigeration of blood fameo I assume he iso 176 Dr. M.: Yes, he was doing work on the blood there. Dr. O.: The storage of blood and preservation. Dr. M.: He was a very likable chap. Of course, I saw a great deal of Robbie, too, after he came to Chicago and at his retirement; but he was really a very excellent man in his own right then. Dr. O.: We have one of his publications on display now in an exhibit in the Library on the history of blood transfusion depicting his work on the refrigeration of blood and the addition of glucose during World War I. Much of his work was lost sight of really for many years until the Spanish Civil War. Dr. M.: He was one of Dr. Cannon's men. Joe Aub and Robbie were his right bowers. Dr. O.: I was very amused and delighted to see a statement you had in reference to Miss Barnard in which you say, and I quote, "a capable but incorrigible nurse as most Hopkins graduates; has no idea of func­ tion!" (Laughter) Since my mother's a Hopkins nurse I had to point this out! Dr. M.: Well, she wouldn't know Miss Barnard. Miss Barnard was engaged to the Professor of Surgery at Rochester. Dr. o.: Morton? Dr. M.: Morton. She married John Morton. 177 Dr. O.: For heaven's sakes, I've heard many people refer to "Dr. and Mrs. Morton" and---- Well, I'll be darned! Dr. M.: And the other amusing part--she could be very absentminded and she was embarrassed to get in the shower in Miss Fitzgerald's presence with her boots on! (Laughter) With her boots on, so we be­ deviled her to the end of tine. She was a very competent nurseo John Morton was a very capable man. Dr. O.: This may be, actually, a very personal question, I don't mean to pry, but I was rather interested--you made reference to some­ one in your diary by the name of Grace. Dr. M.: Oh, Gratia Furman, now this is one of these absent details. I never knew her, really. She was a very beautiful girl in Norristown and I never met her. It was just from afar, I admired her. I think I was quite infatuated with the girl. Dr. O.: We had mentioned, not on tape, but off tape you had told me, and there is a note in your diary during this period of the death of Billy Mitchell's younger brother---- Dr. M.: Yes, that's Johnny Mitchell. Dr. O.: ----Johnny Mitchell who was, of course, from Milwaukee. Dr. M.: Yes, and Johnny had been a center on the football team--a very light center. Of course, I was team physician, and he was a very 178 close personal friend. We had dinner together at Neufchateau. I think I told you the other evening that within a week after we had dinner, I saw that he had come down in flames. And, as you say, there's a picture of his grave. Dr. O.: There is a picture of his grave that you had apparently taken. I was aware from both an interview I had last year with J. Mo T. Finney, Jro--John Finney--that he and John Paul worked as medical students there in the Central Medical Laboratoryo I would assume, or I had assumed for some reason, that they were probably there for quite some time; but ac­ cording to your diary they arrived on May 3 and left May 25th, and headed right back to the States. Well, very candidly, was this something they were able to do because John Finney was John Finney or were students really assigned for just a month at a time? Dr. M.: No, they were not ordinarily. They ordinarily went right through and they, I think, had come with the unit. Dro O.: The Hopkins unit? Dro Mo: The Hopkins unit; Base Hospital 18. They were at Bouzoilles sur Meuse; General Finney referred to it as "balls on the moose!" And then assigned to us and from there went home. Dro O.: I see. Well, they had been there a period of time, I suppose, working as aides and orderlieso Well, that makes sense, but I was just so surprised that it was such a short stay at Dijon; I couldn't envi­ sion that that was their full stay overseas. 179 Dro M.: There was an Inter Allied group that was addressed by a series of speakers. The American Red Cross developed these conferences as a medium of communication for the medical officers of any of the services. I know that I attended meetings where Shock was concernedo I attended one meeting that I related to the students just recently-­ Professor Babinski spoke to us, and he said, "Gentlemen, my test is minimal, selective, plantar stimulation," and every time I see them drawing blood I think of his mild statement. Dro Oo: The only person I don't believe you did mention was Captain J. M. Steiner. Dr. M.: Yes. Joseph Steiner was a roentgenologist from the Roosevelt unit. He was with us for only a short period of time and did not go into the field with us. He was assigned to the Dijon laboratory for a short period. A very able roentgenologist. Dr. o.: I was quite interested to see, and I was wondering if you were familiar with the group formed by Yates, Verdi, and others with J.M. T. Finney as honorary head of same, as well as others who were involved in front line operations at one time or another in the first World War. The group was called ''The Ee lat Club." Dr. M.: That is very interesting because the Eclat Club was formed from those who had been in the service in World War I and I know that Jack Yates asked me whether I wanted to be considered and I said, "No, I think it's entirely surgeons." 180 Dr. O.: Well, I was just going to say, you were certainly a natural because you worked very closely with several of these people. Dr. M.: Yes. Well, there was the proposal; but it was a personal and private one and not an invitation from the Club itself. It was no such group from the medical side that I knew of. I have charac­ terized Dr. Finney in my Remembrancer. Dr. O.: Yes, yes, you have very nicely in your Remembrancer. I sense from some of the things you have in your diary--this may be a rather large question to take on right before lunch, we may want to put it off until after, but I'm wondering if you could expand on what you felt the basic problems were between the Regular Army Medical Corps and the Consultants as evidenced between such people as Keller and his run-in with Finney. Also I noticed that you had correspondence with Dr. Finney after the war in which the two of you discussed the need for demilitarization in the Medical Corps. I assume that has bearings on the matter. Dro M.: Oh my, that's for after luncho I would rather have lunch first. [Luncheon break] Dr. M.: The relationship of the civilian practitioner or the reserve medical officer to the regular army establishment in World War I was an occasion for serious concern on the part of the former. While it was recognized by all concerned that the enlistment and participation 181 of the reserve officers in combat were necessary in any national emergency, the lack of due consideration for the utilization and advancement of such personnel was equally conspicuous. This circum­ stance was manifest in many directions, not the least of which was the detachment of the consultant group from the command and from their innnediate supervisoro To bring this detail into sharper focus, the specialists or consultants who had international positions at this period--1917 to 19--were stationed at Neufchateau. Early, Colonel William Keller was likewise at this post; but with the movement of the command to Tours, a matter of a number of miles with insecure trans­ portation, the actual rapport between the regular officers in direct responsibility and the consultant group was most tenuous. The support given by the reserve officers taken freshly out of civilian practice was generally acknowledged and at the conclusion of hostilities when General Jo M. T. Finney, Chief Consultant in Surgery, was leaving the Theater, he stopped to pay his respects to Colonel Keller who was the Director of Professional Serviceso Check that title if you will please. In any event, Colonel Keller took occasion to thank General Finney in such terms as, "It has indeed been a privilege to work with you and to observe your contribution to the welfare of the sick and wounded soldiers in the American Expeditionary Forceso 11 Whereupon General Finney responded, "I wish that I might say the same for my relation­ ships with you, Colonel Kellero There has never been an occasion or a situation, in which you could have augmented our effort when you have not obstructed and I cannot say that it has been a privilege to work with you." 182 This conversation was related to me by General Finney with the state­ ment that his realization of my interest in medical history led him to put his reaction on record in the hope that I might relate it if the occasion arose. In general, this interchange represented the position of the reserve officer at the conclusion of World War I. In most instances, the efforts at recruitment of such men who had seen service and who had experienced frustrating incidents with the officers of the regular complement, were met by such disaffection that there could not be anticipated a material participation in reserve affairs after World War I. Fortunately, this position underwent material change in the interval between World War I and World War II by reason of a recon­ structed pattern on the part of the Regular Army Medical Department in the attention to training and educational opportunities for their components. Dr. O.: Was this a "condemnation" of primarily the military structure over concern with rank of the Regular Army medical man or was this also combined with a sincere feeling that he was not as competent a medical man as the reservist or the civilian coming into military service? Dr. M.: I think that in the main it was a protective attitude, perhaps engendered from an inferiority complex. But the fact remained that there was no studied effort to develop a close rapport with the reserve officer. Indeed, at the conclusion of World War I a number of us gave serious consideration to the abolition of rank in the Medical Depart­ ment of the Army. Most of us realized that our function was primarily 183 medical. In whatever capacity we served, our duties were not essen­ tially military and we were respected for our adherence to the highest ideals of medicine and for the medical services that we were capable of rendering and not in any sense to be judged on the basis of our military competence. As a matter of fact, many of us had had absolutely no military training nor yet had any experience in the fundamentals of military formations and military formalities. This circumstance may, out of hand, seem, in a sense, contradictory, if, by the same token, the sharp distinction that has been traditional between the line and the medical department has not led to serious question as to the ultimate wisdom of rank among elements in the armed forces that do not have actual command responsibilityo This argument has gone around the table frequently in the pasto It is interesting that it has largely passed into the discard in recent years, so that rank still obtains and there has been no intimation that it will be lost to the Medical Departments of the Armed Forces. [Pause] Dr. M.: World War II found this nation in a better physical and psycho­ logical mood than World War I, largely by reason of the gearing of our economy and thinking to the Lend Lease Program that unquestionably gave us a head start when war was declared. At this period of preparation, Surgeon General James Magee requested that I take the responsibility of forming a Base Hospital Unit to become the 44th General Hospital from the staff of the University of Wisconsin Medical School. Previously, 184 I had been active in support of the 135th Medical Regiment of the 32nd Division, so that there was a definite period of preparedness before the actual declaration of war. To 44th General Hospital staff­ ing, Dr. Frank L. Weston was named as Chief of Medicine, Dr. Joseph W. Gale, Chief of Surgery, and Miss Ida Bechtold, Chief of the Nursing Service, on the recommendation of Drs. Weston and Gale. The situation was such that I declined leadership of this unit for the express reason that I hoped to return to the University of Wisconsin and I did not believe that a commanding officer of a general hospital would find favor in this responsible position after the conclusion of hostilities. I did not confide my volunteered service to the faculty; but when the announcement of the constitution of the 44th General Hospital was made public, Dr. Weston indicated that I had already been recruited for active duty. In this particular decision, obviously the family respon­ sibilities were taken under careful advisement and Maude agreed com­ pletely to my decision, realizing that I had no choice in the matter so far as conscience was concerned. Actually, we had gone through a period of intrauniversity evaluation, in which we were confronted with the establishment of essentiality. It was rather a revealing experience in that essentiality.appeared to be a state of mind and not of actual need or availability. This disillusionment was not unexpected, but a little bit trying in times when the nation's actual existence was under fire. In this direction, in other words within our own household, there was complete agreement that my services were much more required in the national defense than in the teaching and administrative 185 assignments of the University. When departure was scheduled, the President convened a meeting of the medical faculty and with glowing terms that I did not appreciate, gave me a watch as the gift of the Regents. I have always considered it a very kind gesture; but I was not quite sure, at the time, whether it was an effort to ease my way or simply a passport to an easement of conscienceo My assignment was to the Lawson General Hospital at Chamblee, Georgia, just outside of Atlanta. General Sheep who always took one step to my three--most prodigious walker--was a splendid leader as Commanding Officero The Chief of Medicine was Colonel Cooley, a rather sensitive and repressed individual who nonetheless was a most adequate leader. In surgery, Colonel Sloat was Chief; in psychiatry, Colonel Ernest Parsons, and in orthopedics, Colonel Lowry. One or two elements of this particular relationship should now be brought into focus. Colonel Sloat was an orthopedist by training and apparently had come afoul of Colonel Kirk in their careers in the Regular Army service and the future was to prove whether or not grudges were heldo Colonel Parsons, a dynamic, driving individual, was to cross paths with me at later dates in our mutual assignments overseas. The early movement of Colonel Cooley left me as Chief of Medicine. I can frankly say that entering upon the new responsibilities with a clear slate and a splendid young staff, I greatly enjoyed the oppor­ tunity to further develop the already excellent service that had been initiated by Colonel Cooley. Our conferences were rich in discussion 186 and directiono The rounds were made regularly with the young staff men such as Tyler, Chamberlin, Bartlett, Logue. Henry John, more senior among the group, was named as Assistant Chief of Medicine. We alternated on rounds and I made weekly sanitary rounds to maintain the quality of the physical services of the several wards. This had a very competitive aspect and each ward was given a stated value for the week and one was declared the ''Ward of the Week" in turn as they excelledo The conferences were extended to include X ray where I found Albert Bowen, a classmate at Pennsylvania, in charge, then the clinical pathologic conferences, cardiologic conferences, etc. Period­ ically, there was an invitation to make rounds at the Grady Memorial Hospitalo This outlet broadened my interests and gave me renewed contact with Dro James Paullin, a wonderful host and a splendid internist. Dro O.: Did the service at that period make an attempt to let the Army's physicians get in for rounds and things at the surrounding civilian hospitals? Dr. Mo: I think it was entirely on a personal basis. Dro O.: And it was up to the base commander. Dro Mo: Yeso If it had not been for Jim Paullin. The invitation, of course, was from without and this was a personal detail. Early it became apparent that my military duties would interfere with my responsibilities as Secretary-Treasurer of the American Board of 187 This blank page is inserted to correct an error in pagination. 188 Internal Medicineo When I proffered my resignation, it was declined; but for the emergency, Dro William Ao Werrell, my assistant, was made the Acting Secretary-Treasurero During one of these visits off post, there was a conversation followed by a letter from Hugh Morgan, who was Chief Consultant in Medicine to the Surgeon Generalo Dro Oo: He had been Professor of Medicine at Vanderbilto Dro M.: Righto His inquiry was first as to my availability for foreign serviceo Assured on this point, he requested further infor­ mation as to my experience with the British: Did I have friends? Was my earlier service congenial? Did I feel that I could fit into a position that involved not only continued but constant interchange with the British? Obviously his direction of thinking was apparent. At a later date I learned that he had himself preferred this particu­ lar assignment and that I was his second choice! Only his indispensa­ bility to General Magee at that time and later to General Kirk led to his continued activities in Washington. When the word came down that I was to go on foreign duty, I was called to General Sheep's office. He asked me whether I had not manipulated this order in my absence from the post. I assured him that I had not; that this had been a movement from headquarters and that Colonel Hugh Morgan was the one who had recommended me to Surgeon General Magee for this strategic assignment. I was ordered forthwith to Indiantown Gap for indoctrina­ tion and at this time Dory, Mrso Middleton, met me in Harrisburg. We had occasion on orders to go to New York, to visit at Jeffersonville, 189 then some delay in the transportation--! returned to Jeffersonville to my folks' home and visited with the family and with Dory again. We were shipped on the Tindarius. In this movement there was an ominous detail of the fall of a crewman on an adjacent vessel to our docked ship from the riggings to the deck on his head--a crushing fall. But Tindarius took off and picked up a convoy off of Montauko Incidentally, all vessels in convoy moved just as rapidly as the slowest, so that we had a long and tedious voyage across the Atlantic. We landed at Belfast; but en route certain of the acquaintances were very close. Particularly would I refer to Colonel O. H. Stanley who was to be a warm associate over the period of our early service in the European Theater of Operations. Maine born, he was a most taciturn individual, and yet with a very keen sense of humor. The scattered personnel gave me small medical outlet since, as senior officer, Colonel Stanley had indicated that I was to hold sick call and to give all medical care. There was one young civilian, for whom administration of salvarsan for syphilis was part of routine duty. The personnel of varying ranks and services included some six or seven nurses of whom I was to see very little in our subsequent service. We landed in Belfast, had a very short turn around the city and then were sent to Stawraer, Scotland. From here by train we were carried to Cheltenham. The billet to which Colonel Stanley and I were assigned was the Ellenborough, where we were to live for approximately two years. 190 The activities at Cheltenham were at first rather stereotyped and under other circumstances might have been irksomeo However, all of us realized that the period of organization would take time. For a background with the support of Colonel James C. Kimbrough, Director of Professional Services, I set up a parallel to the table of organi­ zation of the consultants in World War I in the American Expeditionary Forces. Our headquarters were at Benhall Farm, a series of buildings constructed from tile for later use; one story and rambling, as a protective device against destruction to a larger structure by bombing. From the outset, I set about establishing close relationships with the British, Canadians, and Norwegianso Visits to London were directed toward my opposites in these several national groups with particular dependence on the British and Canadians. General Alexander H. Biggam was the Chief Consultant in Medicine for the British forces and I found him forthright, highly knowledgeable and most helpful in every detail of organizationo By the same token, I visited the several subdivisions of his office to establish rapport and to gain basic information as to their operational patternso In the Canadian forces I was most fortunate to find a kindred spirit in Colonel Lorne C. Montgomery. From his general physique and active person, one might have judged that he had been a rugger in his day, and such was the caseo My first encounter was an interestingly characteristic one. After we had had a most profitable exchange, in which I was largely the recipient, "Now, Middleton, before you go, I want to give you 191 one word of advice," he said, "Never let these British see you salute me or call me, sir. They will inmediately judge you as an nferior or a subordinate." And I said, "But Colonel Montgomery, 1 )U re a full colonel and I'm a lieutenant colonel." He said, ''That akes no difference, when the British are around you are my peer. all me Monty and do no saluting, and do not address me 'Sir'"• r. O.: Isn't that interesting. )r. M.: The Norwegians had no organized pattern; but the contact Nith their representatives proved a very significant one at a later date which I shall relate. The Conmanding Officer of the Conmunica­ tion Zone was Lt. Gen. John C.H. Lee, better known to the common ranks as John "Courthouse" Lee, a very exacting and demanding officer, religious, meticulous in his personal life and affairs, he was nonetheless a martinet insofar as his interchange with his subordinates was concerned. Many tales, apocryphal as well as actual, are told of him. He had a very intense, almost a fanatical, protective attitude toward the food or provisions that were afforded the troops. Maintain­ ing that they had been brought over at great cost and great effort, he insisted that they be utilized to the utmost advantage. Not infre­ quently he would go through the garbage pails to see how much was lost. And this is related, and I think undoubtedly true, that seeing a whole apple in the bottom of the garbage can, he would reach in, pick it up and wipe it off and say, "Here's one you wasted," and eat it himself and pass another to an accompanying officer. 192 I was at one of our station hospitals outside of Winchester when General Lee was coming on an inspection touro You can imagine that there had been a lot of preparation since it had been bruited abroad that he was about to arriveo When his Southern Base Section repre­ sentative, General Thrasher, edged up to me and said, "Colonel, where's all the garbage?" I said, ''That's for you to find," because in the bottom of the pail, in a hospital that had several hundred patients, there were only about two inches of garbageo I had seen the detail bury the rest of the garbage before the general arrived! On one occasion General Lee came through a hospital in Southwestern England (Barnstaple) that was not yet opened. A holding unit with a very junior captain in command was doing housekeeping only. The general arrived unannounced; but the captain had his wits about him and said, "General, it's just before noon, we're having our dinner meal at noono We have the best cook in the European Theater. I wish you would have food with uso We might have it before you go on your tour of inspectiono" "Oh, fine, fineo" The General said, "You know that this fried chicken is goodo" The captain pursued his advantage, "You haven't tasted our prize. The cook is one of the best bakers I've ever known." And they served the General his favorite dessert, apple pie with cheeseo As he whisked away from the table, he said, "Captain, the man who.can put a mess like this at a detached unit as you have, needs no inspectiono Good day!" (Laughter) I think the captain was a splendid psychologist! 193 The Chief Surgeon for the European Theater of Operations was Colonel Paul R. Hawley. I have characterized him in the Remembrancer; but just by way of passing, I would like to make a footnote if you please, and that relates to the basic character of the man. He was brilliant. He was a splendid organizer. Particularly strong in his ability to delegate authority; but having delegated authority, he insisted that with it went responsibility. He held the officer under his command to very strict responsibility for the discharge of the duties assigned. He was impulsive. He would come to judgment quickly and then regret at leisure. Those of us who were close to him--! served with him for over three years in very intimate and almost daily contact--knew that we could judge of his temper and his receptivity by his reaction. I would go to his Executive. The one with the longest period of service was Colonel Howard Doan--"Pete" Doan to most of us--and I would say, "Pete, what's the climate today?" He said, "Get the hell out of here; don't come near him." [End Side II, Reel 5] [Side I, Reel 6] On the reverse side of the picture appearing before the Executive, he would indicate that the Chief Surgeon was in a receptive mood and one might go ahead with any problem that presented itself. I cite this because if I found Colonel Hawley or later General Hawley in an irascible mood or if he were unreasonable in any statement, I would excuse myself and say, "Chief, I'll be back to see you when you're 194 in a receptive mood. There's no use of our discussing this now, because I do not think we'll come to a meeting of the minds and it will be a waste of your time." The attitude of the Chief toward his own branch of service--the Regular Army medical officer--was one of singular discrimination in the sense that he would not tolerate any lapse or delinquency on the part of such an officer. I'll take an example without mentioning names. A chief of a given service or, in this instance, a hospital commanding officer who was obviously ill, but who was not a particu­ larly effective administrator, who completely despised administrative duties and wished to get back to clinical responsibilities. When I would report, as I did in several instances, the sickness of such an individual, the innnediate answer was, "Bill, be sure of your grounds. If he's ill, I'll stand behind you completely; but don't for any reason defend him if he is not a sick man, because I will not tolerate it--a regular officer who is delinquent in his responsibilities." So this was an attitude that characterized his entire relationship with his own fellows of the Regular service. It was interesting because he would bend or sway a little bit when dealing with a reserve officer. Dr. O.: He would not take this firm view with a reservist. Dr. M.: No, no. He would have a little bit more leniency, be a little bit more willing to listen to reasons that made this man a better clinician than administrator. You could reason with him; but 195 if he were a Regular, no, he would have ~o part of it. And I'm turning to another one who was a clear alcoholic whom I had been asked to see and who had a very clear physical reason for transfer to the zone of the interior. I presented this patient in meticulous detail to the Chief. When I got through, he went over the same detailo "Bill, is this a medical transfer that you're recommending?" I said, "Yes, siro" "You're sure you're not protecting that damn drunk?" I said, "No, this is not the situation. I'm simply reporting a medi­ cal situation and I stand behind ito II The Chief, without exception, supported you. I'm going to bring this up in another relation insofar as our functions are concerned; but the complete and implicit confi­ dence of General Hawley made his team pull together, you see. It meant that he had no defectors, noneo The Chief of Professional Services was Colonel James C. Kimbrough, as I have indicated before, and this was an appointment of an individual who was never happy, I should say was unhappy away from his patients. He was the leading urologist in the Regular Army and you might have thought that Walter Reed was his personal property!--"at my hospital I have such and such patients and I have such and such assistants and I have such and such residents." He was universally respected for his skill in his specialty. He was a Tennesseean. He said he didn't put on shoes until he went to Hiwassee College. He was a graduate of the Vanderbilt University in medicine, a classmate of Hugh Morgan's, I think. But a characteristic of him--when the treatment of syphilis 196 was transferred from urology to the dermatology and syphilology section, he said, "You know, I never could trust Hugh Morgan. I knew he'd slip one over on me!" Jim really acted as though he had developed syphilis and gonorrhea, that they were his own particular preserve. He would get on the telephone when he didn't have any­ thing else to do and call up another Regular, "Oh, Charlie, that you, Charlie? Got any clap up there?" And then the nurses and the secre­ taries would start to scatter because they didn't know what he was going to ask next! (Laughter) I told the story in the Remembrancer how down to earth he was. He had great confidence in John Robinson who was Chief of Urology over at Headington, the 5th General Hospital of the Presbyterian affiliation from New York. There had been a series of patients who were discharged from this hospital on the basis of enuresis. When Jim came out to get into the car, he put his arm around John Robinson and said, "I don't want you to feel bad, John. I couldn't go with you all the way, you know; but it would be a pretty bad idea of the news got abroad that you could piss your way across the Atlantic!" (Laughter) Well, Jim was a character. He had to deal with a bunch of prima donnas and you realize that consultants in general are men of position who had their way in civilian life. This circumstance meant that Jim had to show unusual talents. He would first cajole them. Then he would quote Shakespeare and then the Scripture. Finally he'd burst out into the vilest profanity you have ever heard! He was priceless! I was very fond of Jim. He died of bronchiogenic carcinoma after the 197 war, and I saw him as a patient in Walter Reed Hospital. He was not fairly treated by the authorities in the European Theater. I blame some of my associates for plying him with liquor. On one occasion, we went to Taunton and they gave us two quarts of liquor--there were three of us; they gave Elliott Cutler one quart, Jim a quart and, of course, it was wasted on me; so that I didn't get any. On the way from Taunton to Bristol where the 298th General Hospital was stationed (Frenchay Park), Jim drank his entire quart of liquor. When he arrived there, he was quite high and it so happened that there had been a replacement of one of his friends, Colonel Kirksey, by one of the officers of the 298th as Commanding Officer of the unit. As guests, because we were stopping for dinner on the way back to Cheltenham, you'd thought that Jim would have had some reserve. Instead he started out with a most profane denunciation of any con­ nivance and any intrigue that would undermine his regular officer friend. There was not any reservation; but I blame Elliott Cutler for urging Jim to drink because he could have stopped ito I was riding in the front seat and Jim and Elliott were in the back seat. Liaison with the other Allied medical departments was imperative; but before this we had to resolve our local situation. Elliott Cutler arrived about six weeks after I had been in Cheltenham. With his tremendous dynamic force, he had set up the pattern of the cabinet of specialists that he wanted about him in the office of the Chief Surgeon in Cheltenhamo He had chosen his meno Other men had 198 been put into this organization. They were a strong group. I think that I have given you most of them. In neurosurgery he had Loyal Davis; in plastic surgery, James Barrett Brown; in ophthalmology he had Derrick T. Vail; in orthopedics, Rex Diveley; in otolaryngology, Norton Canfield; in anesthesia he had Ralph M. Tovell; in X-ray, Ken Allen [Kenneth D. A. Allen]. Then eventually he brought Robert C. Hardin into the area of blood procural. A very excellent group by all standards, I think. The changes in this group were rather serious. I had gone over the same potential requirements and come to the conclusion that only in two areas of medicine the work was so overwhelming in neuropsychiatry and in dermatology and syphilol­ ogy that it required full time supervision. To these posts there were appointed first, Lloyd Thompson in neuropsychiatry and then Donald Pillsbury in dermatology and syphilology. In other posts it was my concept that they could advise the principles in infec­ tious diseases, Yale Kneeland; in cardiology, Gordon Hain; in tuberculosis, Theodore L. Badger. Dr. o.: I have th~t chapter handy if you want it. Dr. M.: Right. No, that's it. They were obviously all in their own right strong men. They were to maintain their responsibility as Chief of the medical service of one of the large, thousand-bed hospitals, but they would have the theater responsibility for the decisions and determinations of policy regarding infectious diseases, cardiovascular diseases and tuberculosis. They rose to each of these 199 occasions when the problem presented itself. We had the close inter­ change with the Chief Surgeon and, as I have indicated elsewhere, brought our respective approaches to his attention, Elliott Cutler with his cabinet and my suggestion that we have only a minimal repre­ sentation in Headquarters or in the Chief Surgeon's office and that the others would be Theater consultants with the primary responsi­ bility in their own hospitals. Then they would move to increasing responsibilities, first, in the Base Sections and then as these were further broken down we had 15 Hospital Centers, each with a consultant. Seven of those were in the United Kingdom and eight on the Continent. The Base Sections in Britain were Southern, Eastern, Western, and North Ireland, and in France we had Normandy, Brittany, Oise and Delta Base Sections. There were five army surgeons and we attempted in this organizational pattern to have the flow from the Army to the Base Section and there broken down into the Hospital Centers. You could, in a period of minutes by telephone or otherwise, communicate to these several consultants and theoretically carry out any professional policy. One did not have to communicate through chains of military command which is extremely important. This was to prove a wise decision. Now, there is a diagram of that in the back of the history. It is not in the substance. Dr. O.: It's not in that chapter? Dr. M.: The Allied Medical Departments--the monthly meeting of the British consultants at Hyde Park Gate. Alexander Biggam, he was a a 200 Major General--Sir Alexander Biggam--a specialist in tropical diseases and very worldly-wise in this area, a recognized authority. He was called to the United States two times or more to advise in the matter of malaria control, for example. He was my opposite--he was Chief Consultant in Medicine for the British. He had his meetings in Hyde Park Gate. Munro was Elliott Cutler's opposite and then Sir Alexander Hood was in the position really of the Surgeon General in Washington with these consultants at that level, you see. Meeting with the Subconnnittee on Medicine in the War Office each month throughout the period of these three years led to a very intimate understanding. Of course, I could go into personnel of that group; but I shall not at this time. My chief towers of strength were Biggam, the Canadian representation, Montgomery, and, oh, to a lesser degree, men in neurology and psychiatry and so forth; but they would fit in more generally with the senior medical consultants, Thompson and Pillsbury, as I have indicated. Then another element of great importance in rapport among these allied medical departments was the Interallied Conference on War Medicine. It met monthly at the Royal Society of Medicine under Sir Henry Tidy. The legwork was done by Jeffrey Edwards who was secretary. It was a very, very profitable gathering. Problems of the several services were here discussed. The Interservices Consultants Conference was originally under the leadership of John A. Ryle. After he resigned, Sir Alun Rowlands, of the Navy, took it over. There is one highlight in the exchange with the Interallied Conference on War Medicine that 201 I'd like to mention. The human elements are obvious. To lighten the serious tone of this meeting, General Hawley was projecting our planned reception and care of the sick and wounded against futurity, you see. He said that he was rather interested in what they had said about the Royal Navy and their major contribution. He wouldn't minimize it in any sense; but if they were to take care of all the casualties that we would have to meet, they would do their dressings in Davey Jones' locker at the bottom of the sea! I never expected such an explosion. The British rose to their feet in supreme dignity and indicated that they did not feel that it behooved a recent ally to cast aspersions on the quality of service in the Senior Service. So far as this was concerned, they were quite certain that the Royal Navy gives a good accounting of itself regardless of the circumstances. Well, it's the first time in public I'd ever seen the Chief taken down. He was subdued and had to submerge himself in liquor that night. (Laughter) The importance of our briefing and evaluation of existing hospitals at an early date because they were very few was brought out latter­ ally, as we got increasing numbers. I would like to interpolate the personal word as to our mess in Cheltenham and how we lived in a period of two years when we were getting ready, and then go to the field if I may. The mess at the Ellenborough Hotel was a family hotel in peacetimes and I have visited it since the war. It's very quiet, very comfortable. -. 202 One had his own room without a private bath. My room overlooked the garden--small garden but always well kept even during war periods as a British garden would be. I was quite taken aback when we came to the Ellenborough that Colonel Stanley should insist that I be his tablemate. So that this very taciturn maniac--and that's spelled m-a-i-n-i-a-c---- Dro O.: Oh yeso (Laughter) Dr. M.: -----would go through a meal without any interchange of conversation. Then he's day, "Let's go for a walk, Bill." And we'd walk maybe for a half hour and then suddenly he'd chuckle, burst out in some very amusing little incident of the day or tell me about his family--wife and a son, his pride and joy in the Air Forceo But we might go for hour on end without a word between uso He was interested in music and Town Hall was about a long block or block and a half from the Ellenborough. We would go to any and all concerts thereo Sometimes they were quite good, so that we early said that we could stand for Parliament any time now; we'd been there so long. If I had free time on the weekend or Sunday, ,I would walk over the Cotswold Hills--! don't know whether you know the Cotswolds or not. They are a series of hills arranged to the west and south of Cheltenham; Cheltenham is down in the basin here about seven or eight miles from Gloucester and the Bristol Channelo Bristol--! was driving down there and decided that we would turn off and this driver--we had civilian women drivers, I'll come back to that in a moment--couldn't quite 203 understand why I wanted to turn off at this particular spot. I said, "You know ·that I am going into this churchyard." When I came out, she said, ''Why would you come down here to this churchyard?" I said, "Edward Jenner did his original vaccination here and I wished to see where he had been." She said, "You American people are the strangest people and go to the strangest places!" The British drivers were an interesting groupo They were women. Not infrequently their husbands were in service or they might be maiden ladieso They drove our staff cars. At the early period, we rode in the front seat with them and later they said that that was not too good, to ride in the back seat. One of the drivers, when I was riding in the front seat, said, "I don't know about these American officers; driving along, you don't know what's going to happen; they put their hand through your hair!" I said, "You're perfectly safe; you can drive on and your hair won't be disturbed!" (Laughter) But they were really a very wonderful group in many ways. I think of one who was a schoolteacher--a rather sharp-faced individual--and her name was Vicks and I couldn't resist the temptation of introducing her as '~iss Vick's Vaporub." One of the young officers acknowledged the introduction and said, "So good to meet you, Miss Vick's Vaporub," and she stomped out, "I knew someone was going to do that someday!" (Laughter) But I was thinking of the occasion when we were in East Anglia and returning to Cheltenham, we were obviously in trouble. (I happen to 204 have the net result of it here.) I saved this for you. [unwrapping a worn nut] The car started to wobble. I believe we were coming into Bedford. When we got out, this front wheel was obviously in trouble and they took the wheel off and found that it had sheared down to this point--see where it had broken there? And of course if it had happened in transit we'd have been in trouble; but that was one of my narrow escapes. We'd run out of gasoline, we were short and only the fire department saved us. They gave us gasoline to get home. The conditions under which these women would drive--amazing; how they ever accomplished their ends, I don't know. Miss D-a-l-z-e-1-1 and she said, "Don't call me Dalzeel because my name is Deal. I come from the Shetland Islands!" These women were an exceptional group and I am reminded that Derrick Vail I think was a little bit jealous of the willingness of these women drivers to take me over him, called me "Willie, the Wolfie"; I had nicknamed him "the evil old man." In any event, this was a pattern and of course saved manpower. When we had military drivers they were not always as careful nor as able as these women drivers. The Davis, proprietors, ran the Ellenborough. When I was transferred across the channel to France, I returned to Cheltenham and stayed there. I tried to pay for my overnight stay and I was a guest of the house. (Dory and I have been back there twice and again, no exchange of the coin of the realm!) So that there was a definite warmth that we all felt. 205 Research was not as actively pursued as the opportunity might have prevailed, had it been in other than wartime. I had named Ralph Muckenfuss as the Director of Research for the Theater and he was in our official family; but he was the Commanding Officer of the General Medical Laboratory at Salisbury. Ultimately, there was a design for interchange of medical officers between the line and combat units at rest and the hospitals that had available places for men to be moved in as they exchanged their young officers to the field. This did not take the officers of the hospitals--the General Hospitals--to combat position or responsibility; but it did give them a feel of troops that they could not otherwise get. By the same token, it enabled the men of the line to come back for refreshment and it was a very profitable exchange. Its influence was to make a centrifugal movement possible where centripetal action was the normal. It was very important from the standpoint of the Air Force. I had occasion to feel that the men in the dispensaries of the Air Force were perhaps the most neglected of all of the medical officers because they had only the acute casual illnesses and they transferred these sick patients to the hospitals. They soon got quite stale and disaffected. Dr. o.: That's true. This now is the Army Air Force? Dr. M.: That's right, the Army Air Force. So that arranging with Colonel--later General--Grove and Armstrong, we could move medical officers of the fixed hospitals into the Air Force of the Army and 206 the Air Force medical officers into the units of the hospitalo This worked very well up to a pointo Then we found a very disturbing situation that a number of the men from our general hospitals could not acconnnodate to the psychology of the Air Force. Thereafter it became a unilateral moveo We sent in the officers for a period of refreshment; we could not send the young medical officers from the hospitals. It was interestingo One of the most rewarding of our relationships within the Chief Surgeon's office was with Preventive Medicineo Colonel John Gordon of Harvard was the Chief of Preventive Medicineo Virtually daily interchanges occurred between him and me or some members of our staff, so that there was a ready connnunication from the clinical standpoint to preventive medicine, ''We are having an epidemic, some­ thing that looks like influenza, John; you'd better look into it and see whether it is or noto I have preached to the medical officers of the Theater that we have no influenza until certain conditions prevail and now they are beginning to appearo" So that he would come to me and say, that some of their men in preventive medicine in one or other unit thought they were encountering something that might be Weil's disease. I can tell you that I traced down Weil's disease in ten or twelve places and never could find an actual incident. My first official survey by way of water was to North Ireland. Among other things that I encountered there, was an epidemic of hepatitis and it proved to be largely serum hepatitiso The overwhelming hoards 207 of rats which existed there, just simply appalled me. When I came back, in my report, I had indicated that we had to think such things as rat bite fever and Weil's disease. When I said "plague", I got actiono They said, ''We'd better get after that threato" So that only a word may stimulate action under certain circumstances. This relationship with Preventive Medicine was to bring large dividends in my judgment because the first line of defense in military medicine is prevention and certainly the close liaison with preventive medicine paid off well. Dr. O.: Could I raise a question here, Dr. Middleton? One of the letters apparently that I came across in going through the correspon­ dence I noted down here. It was a letter from a Dr. John S. Hunt, January 30, 1948 to you in which he said, "cooperation between the medical consultants in preventive medical service was poor during the war, frequently contributed to by very petty jealousy and rivalry." Now is he speaking of a lower echelon------ Dr. M.: That couldn't have been in our theater. That was not in our theater. We had daily interchange, as I say, and at one period, John Gordon, requested a transfer to London. Within a period of weeks he decided to return. From the first, I considered that it was a poor move, because we did not have the door-to-door interchange that we had had before. No, this never applied to our Theater. I do not know John Hunt so I probably answered him as to what we had experienced. I think that in this letter to Tom Wayne, I have indicated the 208 experience of the European Theater quite vividly. There is no point to enlarge upon this except to quote directly from my answer to Colonel Tom Fo Wayne of December 11, 19500 Dr. Oo: Right. Fineo We have that in the record then so that people can make direct reference to it. Dro M.: The conferences of the Chiefs of the Medical Services was a device to bring a close interchange among men with mutual responsi­ bilities in the Theatero It gives you some idea of the magnitude of the growth or the tempo of growth in the Theatero On March 19-25, 1943, fourteen of sixteen Chiefs of Medical Service met in Cheltenham to discuss their problems and in the history you'll find this outline. July 30 there were 22; in 1944 there were two sections, a total of 70--one meeting, January 26 and the other, February 2. The Base Sections meeting on January 26 were Eastern, Western, Central and North Ireland, and the 2nd of February it was the large Southern Base which had had the greatest growth. The Allied Consultants Club was actually largely an English-speaking group that met for social purposeso The functional consultant was rather clearly defined in the history, not only a matter of policy insofar as disease is concerned. The admin­ istrative details are centered about a Chief Consultant in Medicine to the Chief Surgeon of the Theater and the interchanges occur among the elements of the Chief Surgeon's office. He has a very personal interest in the actual patient care. When we had as few as 16 hospitals in this period of 1942-43--up to July '43--it meant that I could go to each hospital once a month. 209 Dr. O.: You made medical rounds. Dr. M.: I made medical rounds each time I went into a hospital and that was with my stethoscope and not with the white gloves and towelo So that I knew what medicine was doing. By the same token, it gave me an unexcelled opportunity to evaluate the medical officers. You will recall that one of the functions of the Chief Consultant, when it was possible, was to brief and to interview every medical officer who came into the Theatero I would visit the unit as they were bedding down, and we would go over the personnel of the medical department--their background, their training, their interests and so forth--and try to get almost a snapshot evaluation of the man. Much more valuable was the opportunity to see that man at work on his ward; to go over his patients with him. The period in which we grew so tremendously was in 1944. I will come back to that in a moment. By the 2nd of February, 1944 we had a total of 70 hospitals, and now in 1944 there came into the Theater 108 1,000 bed general hospitals, four station hospitals from the Zone of the Interior, the United States; four general hospitals and two station hospitals from the Mediterranean. So there were 112 general and 13 station hospitals. Fifty-eight of these hospitals were without ade­ quate chiefs of medicine. So you see, what had been building up during this period was an evaluation of the pool of available chiefs. I want to recur to that detail in one memento Ultimately, there were in the Theater 259,725 beds and 183,550 were in fixed hospitalso Actually we 210 had in Britain almost 140,000 beds set up before D-day. This was, of course, a tremendously massive medical operation for which General Hawley was ultimately responsible. In this grace period of virtually two years, from 1942 to 1944, we had had all the opportunity to bed down and to get these units into as smooth operation with personnel as fairly distributed as possible. When we first went around among our hospitals, we encountered an intense loyalty to the affiliated unit--"Oh no, I don't want to move. Don't move me whatever you do, Colonel. This is my unit and I want to stay with it." These men eventually realized that with a transfer they could anticipate a pro­ motion. They might go home as a Lieutenant Colonel rather than as a Captain or a Major. In the year 1944 we had to find 58 new chiefs of medicine for these inadequately manned hospitals. We could do it without serious faulting the manning of a given hospital because we knew where strength lay, largely in the affiliated units. I went to Colonel Max Keeler, commanding the 5th General which was a Harvard affiliated unit at Odstock just outside Salisburyo I had to step over two Irish bird dogs to get to his desk. I said, "Max, I've come to tell you I'm going to select five of your Chiefs of Sections and make them Chiefs of Medicine in recently arrived hospitals." And he said, "Bill, you can't do that. You're breaking up the best unit in the European Theater." I said, ''Max, I want you to listen to reason now. I'm sick or wounded. Must I come all the way through the chain of corrmand--channels of communication--to get to the best hospital?" He said, "I want to aska favor, Bill" I want to see the Chief before 211 you make your recommendation." I said, "Well, I'm going to stop at two other hospitals and deliver some other messages on my way to Cheltenham, so that you'll have ample time." As soon as I got into Benhall Farm in Cheltenham, I was called by the Chief, "Old Gravel Throat." "Bill, what in the hell are you doing breaking up that best unit down at Odstock?" So I told him exactly what I had told Max Keeler. I said, "I'm no more anxious to break up that unit than you are, Chief; but someone has to take the responsibility for seeing that care is given in a distribution that will insure the earliest atten­ tion to the sick and wounded. No one under the sun can justify the hunting out of one isolated unit that happens to be overstaffed. Now I can take five men out of the 5th General and I can assure you that you will still have a strong Harvard unit." Of course, I won the day and these men got their promotions and the soldiers got better care because they had the leadership of these outstanding medical offi­ cers who were transferred. Another detail in this large experience of thousands of medical officers--- I picked out five men who were going to go to the top. All except one of those men have, in the intervening years, come through and it has been a very interesting---- Dr. O.: When you say "go to the top," becoming full professors some­ where eventually postwar? Dr. M.: That's right. Full professors and outstanding men----- Dr. O.: These were people you had picked when they were in their captain level in the Army? 212 Dr. M.: Captain or lieutenant. Another situation----- Dr. O.: Would you feel free to mention who they were? You don't have to mention the one who didn't but the ones who did. Dr. M.: Oh well, you take Sam Asper, Jack Myers, Richard Ebert, Gutzer, and John Brown, those are the five. Dr. O.: Now, Ebert is the chap who's now at Yale? Dr. M.: Professor of Medicine at Minnesota. Dr. O.: Sam Asper I know. He was one of my teachers. Dr. M.: Oh, was he? Dr. O.: Yes, at Hopkins. Dr. M.: Oh, Sam was a great one. He's president-elect of the American College of Physicians. He's a wonderful chap. He was in Wisconsin attending the Regional meeting of the American College of Physicians at Oshkosh recently and he said some things that I think were a bit exaggerated. But the other situation I wanted to relate to you was the men that I have mentioned were men of promise and capability. It didn't take any magic to determine that they were going to go places. The impor­ tant detail was that men who at that early period denied emphatically any prospect of availability, would come to you privately and say, 213 ''Well now it looks as though I might stay a major. I know I can't go above that rank in this unit; so if you have another opportunity open----" Hence this was not a rending of ties that was not in the interest of these men, and it brought tremendous dividends to the serviceo The regularity with which these recommendations were honored, is a further measure of the confidence of the Chief in his consultants. I say without any reservation that there was never a single recommendation for the movement of personnel that I made that was not respected. When you give to the consultant this range of first authority, though he has no command authority and then hold him to responsibility, I think that you have wielded a very strong arm and certainly have given him a position that is enviableo He didn't wish to be called the Director or the Chief or anything; he was just a consultant: in that respect he was honored as though he had line authority. In the matter of the continuity of interests----you see I had been a battalion medical officer in World War I. I had known what it was to be detached. I have a confession to make that I have cited in some other place. To be sureo I hadn't slipped all the way because I knew that I was not able to follow patient after patient with severe constitutional manifestations--high fever, running pulse, perhaps some signs in the chest or abdomen and I would send him from my aid post in the line and I wouldn't know a thing that happened. So that--you'll be amused. I had never been a great lover of Dickens and '~he Tale of Two Cities" was the only book of his I ever thought 214 was very exciting; but I got ''Martin Chuzzlewit" to read in the trenches. I knew that my power of concentration hadn't gone com­ pletely---- When such recollections cc:>me to you, your sympathy is with the man on the line or the man in the detached position. This was the occasion for the interchange that I recommended that had been effective in the Army, but in the Air Force became unilateral. Now in the development of the follow-up card, I had this particular design in mind. The interested medical officer, wherever he was placed, could have his name on the front of the card for return mailing and on the back would be a brief record of what had happened to a patient whose name was given and what the ultimate disposition had been. It needed only a few words and a little human interest in the welfare, first of the patient and then the medical officer. Dr. Oo: Was this well-utilized by the line men? Dr. Mo: It was, I would say, in varying degrees dependent upon the divisional surgeon or the medical officer himself; but it was used materially so that it had some impact. I had another device that would sound unusual in a strategic positiono I had accessibility to the weekly reports of disease and casualties, deaths. Whenever there was a preventable disease, I kept a summary of the recordo I went to the laboratory--! should sar sent to the General Medical Laboratory, Salisbury--for sections of tissues (you saw some of those that had been submitted) and I used this as a 215 device to check on whether there was some preventable disease or preventable death that could be accounted for. [End Side I, Reel 6] [Side II, Reel 6] Dr. M.: This device unquestionably paid material dividends. In the majority of instances the involved medical officers were grateful for the manifestation of interest at Headquarters. Occasional pique was expressed; but in general this was not material. Dro O.: Pique in the sense that they thought you were checking on their diagnosis? Dr. M.: Right. In any event, the knowledge that there was interest at higher echelons, gave substance to the efforts of the medical officers in the Theater at large to check on or improve their approach. From an education standpoint, there were studied efforts made in several directions in the Theater. The Eighth Air Force Provisional Field Service School was established at High Wycombe and members of the Chief Surgeon's staff were invited to participate in its program. The opportunity to meet with the officers of this element of the Army, at that time, were very rewarding and, again, it became evident that the officers in this branch of medical service were in serious need of refreshing clinical exposures. The Army Medical Field Service School at Shrivenham Barracks was a counterpart of the Eighth Air Force Provisional Field Service School. Similar functions were served 216 and the opportunity to meet with the nurses as well as the medical officers was an important element in consolidating the effort. The , Army Medical Field Service School was transferred to Etampes, France in the Spring 1945. After the cessation of hostilities, it was obvious that there would be a considerable span of time in which medical inactivity would attend the military lull. Accordingly, a plan of professional reha­ bilitation was recommendedo With the cooperation of a very represen­ tative segment of the profession in Great Britain, stated exposures were scheduled for the refreshment of our medical officers before return to the United States. With very few exceptions, this plan failed with the redeployment of the troops and officer personnel for Pacific service. Nevertheless, it had all of the prospect of the most successful venture. The action of the American Board of Internal Medicine in authorizing overseas examinations by Captain William J. Mccann, USN, and myself--afforded an unusual opportunity to the affected officers. This particular offering was availed of by 113 candidates with four reexaminations in the European Theater of Opera­ tions. Seventy-three of these candidates passed--65 percent; 41 failed--35 percento In the subspecialties, there were very few represented--one failed a special examination in cardiovascular disease and one passed. One passed the subspecialty examination in pulmonary diseaseso This device which was implemented by the par­ ticipation of a number of volunteer guest examiners with the 217 designated special examiners of the Board, therefore gave to the Medical officers in the European Theater for which I speak, oppor­ tunity to keep abreast of professional advance with the distinct feeling that they were not prejudiced in this direction by reason of military serviceo Unfortunately, the significance of certification was overlooked in the sense that the military establishment gave credit to this particular recognition when the American Board of Internal Medicine had been on record that neither hospital appoint­ ment nor professional advancement should depend on this criterion aloneo Dr. O.: That's an interesting point. You say that they, the armed services really put more weight on whether a man had his Boards or not early on, and the Boards had to point out that----- Dr. M.: No, I mean to say that that is a matter of permanent recordo That from their establishment, the American Board of Internal Medicine and the American Board of Surgery said that it should never be used for hospital appointment or emolumento See what I'm driving at? Dr. O.: Yes. Right. Dr. M.: Here it was that it should never have been used as sucho As a matter of fact, I have a conscience in the matter because I in­ sisted that Yale Kneeland never take the Board examinations since I wanted to point out that the Senior Consultant in Infectious Diseases was not a Board Certified man! 218 Dr. O.: I'll be darned. So that nobody could point and say, "see it's only 'the club,' 'the fraternity' that has these positions!" Dr. M.: The matter of drug supply was one that affected the profes­ sional services directly. The consultants were called not only in formulating the tables of basic allowance of drugs for the invasion of Africa, but also for the Operation Overlord. In the latter respect, it is a matter of personal interest that I had recommended ten times the basic allowance of diphtheria antitoxin before the invasion. When the weekly reports were coming in at the Chief Surgeon's consultants' meetings, I was regularly twitted because there was no evidence of diphtheria on the Continento I held my peace because I had inside information that as soon as the American had contact with the prisoners of war or with the civilian population, there was enough diphtheria on the Continent so that any requirement that had been predicted in my recommendation was met by the available antitoxin. Another interesting drug that came into sharp relief was quinine. Quinine was obviously a drug with specific indications. When malaria became a transported problem on the return of troops from North Africa to the European Theater, all measures had to be taken to protect its limited supply. Accordingly, none was permitted to be used in conditions other than malaria--an obvious answero The introduction of antimicrobial agents was a product of World War II. Historically, Alexander Fleming had discovered penicillin in 1928 and his first paper was published in 1929. When the Oxford group, 219 under Howard Florey, was exploring the area of lytic agents, they encountered a drug that had been neglected, in the form of penicillin. With his group, Florey actively pursued this line of approach and penicillin became a very important element as one of the significant antimicrobial substances. A reception for the American medical officers of the immediate area of Oxford took me to the University as a representative of General Hawley. There I met Howard Florey who invited me to come to his laboratory--the Dunn Memorial Laboratory at Oxford. On my return to Cheltenham, I consulted General Hawley who acquiesced in this arrangement. On the 24th of October, 1942, I availed myself of Professor Florey's invitation and was interested in his reaction. He had been most optimistic in the reaction of the Americans to his suggestion that they investigate his line of approach further. After a year's time he was disappointed to have had only three products from America, none of them of potency comparable to his own penicillin. He nevertheless took me through the laboratory. I was amazed. The room was not more than twice this size and he had earthen flasks in which he was growing the mold on shelves around its walls. This, in effect, was the total source of penicillin in October 1942. Nevertheless, after he had expressed his dismay at the lack of effective American contribution up to that time, he pledged two-thirds of the total product of this laboratory, and the instruc­ tion of our personnel by teams, and incidentally, Rudy Schillinger at the 2nd General Hospital at Headington just out of Oxford, headed the first team. Two-thirds of his product, plus instruction at the 220 hands of his wife, for American forces. This was Lend-Lease in reverse. Of course it saved many American lives among the wounded crewmen of the Flying Fortresses of that period. Dr. Oo: It wasn't too long after that, was it, that we started our commercial production of penicillin? Dr. M.: Well, it came when A. N. Richards took the helm and got industry behind production. Of course, some of the basic work was done here at the University of Wisconsin. What I am driving at is that there was a lapse of a year in which he got only three ineffective products from American sources. I have always felt a deep debt of gratitude to Florey--gone now too--~e~ause of his magnanimity even in presence of this disquieting lack of full support until A. N. Richards got at the wheel and put this country into production. The Eighth Air Force was the beneficiary of this particular decision because they were doing high level daylight bombing and it was the Flying Fortresses that were having the casualties, as I have stated. Dr. o.: They were shot up pretty badly. Dr. M.: The question of our preparations I have indicated the magni­ tude of the hospitalization preparedness for invasion. The preparation of the sites in certain instances, ground was prepared and the concrete laid for the floors of the buildings or for the mounting of tents if they were to be tented, before they got in and tore up all the ground and found themselves in the muddy morass before they realized ito The 221 matter of the facilities of these newer units that the British built interested me. They still persisted in the Nissen hut or the long pavilion-type which had its virtues; but they were heated by round stoves fed with soft coal from on top which was open on feeding. Of course, we had the heavy smudge that bellowed forth. The corridors were rarely covered or if covered, rarely with siding that protected movement in inclement weather between or among the units. There was always a lack of adequate facilities for bathing and for toilets; so that there were certain inherent deficits in these units that we took over from the British. In the better ones among them, there was obviously the preparation on the part of the British for their utili­ zation under the National Health Act, should it go into effect, which it did, as you know, immediately after the war. The question of the movement of troops I have already indicated to you that the evacuation of certain catagories of disabilities to the Zone of the Interior was subject to periodic question. I know that Johnny Robinson and I had to go to certain of these areas to be sure that their movement was in keeping with the troop requirement of the situation. This became very trying, as you know, when the Ardennes attack came in the winter of '44 and the Bulge that resulted from the last thrust of the Germans. At that time, you may remember that General Bradley who was responsible for the disposition of troops in front of the Ardennes Forest, said that this was a calculated risk, but it might prove to be the undoing of the Germans because he has exhausted his reserve. It proved to be eminently true. 222 As we then went overseas the Overlord Operation--the invasion of France--we had all of this background of preparation. We'd had two years to get ready. We had everything by way of equipment, personnel, and back-up from a medical standpoint in Great Britain. Some of the strength and weaknesses I have indicated. The night of June 5 had been disturbed by the steady hum of planes overhead, and the invasion was announced by radio on June 6--enormous scale--but definition was lacking at the timeo In the period immediately preceding the invasion, my time had largely been occupied in assuring the preparation of the receiving hospitals on the British line of evacuation and the Chief Surgeon and Elliott Cutler had gone to the port of debarkation. Unquestionably, the preparation for this invasion had involved every possible protection to meet any exigency. Singularly, after the beachheads had been established on the Normandy coast, I took the position of the "second guesser" having followed the Hitler line of reasoning that this was a mere feint. In my judgment Omaha and Utah beaches were not really the ultimate objective; but as in the case of the "Der Furhrer" I, too, was wrong! The anxiety in awaiting the result of the initial attack and in casualty return of the invasion left us in rather an exhausted state for some timeo The transfer of the Chief Surgeon's office to France was delayedo The Boche wreaked their vengeance on London. One incident on June 23, 1944 upon arrival at Waterloo Station, was anticipated in the alert soundingo Standing in queue for a taxi, a blast of the bomb came just on the opposite side of the station, a negative wave threw all the remaining glass 223 from the station windows into the street. Several factors spared our position in the intermediation of the station, the difference in the levels in the impact and direction of the missileo The casualties rushing past, a cloud of smoke emerging from behind the station, traffic jams, left no doubt as to the havoc that was wrought. Five were killed in this explosion. I was interested in the attitude of the British at Hyde Park Gate on the occasion of another attack. They all hit the floor when the alert was sounded and only those of us from the outlying areas stood our ground. Of course, they were wiseo The movement to France was by way of a DC-3 and after the usual con­ fusion I was taken to the First Army Headquarters, lunched with the staff and met my friends, Colonels Rogers and Gorbyo Our eventual headquarters were at Valognes. We had the experience of going behind a barrage of artillery fire at Carentan that had occurred just a few minutes before our arrival; but the stay in Valognes was only a short one and occasioned certain incidents that are still quite clear in my mindo One of these was a moonlight night when Torm:ny Thompson found a trumpet and gave us a fine solo on the same; we did not know he had the talent! General Kirk made two visits to the European Theater during our period of residence and the quality of the man stood out clearly. His interest was primarily medical; but he had not forgotten his grudge against Colonel Sloat. I learned he had detailed him to a very obscure hospital in the Pacific northwest. 224 Dr. O.: In this country? Dr. M.: Yes, the Pacific northwest. We had several interchanges, but I found him a very stimulating individual, a little bit acid and brittle, but nonetheless a real physician. On one occasion I told him that he was the first Surgeon General that I had seen behave as he did when he made a visit to a hospital. He said, ''What do you mean, Middleton?" I said, "You did not pay any attention to whether the beds were lined up. You paid no attention to the floor; but you went right to the orthopedic service to see how the patients were getting on." He said, ''What did you do?" ''Well," I said, "I went to see the medical patients." ''Well, what in the hell are we here for?" On August 22, the movement of headquarters to Valognes was arranged and went by plane to Omaha Beach to the new headquarters of the Chief Surgeon at Valognes. This location was in the field and, as I have indicated above, one of the memorable evenings was enriched by Torcmy Thompson's solo. Before leaving Cheltenham, while dictating to Miss Rigby, I was diverted to the appearance of a jet-propelled plane streaking through the sky. As I watched it, it started to roll and I remarked that I had seen one stunt earlier this week. Then black objects--three or four--went out to either side and the disintegrating plane dove earthward as a dead bird! The pilot was killed! Dr. O.: This was the experimental days of jets? Dr. M.: Yes. 225 By September 17, the headquarters of the Chief Surgeon were moved to Paris, and I was delivered at the George V, the most swanky hotel in Paris. The circumstance was determined by the habit of Commanding General John "Courthouse" Lee to provide the best for his own purposes. Dr. O.: The date is November 13, 19680 We are continuing with Side II of Reel 6. Dr. M.: The Chief Surgeon's office was in the Avenue Kleber, Paris, within the shadow of the Arc de Triumph. The staff was consolidated here after having had some division by reason of the Chief Surgeon's removal to Londono This circumstance led to some administrative con­ fusion, but was nonetheless effectiveo To recur to the period immediately preceding the Overlord Operation, there were opportunities for professional contacts that were to redound to one's personal advantage and to the credit of the medical consultants in the European Theater of Operations. Lectures were given at the British Postgraduate School in Hammersmith, London, at the London Hospital, University College Hospital, and before the Cardiff Medical Society. Several incidents relative to these meetings are at least interesting to me. In the London Hospital experience, a certain delay in wartime taxi service brought me to the gathering of students and staff, a period somewhat delayed, and there was a scuffling in the audience, whereupon on introduction I said "that I had still a few pearls to cast" which immediately won the audience to my side. In the procedure of demon­ strating the lesions of primary atypical pneumonia on the blackboard, 226 I drew a diagram of the lung. After the meeting, Donald Hunter said that, "Bill, you took two long chances. The first I thought you got away with nobly; the second I was quite certain that the students whom you queried as to the order of the drawing and what it repre­ sented, anatomically, might say a white elephant or anything else. You have to give some leeway to the British medical student." At Cardiff a most heartening experience after a very rewarding session before the Cardiff Medical Society was a dinner in my honor with the Lord Mayor Griffith presiding. The occasion gave me the opportunity to indicate that we had an exchange Welsh medical student, under the Rockefeller Fellowship Plan, at the University of Wisconsin Medical School. And I was only giving, in turn, a half of my heritage in that my maternal grandmother and paternal grandmother were of Welsh origin. The British had suffered the trials of the London blitz and the war­ time London was in considerable contrast to the peacetime London that I knew and the London of World War I. There were still the revelries at night and the streetwalkers that found Piccadilly and other popular soldier areas. In general, our duties in London brought us to the War Office for the Medical Division of the RAMC consultants' meetings monthly at Hyde Park Gate. We billited in hotels, as a rule the Mount Royal or the Cumberland. Eventually my associates found the official billet in 2 Hill Street much more to their liking because there was no necessity for reservations and there were always convivial souls who were on like missions in London. The library of the Royal Society of 227 Medicine afforded a reading outlet that was superior to any available to us in our offices. The book shops in Barlebone attracted my attention and I made a number of valuable acquisitions in my ramblings. Always, when there was free time, I went to St. Martins-in-the-Field.· A tribute to our mutual appreciation of the spiritual life of the Anglo-Saxon forebears. Maude and I always attended services in this church when in London. The headquarters for the Medical Department in London were in 9 North Audley Street nearby Grosvenor Square, a center of American activity. Colonel Charles Spruit, as Deputy to General Hawley, was the senior officer there. His staff was a very efficient one; but more to Charlie himself, a brilliant individual, scholarly in all measures, he was nonetheless rather arbitrary and dogmatic in his pronunciamentos. His one failing was an inability to project appropriate values to time. On one occasion he told us at officers' call that it would be a very short meeting and we need not take seats. After an hour and forty minutes, it seemed as though we might have properly been given the restful position of seating ourselves! The personal tragedy in Colonel Spruit's family undoubtedly affected his attitude toward life. A backward child, more of an imbecile than higher grade, was always referred to as the "Little One," and unfortunately kept with the family. He lived to his thirties and after Charlie's retirement was still a burden to the family. Charlie himself died within a few months of the "Little One's" death. Highly regarded in the line as well as medical circles of the Regular Army, Colonel Spruit was a 228 frustrated individual. He had looked forward to the invasion with keen anticipation and apparently had been promised a post with the advance unit. However, after the Overlord Operation he was given a very few days of service in France only to be returned to London. It befell me to discuss the situation in detail with him since he felt that his trust had been misplaced. I indicated to Charlie that in the last analysis, from the standpoint of the magnitude of the task, his responsibility was much greater than any other officer in Overlord, since there were many more hospital beds in Great Britain after the invasion than on the Continent. Eventually, he adjusted himself to this psychology and did an outstanding job and was rewarded with a star. The battering that London had taken, from a physical standpoint, removed many landmarks and the docks, in particular, were badly dis­ rupted. The fortitude of the Londoners, however, was conspicuous and made itself felt even when the bombing continued by way of the "buzz bombs" and other missiles. The surgical consultant group has not, at this point, been given appropriate notice. As I have indicated, Colonel Elliott Cutler, Chief Consultant in Surgery, and I did not see eye to eye insofar as organizational pattern was concerned. His cabinet grew in size and importance. By the same token, it became a "millstone around his neck" by reason of the inability to keep highly qualified individuals busy in the period of preparation. Two years is a rather long time 229 for men of caliber, whom I shall mention, to remain relatively inac­ tive unless they have a task in preparation that measures to their mettle. In general surgery, eventually, Ambrose H. Storck was called, but ill health led to his withdrawal and replacement by Colonel Robert M. Zollinger, an extremely able surgeon and administrator. In nose and throat, Norton Canfield remained the senior consultant throughout the period of activities. His one failing was his overweening desire to ride a motorcycle which led to much amusement on the part of his associates and to not a little disturbance by reason of an occasional misadventure! In ophthalmology, Derrick Vail, a brilliant eye surgeon, served for the major period of activity and was replaced by James N. Grear, Jr. at a later date. Rather interesting was the circumstance of Derrick's intense desire to get the _train on the roado His open resistance to diversionary action was reflected in his open discus­ sions with his chief, Elliott Cutler. In this particular direction, he was strongly supported by Loyal Davis, senior consultant in neuro­ surgery, who was early relieved by John E. Scarff and then in turn R. Glen Spurling took over the reins. James Barrett Brown in plastic surgery did not remain in the European Theater for a long time, but as a messmate at the Ellenborough in Cheltenham, I always referred to him as "the scrounger" because as soon as the PX was opened, Barrett was there to replenish his larder! He was succeeded by Eugene Bricker. The field of urology was covered by John Robinson and in this instance there was mutual responsibility for his services to the 2nd General Hospital and to the Theater in his special field. Unquestionably, a 230 most able representative of this areao In X-ray, Kenneth Do Ao Allen, a Pennsylvania graduate 1916, I believe, and a very well-recognized authority in Denver, Colorado, did a splendid job. His protection of the X-ray film supply, however, led to some conflict with Colonel Theodore Badger, Senior Consultant in Tuberculosis, when a survey might have been meaningful in the reflection of the impact of overseas activity on the incidence of tuberculosis. The area of transfusion was eventually covered by Major Robert Hardin, a friend from the University of Iowa, who was taken under Colonel Cutler's wings and given a very wide responsibility. The temptation for detached duty was obviously a great one, particularly to the members of the consultant staff who were not overly active. Periodically, sometimes singly or in groups, these consultants went to North Africa and Italy. One notable example of the apparently purposeful assignment of consultants was the tour of duty of Colonels Cutler and Davis to Russia. Their divergent reports were the source of great entertainment and amusement to the staff on their return. Almost without exception members of the con­ sultant group were returned to the Zone of the Interior for the advice of the Surgeon General or for certain personal or official reasons. In my own instance without assuming superior dedication to my fellows, I resisted every effort to move me whether to a foreign area of wider interest or to the United States. I felt keenly the necessity of maintaining a constant contact with the operation at hand and in the case of medicine, there was never a time when there was not a job to do. The delegation of authority to the several Senior Consultants and 231 to the Base Section and the Hospital Center Consultants was a very ready one and my confidence in these associates was certainly so profound that I could readily have called one of a number into my position to spell me for a call to Bari, Italy for a special con­ ference, to North Africa for certain periods of observation, and even to Russia as I was invited by the Chief Surgeon and by Colonel Cutler. However, I did not give way to these temptations which could only have been superseded by the desire to be at home. As a method of reinforcing the rapport with our British associates, General Hawley instituted a series of dinners, first at the Thirl­ staine Hall in Cheltenham and then at the Georges Vin Paris. The guests were drawn from the highest ranks of British medicine and unquestionably the contact with men like Moran, Munro, Montgomery, MacGrigor ---- [End of Side II, Reel 6] [Side I, Reel 7] Dr. M.: -----Whitby, Tidy, Melanby, to mention just a few, that indicate the design of the Chief Surgeon. The one dinner at which a high Russian officer was a guest at the Georges V, in Paris, had a personal overtone. The officer approached me twice and made the motion of a toast and I tried to make it clear to him that I was not drinkingo General Hawley, realizing that there was an impasse, came to us and said, "You must realize, General, that the Colonel has a 232 bad dose of clap and therefore cannot drink!" Whereupon the Russian officer bowed low at the waist in deference to the wayward American! (Laughter) And of course the story was to stick with me for the rest of the time! Dr. Oo: Yes, I can imagineo Dr. M.: Mention has been made of the conspicuous service of the civil­ ian British women as drivers in the movements of the consultants in Great Britain. A further note should be given to the secretaries who were assigned from civilian ranks to each of the consultants. Miss Cooper, a redhead, highly intelligent and effective, was the secretary to General Hawley, and after Pete Doan, she was our court of final appeal for approaches to General Hawleyo She never leaked and I felt that she was a most competent secretary. To me was assigned Patience Trelawny who changed her name to Rigby when her mother had divorced her father, Mr. Trelawny. Miss Rigby was a highly intelligent young woman, a linguist of some capacility--particularly in French--and most faithful to her trust. However, she was quite temperamental and felt that she should be in more active service than secretarianship. Quite accurate and faithful, she rendered invaluable service to me. For some reason, the Chief Surgeon inevitably assigned me to the Surgeons General when they visited the European Theater of Operations. I have cited certain interchanges with General Norman Kirko His prede­ cessor, General James Magee, was a rather large and outgoing Irishman without deep professional interests who maintained a suave exterior 233 and a very warm handclasp for every individual whom he met. Two incidents remain very clearly imprinted on my mind. One had to do with a formal dinner given to the General at the RAMC mess in Aldershot. After the soup had been served, I was taken aback to see eight or ten officers about the table lighting their cigarettes. I turned to Johnny Douglas, Colonel, RAMC, liaison with General Hawley, and said, "Have they all gone mad? I never saw cigarettes lighted in a British mess until after the port had gone around the second time." Johnny ex­ claimed, "Don't you see, Bill, they're just trying to protect your damn Surgeon General!" General Magee had lighted a cigarette after eating his soup! The second episode related to General Magee's rather naive attitude toward clinical medicine. We proceeded to the laboratory at Salisburyo After dinner the groups were seated in the mess for a general chat and the General turned to one of the officers and said, ''Where is Middleton?" and someone allowed that I was examining a very ill patient with pneu­ monia on one of the wards. The General said, "This I want to see." Imagine my surprise when he was ushered into the patient's room where I was examining the patient. I said, "General, this soldier has some interesting signs of consolidationo Will you use my stethoscope?" He said, "No thank you, I'll just look at the X-ray!" Dr. O.: Thereby hangs a tale. Dro M.: The British were obviously very hospitable to us and we built about their relation a rapport that we could not share with the 234 Russians. I was, therefore, quite taken aback when General Hawley asked me to show Colonel B. A. Osipov, liaison with the Russians, all of our records--this was in October, 1944. I said, "You mean Secret?" "Yes," he said, "and Top Secret!" I said, "Really, General Hawley, I should have you write an order to that effect." "Oh," he said, ''we have witnesses, Bill, it's perfectly all right." So with his insistence and assurance, I proceeded to give the Russian representatives all of the information that I had in my files--every order, and where there was a desire on instructions from General Hawley, I had copies typed on the scene. When we had finished a day and a half review of this order, the Colonel was profound in his thanks and asked if there was anything he could do for me. I said, "No, frankly, Colonel Osipov, there is nothing you can do," (This was translated through an inter­ preter). I said, "I am curious about two diseases. It so happens, as things are moving, we may have to come up from the south and into the Balkans and I should like to know the status of the typhus situa­ tion." He said, "Have no misgivings at all, the Russians get two baths a week-every soldier gets two baths a week. There's no typhus fever in our midst." I had secret information from official sources that typhus fever was rife. As a matter of fact, I could have given him the exact figure for the typhus incidence in that area of the Russian Army. And then I said, ''We may go to the Black Sea and we may come up through that section of white Russia if events turn that way-­ the Black Sea and the Ukraine. What of malaria?" He answered, ''Well, you know the Ukraine is the bread basket of Russia. It's the most 235 fertile land in the entire nation and it's perfectly free of any malaria that you are suspecting." ''Well, I thank you very much." After he left, I drew out the large drawer of my desk and had the map of the League of Nations showing the distribution of malaria through the world. The Ukraine had the second heaviest incidence of malaria!" It was almost inconceivable! Quite unexpectedly, two honors came to me during the period of the activities in the European Theater of Operations. First, I was made a Foreign Honorary Member of the Association of Physicians of Great Britain and Ireland. In this relation, two incidents are of signifi­ cance. One related to the discussions with Sir Henry Tidy and Charles Newman relative to the possibility of joint meetings with the American forerunner--the Association of American Physicians. On one of these occasions, Sir Henry (Tidy) was rather withdrawn and to bring him out I made some connnent relative to his interest in glandular fever which Americans termed infectious mononucleosis. I said that there was one observation that I felt of some value from the clinical standpoint namely, the fact that the platelets were never reduced in infectious mononucleosis (there have been some isolated incidences since that time) whereas they were always reduced in acute leukemia. He hesitated for a moment or two and then said, "Strange, I never thought of it; cawn't be too important!" (Laughter) The second situation had all of the potentials of an embarrassing cir­ cumstance. The announcement of President Roosevelt's death had just 236 come across the cable when the Association was meeting. I was quite surprised when its president, Gordon Holmes, invited me to the front table alongside of him at dinner. In his speech he extolled the virtues of President Roosevelt and all the while I thought that he was going to call on me to respond. And not being particularly kindly toward the President, I knew that it would be a very stilted response. Fortunately, after he had discharged his international amenities, he proceeded with his appropriate presidential remarks and I was not called on. The fellowship in the Royal College of Physicians was an honor that had never entered my mind. Lord Moran, its President, whom I knew quite well, although I never considered him a close friend since I felt that he was a cold fish in every respect (he has since proved himself so), inducted me on May 18, 1944. This relation naturally is a cherished one. The clinical problems of the Theater were obviously all possessive in our mission. The only reason for the existence of the hospital was the care of the sick and wounded soldier and therefore its staffing was to discharge such a mission. I have in another relation and shall emphasize again the importance of prevention particularly in the military, but a phase that could appropriately be emulated by the civilian practitioner. Obviously, this approach is the ideal of medi­ cine--widely acclaimed and not too widely practiced. Venereal disease has, throughout military history, been one of the serious responsibilties 237 of the Medical Department of the Armed Forces. Focus was sharply drawn to this matter by Colonel Donald Pillsbury's report of the sitw tion in the Mediterranean Theater where there were "soldier houses" and, presumably, carefully controlled inmates. The incidence of venereal disease was overwhelming in this Theater and we set about to meet the situation before the invasion. Interesting was the manner of approach. All of the Venereal Disease Control Officers and the specialists in dermatology and syphilology were called together by Colonel Pillsbury on my instruction and the situation carefully laid before them. There was already abroad the rumor that General Patton was to come to the European Theater to take command of the then form­ ing 3rd Army. This was the challenge, for all of us knew General Patton's attitude towards this problem. [Pause] Dr. O.: This is in the control of venereal disease. Dr. M.: The consensus of the meeting was communicated to General Hawley. In a very profitable conference, General Hawley agreed that the recommendation of this group should be carried to General Eisen­ hower. The recommendation was that upon the invasion of France there would be no recognition or tolerance of the system of "soldier houses" and that the prophylactic measures would be carried out in their most complete details in the hope that the incidence of venereal disease could be contained. Rather important in this direction was the atti­ tude of commanding officers. The medical consultants had strongly urged that there be no punitive attitude maintained by the command in 238 an effort to control because it simply drove the incidence of venereal disease underground. Dr. O.: Yes. They wouldn't come in for prophylaxis. Dr. M.: No. Exactly right. And when General Patton did arrive to take command of the 3rd Army, he was taken aback to find the firm position of the Commander in Chief in this matter. He spared no effort to determine just how all this resistant attitude had arisen. Nevertheless---- Dr. O.: He really was vocal about this? Dr. M.: Very. The attitude of the medical consultants should be given any credit for whatever control of venereal disease incidence developed in the European Theater. Hepatitis was an everpresent threat in the Army. I think that the studies that were made in the incidence of 22,200 subjects of this infection were helpful in consolidating the picture. I shall have occasion to refer to this in another relation on General Hugh Morgan's visit. The 121st Station Hospital at Braintree, England was assigned the responsibility of establishing whether or not diet and other measures might help in the control of the infection. Apparently a high sulfydryl diet, depending largely upon the methionine as its source, limited the number of relapses in this group of patients. John Beattie was especially helpful in this total effort. To the best of my knowledge, he was the first one to realize that there were two 239 different viruses involved. Up to this time the British had felt that the majority of instances that occurred in patients receiving injections were dependent upon the arsenicals that were being used and they spoke of arsenical hepatitis. Beattie dissembled between what he called the x and y viruses and incriminated the needles as source of contamination for the transmission of the latter. Peptic ulcer disease constitutes an everpresent problem in the mili­ tary. Colonel John Sheldon, of the 298th General Hospital, sought to approach this problem frontally by having a group of active ulcer patients assigned to this hospital and to afford them special treat­ ment with limited duty. The immediate impact of such an action was apparent to most of us, namely, that the command in general--the detachment--would undoubtedly resent special privileges in limited duty for any segment of their personnel. Sooner or later it was doomed to failure from the operational standpoint and we were not surprised when first, the commanding officer, Colonel Kirksey, and then John Sheldon himself asked to discontinue the trial. It is interesting that when we weighed the total service of the peptic ulcer patient in the European Theater of Operations it amounted to an aver­ age of three months, so it was hardly worth the trip across the Atlantic to transport him for overseas service. Dr. O.: May I ask a question about the ulcer problem? Did you, in the military, see many instances of Curling's ulcer, stress ulcer secondary to extensive wounds or anything of that sort? 240 Dr. M.: No, we did not and it has always been a subject of considerable question in my mind just where we could or should place it. Motion sickness was obviously a circumstance that was going to confront us when overlord was planned. The Canadians had made great strides in the use of motion sickness remedies. We conferred with them, and there were other units from the connnand that were studying this subject. I cannot say that there was anything material that came out of it. Some felt that there was too much sedation to make the soldiers alert; but on the other hand the marksmanship of some of the men who were under the moderate sedation of motion sickness remedies, was improved over the control; so that we thought that they might weigh against each other. Actually we can't say that anything was proved. The experience of the British in the London blitz with serious renal damages from crush injury led to serious study of this partic~lar aspect on our part. The cold injuries were early encountered in the high-level daylight bombing of the Flying Fortresses; but these were usually local and not to take the magnitude of the experience of the field. We had the advice of the Norwegians in this area. Of course those of us who had lived in the north, had an appreciation that the majority of medical officers did not have. That protection was im­ portant, I have in another relation indicated the British method of controlling trench foot. The cold injury that had occurred in Northern Italy and then the tremendous manpower attrition in the Bulge gave us further lessons. Actually, they totaled almost two divisions of troops lost in the Bulge to cold injury. The manner of approach by the 241 Norwegians was first as to the fitting of shoes. They claimed that we had too many fittings of shoes so that the lacing could interfere with circulation. Too tight leggings and certainly wrap leggings might seriously impede circulation to the feet. The change of socks and the drying of feet and infinite care that should be given to the feet were stressed. Then they had an undergarment that they called the Brynje that looks like a rather coarse fish net that is placed between the undergarment and the shirt and gives an air space, so that it is pro­ tective against the heat loss in the patient. The matter of gas defense was early thrown into my lap in the European Theater. I attended British schools on gas defense and went to Randle, near Liverpool, where they manufactured the gasses. Although I had been in several gas attacks in World War I and recognized the hazard, I felt that my grasp of the total situation was very inadequate and I sought help from whatever source possibleo The one saving grace was the presence of Lt. Comdro George Lyon, United States Naval Service, in Grosvenor Square, who had a continued interest and expertise in this field. His support was enlisted and his advice was the foundation of our efforts. About this time Colonel Perrin Long was assigned to the European Theater of Operations with rather nebulous terms of reference. In the first place, as he conferred with me, it was his understanding that he would have control of all the chemotherapy in the Theater. I pointed out to him as I did to General Hawley the preposterous thought of crossing lines in this manner that would give him the waterfront and absolutely no manner in which you could possibly bring the picture 242 together. The responsibility for the interchange in research area with the British was a sideline, and Turner apparently had covered this particular issue and was to continue it. I then suggested to General Hawley that with the energy and the intelligence of a Perrin Long we should be able to get materials relative to the gas defense into some order that would formulate a proper approach. To Long's credit he approached this assignment with his usual energy and did a commendable job. Fortunately, since he had by this time aroused the ire of the British who were most critical of his attitude, he was named the Chief Consultant in Medicine to the Mediterranean Theater. Dr. O.: What aspect were they critical of; was it his attitude toward their research work? Dr. Mo: It was his intrusion of opinions and his general personality. Of course, as you know, Perrin was extremely aggressive and that doesn't go well with the British. And I have felt that this circum­ stance was overstated to the Chief Surgeon because I was able to get on perfectly with Perrin and had him do what he could to further the teamwork. To consolidate our position, Colonel William Fleming who was a special­ ist in Gas Defense, was assigned from the Surgeon General's Office and came with the understanding that he was to be in the Medical Division. One of these Regular Army details interfered. Jim Kimbrough went over his curriculum vitae apparently and found that Fleming was senior to him. Accordingly, Jim finagled the matter so that Colonel Fleming was 243 directly assigned to the Chief Surgeon rather than to any subdivision, which was perfectly all right with me. Typhus fever was not an immediate problem to the Armed Forces--! say to the American soldiers--in the European Theater. We have the offi­ cial record that there were 34 instances of typhus fever among troops presumably protected by the Cox vaccine and insect repellants. This was interesting in the fact that with the experience in the Balkans, Near East, North Africa, and Italy, we might have expected a spread. I think that the methods of prevention that I have cited were extremely effective in our area. Although I saw typhus fever repeatedly among prisoners of war and displaced personnel, the number that I have given you is an official figure in the Army for the Theater. One interest­ ing character that entered into this particular problem was General Leon Fox. He was a very short officer, very vocal and very profane. He had ribbons from the pocket of his blouse to his shoulder. He came into our mess in Paris, at Georges V, for dinner one eveningo I made it a habit of eating with elements other than the medical; I lived with the medical all day and so for dinner I selected a place with engineers or with line officers--something other than medicineo I was seated with this group of line staff officers and a small figure of a man, who strutted sitting down, walked across the dining room and one of these engineers said, ''Who is that medical officer with all those rib­ bons?" I looked around and said, "That's General Leon Foxo" He said, ''Well, how'd he get his ribbons?" ''Well," I said, "chasing typhus around the world!" "Chasing typists around the world," he said, 'what 244 did you say?" I said, "Chasing typhus fever around the world." "Oh," he said, "I thought you said typists!" (Laughter) He would tell his story very dramatically, that just by chance, coming across the Mediterranean from North Africa, he was seated alongside General Eisenhowero They got into conversation and General Eisenhower said, ''Well, I see that you're a medical officero In one thing I feel quite secure; I have learned that we have the finest expert in typhus fever on our staff hereo It gives me a great deal of relief." Fox said, "General, I wouldn't be secure. I know that damn little son of a bitch and I don't think he's that good!" (Laughter) Then he would go into his dramatic story of the control of typhus fever in Italy. "I had a ringside seat at the greatest drama in medical historyo We had typhus fever in Rome and several of these people had left Rome and had gone to the extreme south of Italy. There is a five-day grace period and we caught up with these folks and with DDT killed all of their lice and there was no subsidiary outburst of typhus in Italy at large." Which is really a very interesting circumstance because the DDT was a godsend to these individuals who had not had Cox vaccine. Typhoid fever, I've had occasion in relation to World War I to relate our experience there. In World War II, with many more soldiers there were only 46 instances and two deathso This is a very amazing circum­ stance when you consider the condition of the field under which these men served. Dr. O.: These figures are for the European Theater? 245 Dr. M.: That's right. The matter of meningococcal infection, I do not have those figures here, but they are available and the reduction was simply astounding. It was our habit when meningococcal infection developed, to close in and to use chemoprophylaxis. The cultures, as you know, in an epidemic period will show in the nose and throat any­ where up to 50 percent positive for meningococci. We not only dropped the carrier incidence of the organism but also the control of the in­ fection, at this time, by the sulfonamides, sulfadiazine. Later, penicillin came into the picture. The circumstance of meningococcal infections brings me into some of the consultations. It's obvious that I had hundreds of consultations during the period of hostilities in the European Theater; but just to isolate a few. One of my former students, .Captain Albert Neupert, had a meningococcemia and was in coma when I saw him at North Mims. He never rallied and died. I re­ call vividly a nurse at the 298th General Hospital at Frenchay Park, England who had had vague symptoms for a period of weeks. Some aching in her joints, and nothing very obvious, who suddenly developed cere­ bral manifestations. I can see her still with the left 6th nerve out. Blood culture showed meningococci. In the military we are always on guard for meningococcal infections, and I think chronic meningococcemia as evidenced in this second patient, is one that is particularly apt to slip up on you. May 1943, I was called to the Chief Surgeon's office in Cheltenham and told that I had been designated to go to Portugal to examine a Colonel Spiegelberg who had been in the crash in the Tagus River when 246 his airplane was downed. I went to Lisbon by air and found that Colonel Spiegelberg had had Weil's disease. He had apparently swal­ lowed the water when he was ditched and had an aortic lesion--an aortic valvular lesion. My studies required only a short time. I stayed at the Avis Hotel and was very comfortable until I was due to leave the third day. When I reported, they said that my passage had been cancelled in favor of one of the British civilians who had been away from home for three years. I did not make a loud protest; but I thought it was rather an unusual treatment because I was traveling on a VIP status in civilian clothes at that time. I presumed we were going into a neutral country. There was all sorts of whispering and spying going on all around; but I had finally been fitted out in some clothes that looked civilian and carried nothing military on my person. So I went to a lesser hotel since I could not get back into the Avis and the word came that this plane on which I was to fly, had been downed by the Germans who were looking for Winston Churchill returning from North Africa. On that plane were a number of notables, Howard--- Dr. O.: Leslie Howard, the actor? Dr. M.: Yes, Leslie Howard and there were a number of others who were on that flight. So I providentially escaped and then came back on June 4 and I can't tell you what a sense of relief prevailed. I hadn't understood what was going on; but when I got back I realized that our plane had taken a different course. We went straight out to sea. We did not follow the coastline at all--I don't know how far--and then 247 came into England from the west. But Jim Kimbrough and the rest of my associates thought I had been on that plane and had gone down! The consultation with Bedell Smith, I have made a matter of record in other places. General Bedell Smith was the Chief of Staff under General Eisenhower and the General asked for my consultation. When I saw General Smith at the Churchill Hospital, Headington, outside of Oxford, he smoked cigarette after cigarette. When I was through my questioning and examination I said, "General Smith, there's just one thing you must understand. My reputation is not good enough that I can treat a patient with peptic ulcer disease bleeding profusely who insists on smoking." I said, "You give up your smoking or find another consultant." I came to see him the next day and he said, "I woke at 3 o'clock this morning, Middleton, lit a cigarette! I said, am I a man or a mouse and who in hell is that man Middleton anyway, and I put out my cigarette!" So the General and I were friends from that time on. (Laughter) The consultation with Alexis Carrel----- Dr. O.: Yes, that's a very interesting story. Dr. M.: ----is an interesting interchange. This was on October 14 and 31st, 1944 in Paris with Dr. Menetrier. Dr. Carrel had been suspect because in his naivety he entertained and visited with German occupancy physicians whom he had known in peacetimes. So the French thought that he was, if not a collaborator, at least a sympathizer. He was suspect. 248 When Dr. Menetrier asked for my consultation, it had to go not only through the surgeon--Chief Surgeon of the ETO--and the command, but to the American Embassy then to the State Department and back. This was all a matter of protocol that meant nothing to me. I was anxious to see a sick man. When he greeted me, it was most effusively; he had known me only slightly in this country and yet I was an American. He said, "I should never have left America, that's where my friends are." After I had examined him I asked if there was anything I could do for him, and he said, "Oh, I haven't had an orange for four years!" Well, I combed the hospitals throughout the Paris district and found no oranges; but I found a lot of citrus fruit juices. He was ever so grateful. Most pathetic he had hypertensive cardiovascular disease and was in failureo He did not rally. He died shortly after my second visito Here was a man who had earned his place in the medical world, Nobel Prize and all the recognition he could get, and still was not---- Dr. Oo: He was an outcast in his own country. Dr. M.: Right. The participation in the deliberations of the Good~ enough Committee were not perfunctory. I wouldn't say that; but they called Colonel Cutler and me to advise with them relative to their pattern in medical education applied to the National Health Act or the White Paper as it might eventually be developed. Elliott presented the picture from the standpoint of the proprietary school, with the teaching hospital--Peter Bent Brigham. I presented it from the 249 standpoint of the state university medical school, with the hospital attached. The discussion, interestingly enough, with Janet Vaughn and Jim (later Sir James) Learmont was largely about the responsibility of such a hospital and how it fitted into the total plano Of course, Jim knew the picture. He had been in this country for several years; but they were not clear yet how the university could or should control the hospital in their system of medical education, which we all accept in this country as essential to the complete organizational pattern. Dr. O.: I'm not familiar with this connnittee, the Goodenough Conmittee? Dr. M.: Goodenough Connnittee, that's right. It was the working connnittee and it was charged with developing the assignment of the---- Dr. O.: I see, of the National Health Plan. Dr. M.: Then the writing off of Jim Kimbrough to me is one of the sorriest acts of the military establishment that I have encountered. Jim had his failings. He took two shots of liquor and was literally out. With all his failings, he was professionally one of the outstand­ ing men in the Regular Armyo Yet they were out to get him. They felt that he was not representative, he was not carrying ono It was a device by which Elliott Cutler could be advanced. If he was removed, Elliott Cutler then became the Director of Professional Services and his star was virtually assured with such forces as he had in the United States. 250 Dr. O.: Was this supported by General Hawley, this move? Dr. M.: Beyond question, it had to be supported because he was the final judge. They gave Jim the Bronze Star and he said, "Bill, you know what in the he 11 th is wi11 a 11 mean?" He said, ''They' re going to fire me anyway." Gave him a testimonial dinner and all this, but behind it all they had broken his heart insofar as the recognition was concerned. Dr. o.: Was he then just removed to another command or discharged? Dr. M.: Oh no, he was returned to his appointed place in a rehabili­ tation hospital in the United States. I couldn't tell you just which one, but he was transferred on February 10, 1945. Eliott Cutler became the Director of Professional Services, as I have said. Now, so far as military attitude is concerned, there are several details. One is a very picayunish one and I hesitate to recite it except that on its surface it was so ridiculous. Colonel McNerney was the Commanding Officer of the 3rd Station Hospital at Tidworth, England. Being there early and being handy, it was one of the hospi­ tals that I visited monthly. On this occasion we were seated at the officers' mess. All of us had finished our very adequate dinner which was at noonday under this system; but the Colonel did not get up. Finally he said, "Captain, you are not through." The officer said, "Oh yes, I don't want it." ''No," he said, "you took the pie and you're going to eat it." So he insisted that he take the ignominious 251 position of the small boy with a piece of pie. When we left, McNerney said to me, "Colonel, I want you to know I did this as a matter of discipline." I said, "Colonel, I want you to know that if you ever do such a thing again in my presence, it will be the last official act that you have in this Theater. I shall take it up with General Hawley, if you ever do that again. You have no right to de­ mean an officer in the presence of his associateso You could have called him to your office and given him the instructions; but this must never happen again." That is a trivial detail and I hesitate to cite it; but it measured the man. The very strict order of control of the psychologic reaction of aviators had not come home to me until I had listened in to one of their hearings of a pilot who, after a number of missions, had gone souro In all seriousness, I do not think I have ever seen so severe a psychologic dressing as that particular officer goto On the scene, you did not know whether the result would be favorable or whether it would simply sink him into a more depressed state; but their approach in such situations was tough. Dr. O.: Trying to shake him out of it, in a sense, by verbal abuse as it were? Dr. M.: Oh yes. I mean to say they were terrific! It was only exceeded by one other psychologic experience I had. I don't know whether you have ever attended a dishonorable dicharge. 252 Dr. o.: No sir. Dro M.: A dishonorable discharge is one of the most stirring, emo­ tional experiences one could possibly go through. The Board of senior officers took this soldier at Lawson General Hospital and not only brainwashed him with his own misconduct, but indicated to him what this dishonorable discharge meanto "Young man, you are, first, deprived of your uniform. You will take off every mark that would make you a soldier. In the second place, you may never serve in the Armed Forces of the United States again; you may never vote; you are a discredited man, a man literally without a countryo 11 Just simply tearing out everything from under this man. The rather light-sided aspect of the separation of a soldier emerged at Lawson General, tooo He was a sergeant who had been in the Regular Army for 28 years. Sitting on this Board were the Chief of Surgery, Colonel Sloat, the Chief of Medicine, Colonel Cooley, the Chief of Neuropsychiatry, Colonel Parsons, and myself, and the con­ versation was from the regular officers; I was simply an innocent bystander. "Sergeant, you been in the army 28 years?" "Yes, sir." "Sergeant, you know we're at war?" "Oh yes, sir." "But now, you want to get out. Don't you feel that you owe something to your country that has trained you and given you this background? Let me see, you were in cavalry, weren't you?" "Yes, sir, I was in cavalryo" "Like horses?" "Oh yes, I like horseso" ''Well, did you feel that it was a break when they mechanized your unit?" ''Well," he said, 253 "it wasn't so good as when we had our horses." "Sergeant, don't you get on with the group?" ''Well," he said, "I don't get on too wello" A Board member said, ''They' re a good outfit. They come from Texas." "Yes," the sergeant respondedo "But why don't you get on with them? They're good men, you said, they're good fighters." "Yes, they're stout fellows." A Board officer asked, "Just what has been the difference?" He said, "You know they have a national anthem, they call it." ''What do you mean?" ''Well," he said, "The Eyes of Texas Are Upon You"; if you don't stand up, they ball you out. Do it the second time, they'll lam the hell out of you!" He said, "I want out of this army!" [End of Side I, Reel 7] [Side II, Reel 7] Dro Mo: The route to promotion may be devious. I had been recommended for colonelcy for some time. Finally I found myself in the rather unusual position of Commanding Officer of the 67th General Hospital, Taunton, England which I had visited recurrently, but never had any aspirations to command. Really, I was a commanding officer in absentia. This was simply for the purpose of paper accreditation to give me a position according to the table of staff allowanceo On the 3rd of February, 1943 my shoulder eagles were given to me by Colonel O. H. Stanley, Deputy Chief Surgeon. From this period there was recurrent discussion of the prospect of the advance to general officer rank, a state to which I had no aspirationso However, it came to unusual 254 extremes. For example, the Canadians inquired why I was not advanced in rank, because, if I did not hold the rank of brigadier general, they could not get their promotion. So like meets like! Elliott Cutler received his star June 21, 1945 and well deserved it. It had been my observation that he would have been a much happier performer, if he had received this recognition from the outset. My personal position has been a matter of record, in that I have felt that rank was not essential to the performance of the duties that I was called upon to meet. If the allowance of stars were limited, the first to receive consideration should be the Regular Army medical officers, in whose careers this was a pinnacle to which they had aspired. On the other hand, reserve officers had a future to look forward to that was entirely devoid of military rank. Perhaps this frame of mind and attitude, widely known, did not help my cause. The tours of duty of certain of our associates from the Zone of the Interior should be a matter of record. General Hugh Morgan, the Chief Consultant in Medicine to the Surgeon General, came to the European Theater on February 3, 1945. His entire stay with us, until_March 19, 1945, was a succession of most rewarding contacts. In general, my design was to acquaint General Morgan with the chain of communications from the most forward unit to the general hospitals in the bases. We followed this procedure through three armies and, I think, to the advantage of all concerned. Then, too, special services as rehabili­ tation at Shugborough; the special neuropsychiatric unit--130th General 255 Hospital at Ciney; the briefing of the bomber crews in England before heavy air raids on Germany, when as many as four to six hundred bombers would be in movement. This was just to give him an apprecia­ tion of the Theater with its medical responsibilities. The opportunity to meet with the conmanding generals of the several armies was punc­ tuated by certain interesting incidents. Through the good offices of Colonel Charles Odom, we met General George Patton. On this occasion I diverted my visit to Brigadier General Hurley and his staff. Hugh emerged quite excited from his visit with Patton and asked, ''What manner of man is this fellow Patton anyway, Bill?" Then Hugh related General Patton's philosophy, "If you are going to fight them, you have to feed and fuck them!" Hugh said, "He repeated this statement. I wonder if you don't have a problem on your hands." I said that you're not alone! And this brings me to a very interesting analysis of General Patton from the close contact of Charlie Odom who was really his private physician. Colonel Odom said that Patton was a high-grade neurotic. When he slapped the face of a soldier patient in Italy who said that he didn't know even why he was in the hospital, he had acted on an impulse. The soldier was actually suffering from malaria and running a high fever. General Patton couldn't sleep for nights afterward and Odom had to keep him under sedation. In general, even those of us who had no military precedent, felt that this particular act of violence to the conmon soldier disqualified a man for command for the rest of time. 256 My contacts with General Patton were quite intimate and I shall relate them in a moment in another situation. But to continue Hugh Morgan's tour of duty----in addition to these contacts and the meeting with the command of the First Army, Lt. Gen. Hodges, we were invited to dinner. I was engaged in conversation with a colonel of my acquaintance when we were called to seat ourselves. I moved toward a chair to his left, but one of the junior officers approached me and said he was sorry we were seated according to rank. My seat would be in such a position. Hugh Morgan apparently saw this gesture and came over and said, ''What's happened here, Bill?" I told him and he said, "Let's get the hell out of here. They don't pull rank on us like that!" I said, "Remember Hugh that you are the guest of General Hodges and you will take your seat at his right and I will take the chair to which I am directed." Hugh was very, very wroth when we went to the Blandford Hospital Center in England which was under the connnand of Colonel Leonard Heaton, the large flag was being flown, there was a guard of honor and then the blare of trumpets; whereupon I slipped down to the bottom of the car in the back seat. He said, "Bill, what in hell are you doing there?" I said, "I'm not going to face that!" He said, ''The hell you're not. You get up here; you go in with meo You have to face up to it!" (Laughter) But Leonard Heaton was putting on a show for the representative from the Surgeon General! (Laughter) I've held it over Leonard's head ever since that time; but Hugh insisted that I had to face the music with him! 257 On one of our tours in France with Don Pillsbury at this time, I so maneuvered the route that we came into Bazoilles sur Meuse by a back road. Just as we came into the village, Hugh turned to me and said, "Bill, this is Bazoilles," and I said, "Of courseo" It was where he had served first, as a private and then as a first lieutenant in World War I in the Base Hospital 18, with the Johns Hopkins Unit. He was as excited as a small boy. He said they had the same manure piles as when he was there--great shows of wealth, you know! The mayor had married the daugh~er of keepers of the estamineto This estaminet was sort of a club for the young chaps from Johns Hopkins during World War I, so we needs must go in there and look around. The proprietress had been a young woman, daughter of the keeper when Hugh was thereo He recognized her and started to engage her in French. He didn't get along very well until he put his arm around her shoulder and she said, "Ah, Monsieur Morgan!" Don Pillsbury and I said, the Morgan touch! She went into the basement and brought out some bottles of wine, from which she had to wipe the cobwebs, had some cookies for me and we had a perfectly grand time. She had cataracts and Hugh, with his warm heart, insisted that I make arrangements that Derrick Vail have these cataracts taken care of. So the amenities were met. Dr. O.: That's wonderful. Quite a storyo Dro M.: We then went through the Delta Base Section, to Marseilles with Hugh, then Don Pillsbury and I took the train back to Dijon as Hugh took off for the United Stateso But it was indeed a historic tour. 258 Walter Bauer--Colonel Walter Bauer--as a side trip from Sweden where he was giving a series of lectures, stopped at our headquarters and I took him for a tour of some eight days through the forward area. We saw some of the results of the German atrocities and the prisoners of war. I would not permit him to go to Dachau because we did not have appropriate orders. There's one incident that indicates the small breach of discipline. I found that Walter had not carried his canteen with him. When we were cleaning up in the morning I said, ''What are you using there?" He said, "Oh, just tap water; I'm brushing my teeth." I said, "No, no, take some out of my canteen." And about twelve hours later he had a very severe diarrhea, so that he paid the penalty early. It was always a very heartening experience to live with Walter, and I asked him how he got these gnarled fingers, "Is that the reason you went into the study of arthritis as your special field of interest?" He said, "No, Bill, when I caught varsity at Michigan and a game got pretty hot, I'd throw off my glove and catch barehanded!" Which brings us to a question of the study of physical standards. The Canadian forces were responsible' for establishing the PULHEMS system--P-U-L-H-E-M-S. This gave the rating officer an ability to apply certain values to an individual examinee. When the Americans adopted this to our needs, we reduced the formula to PULHES, inter­ preted physical capacity or stamina, upper extremities, lower extrem­ ities, hearing, eyes, and nervous status. This was to be an extremely valuable guideline in the evaluation of soldiers for the eventual redeployment. 259 Returning to the military operations, what apparently had been a situation that had lulled the American people to a false sense of security was, from a military standpoint, a build-up for a potential disaster. The distribution of our troops on the eastern front was designed for the attack of the Third Army in front of Luxembourg with a holding of the line before the Ardennes Forest and then a second strong line to the north of this that might sweep into Belgium at Antwerp, held by the Americans and the British. When the Germans anticipated our attacking movement by any advance in force in the Ardennes Forest to develop what has been known as the Bulge, we were completely thrown off guard and I have earlier mentioned the fact that General Bradley, a real soldier, stated that this was a calculated risk and that it might prove, in the long run, to have been an advantage in that the Germans would exhaust their reserve and would be much more susceptible to attack if we were initially able to hold them. The German drive came within a short distance, just measured by a few hundred yards, of one of the large gasoline depots of the Americans which, if they had captured, would have permitted them to refuel their tanks and advance even further than they did. They overran one of our general hospitals in Ciney, Belgium which was a hospital for neuropsychiatric patients. The hospitals in the Liege area saw the advance stations moving back, the collecting stations moving back, and the evacuation hospitals moving back so that general hospitals even­ tually were the first line of medical support. This was a very pre­ carious situation, and I recall that when I was up in that area 260 shortly afterward, the buzz bombs were coming over and you could see their red tails overhead. They told you that they were on North Street or Middle Street or South Street because the Germans had one, two, or three channels in which they were firingo One of the military maneuvers that has not been completely appreciated by most of us was, in my judgment, the most brilliant of the entire European Theater of Operationso The Third Army under Patton was poised for a west-east attack in Luxembourg. When the Bulge crisis developed, the orders were changed for Patton's army to wheel at right angles and attack from the south-north. To move an army of over 300,000 in such a com­ plicated operation under battle conditions is almost inconceivable. The precision and the alacrity with which this was accomplished, to my judgment, was the most amazing operation in the entire war in our Theater. So that the days after mid-December through Christmas 1944 were very trying--touch and go for a period of time. There were a number of small factors added together to turn the tide and a small detail like the Remagen bridgehead that the Germans had left un­ covered where we were able to cross the Rhineo Very, very important insofar as the total picture is concernedo The war ended May 8, 1945 and it was a memorable day to me personally for a very interesting reason. We were scheduled for one of the Medical Subconmittee Meetings with the British in London and it took me about an hour to get from my billet to Orly Field through devious routes. The celebrants blocked Champs Elysees and the other major streets, so that by back streets and byways we reached the airport. In London I found the same conditions. 261 When I reported the next day at Hyde Park Gate, there was no one there except the janitor to greet us! (Laughter) Dro Oo: The conference had all disappeared! Dr. M.: No conferences whatever. Again, I had the feeling as on Armistice Day, 1918, when everything had dropped out of your rather artificial life. One had to depend on the stability of the people for reconstruction. Redeployment was in order and many men came under the Green Plan by reason of their months of service overseas and the requirements for them. In general, it was believed that a large por­ tion of this army would be redeployed to the Pacific Area. On May 10, 1945, General A. W. Kenner was named the Chief Surgeon of the European Theater of Operations, and General Hawley was made the Surgeon of the Communications Zone. This seemed to me to have been in the books in that General Kenner had appeared on the scene and was obviously close to the high command. He outranked General Hawley in term of service and was a major general, too. His personality was that of a perfectly competent, generally accepted career officer. To his credit he never, in my contact, either undermined my Chief's approach, in which he could not have been very successful, or attempted to throw his own power into relief. He did nothing whatever, to my knowledge, to embarrass General Hawleyo By the same token, I felt that from whatever source this movement had been made, it might have been more diplomatically arranged, had General Hawley been recalled to the United States. It, however, was important that we learned very early that General Kenner was going 262 to disband this very carefully selected and trained group of consultants and have only a Chief Consultant in Medicine and Chief Consultant in Surgery. I do not know on whose advice this plan was evolved, nor do I know that General Kenner had approached any of the existing personnel relative to his planning. There came word that a Pacific Conference was being called by the Surgeon General in Washington. I was informed that I was to represent the European Theater from the standpoint of medicine and I believe that Elliott Cutler was invited too. He apparently had some other irons in the fire and was very dilatory in responding to this. He advised me to find something else to do for the next couple of weeks, so that we could perhaps postpone the Surgeon General's call of the conference. Obviously he was unsuccessful. The order came then to me and he was not invited. I left Orly Field, Paris on the 28th of July, 1945 and arrived at Washington National Airport at 1:00 a.m. on the morning of the 29th of July. You'll be amazed at my most vivid recollection. The Red Cross workers met the plane as it came in and said, ''We're sorry, we're out of coffee, but would you have some milk?" And I said, "I haven't tasted milk for three years!" Dr. o.: For heaven's sakes! Dr. M.: This was an interesting circumstance. But when we arrived in England, one of the first observations of preventive medicine was a very high incidence of nonpulmonary tuberculosis and what was the source? 263 Of their sampling, ten percent of the milk on the British open market had virulent tubercle bacilli, so that the order went forward that the Americans would not use milk. And Wilson Jamison approached General Hawley and said, ''Now this is an unusual opportunity. We know our fault. You can help us, if you can simply make a public statement that you'll not use it because of the tuberculous stock from which it's coming." General Hawley said, "Unfortunately we cannot do that. All we can say is that it does not meet with American standards." This position was sustained by our people in preventive medicine because we would not enter into what was then a controversy in the British Parliament. During this period of our stay in Britain, this matter came before Parliament. The attempt to initiate a pattern that had been applied in this country for the sacrifice of all tuberculin react­ ing cows failed for a reason which you would scarcely guess--inter­ ference with small business! And it was not until about 1946 that they finally adopted a plan that has resulted in control of their bovine tuberculosis. So that that was my return to a most famous product of Wisconsin. From there we went to the Annapolis Hotel where they bedded down twelve of us in a room. Hugh Morgan found quarters for me the next morning at the Army and Navy Club. The proceedings of the Pacific Conference were intensely interesting. I think undoubtedly you can have access to those in the records some­ where. I listened for the entire day and the next morning to a very grave criticism of the medical program and performance in the Pacific Theater. This was without question one of the most unfair commentaries 264 upon an effort that was fraught with many difficulties, that I had encountered. Finally I asked for the floor and General Kirk gave it to me. I said that I felt that these comparisons with the performance of the American medical forces in the European Theater was most invid­ ious. To begin with, we had two years to prepare in the European Theatero We were in areas where transportation by road, by rail, by water, by air was established. There were, if not buildings, there were materials from which we could have buildings. So that when we went Overlord we had a background from two years--a solid two years--in which to prepare. Landing on the Continent, while things were perhaps a little bit less adequate, we did not in any area encounter either the physical handicaps of the Pacific with their jungles and their terrains nor had we the disease hazards. We had no endemic diseases, no epidemics of any proportion. Accordingly comparisons with the European Theater were, in my judgment, entirely unfair and out of order. And I thought General Denit was going to embrace and kiss me--but it was such a justifiable defense for their medical performanceo Dr. O.: General Dennan? Dr. M.: D-e-n-i-t. Dr. o.: Who were the critical forces here, the Surgeon General's office? Dr. Mo: Yes, the Surgeon General's office in the main, and I think some of the people in preventive medicine in particular. In general, it was one of those things in which they were using the European 265 Theater for comparison. It was not a magnanimous movement on my part. To me it seemed so entirely out of focus with the reality of the situation, I couldn't sit by and listen to ito Well, the result was that General Kirk said that he was assigning Colonel Pete Churchill and me to go to the Pacific Theater to review the situation and report to him. I was to be picked up by General Denit and go in his plane to Manila. In their private conferences, Hugh Morgan, thereupon, inter­ ceded in my behalf and said that I had been overseas for over three years and had not been at homeo He insisted that were I to go, I should be given a fixed term of service in the Pacific Theater and not an indeterminate oneo Whereupon I went to greet the folks in Jeffer­ sonville--just outside of Norristown, and returned immediately to Madison. Dory met me in Chicagoo The closing chapter of that particular episode. There came telegraphic orders to "proceed to the Pacific with General Denit as Special Repre­ sentative of General Kirk, to be joined later by E. No Churchill on the surgical side; medical situation not satisfactory, directions to follow." Six days before the scheduled flight, General Kirk called me by phone at Madison and cancelled the plano He stated that collapse was imminent. Thereupon he asked what he could do for meo I told him he was the Surgeon General. If he had further missions for me, I was certainly at his biddingo He said there were none and I should take a normal period of rest in Floridao I asked him whether I did not look fit. He said, •~es, you certainly dido'' I requested then that I be separated from service at the nearest post, Fort Sheridan. 266 The invitation of Surgeon General Raymond Bliss to survey the hospitals of occupied Europe was welcomed. Early in the period of arrangements, there came a further telephone communication with General Bliss rela­ tive to the inclusion of Dr. Charles Drew on the team. Dr. Drew, a Negro, had had a very conspicuous career as an undergraduate and had done outstanding work in the blood procural and processing during World War II, so that with enthusiasm I welcomed him to our team. It was composed of Ralph Tovell, with whom I had worked intimately in World War II as Senior Consultant in Anesthesia, Charles Drew, Rudolph Reich, an orthopedic surgeon from Cleveland, and myself. Our tour included all of the hospitals in France and Germany, but at the last minute Berlin was excluded on the advice of the Conmanding General by reason of the then existing situation. [1949] Certain incidents of the tour are themselves interesting and the offi­ cial report is a matter of record. The visit to Linz, Austria found the mess discussing the excellent trout fishing in the area. Upon my exclamation of great fondness for this delicacy there was no further discussion. In the morning, you may imagine my surprise and delight when trout, caught that morning in a nearby brook, were served for breakfast! On rounds at the Station Hospital in Linz, the group accompanying me was astounded by the command of a sergeant patient who said, "Get the hell out of here and don't ever come in again!" When we turned, the patient's exclamation was directed toward a contract Austrian physician 267 who had ordered aspirin for the control of pain the previous evening and has repeated it later when the pain continuedo The sergeant actually had a frank myocardial infarction. Leaving Linz for Vienna in Colonel Hayes' official car, we were halted at the Danube River for a routine check by the Russian guardo All went well until they saw my civilian passporto Then one of the officers connnanded me to get out of the car. Immediately Colonel Hayes used the magic word "militarish", whereupon the officer stepped back, saluted, and we were clearedo Not satisfied with this official recognition, the driver who had lit his cigarette leaned over the side of the car and insolently blew smoke into the guard's face! Just like any American doughboy! At the Allgemeines-Krankenhaus, there were several incidents that riveted themselves on my memoryo First, the deference of the staff and visitors to the "geheimrato" I was only one of a dozen to use my stethoscope when he described heart murmurs in a patient with a sub­ acute bacterial endocarditis. Incidentally, there were some ten instances of this order in the ward and the staff explained their success in diagnosis by their long continuance of the cultures. In­ stead of our routine of the discard after two weeks of negative results, they continued their cultures for six to eight weeks. I was naturally taken aback when I was entirely alone in my approach to the patient; but upon observation I realized that this was the rule that the pro­ fessor gave the word and read the results and the visitors were supposed to stand by. 268 (2) The "geheimrat" was very enthusiastic in his discussion of the constant temperature chamber where he was making observations of peri­ pheral vascular compromise. When he opened the door to show it to me, you may imagine his embarrassment to find a beautiful nude young woman lying on the bed and his assistant seated at the bedside! We beat a hasty retreat! (3) Professor Eppinger had been a greatly admired clinician in my earlier studies on the liver. His work with Hess on hepatitis was outstanding. When I asked for him, I was drawn into a room, told me that this had been his office. When the Americans came into Vienna, he was called for an interview and instead of responding the following day, he committed suicide! He had been one of the physicians involved in human experimentation. We naturally visited the areas of St. Stephans and the Opera. At the former, we were told that the destruction had not been by bombing, but that the Russians had purposely shelled the famous church from across the Danube! The picture so far as the Opera House was concerned, was entirely different. In this instance, American bombers had been responsible; but one of the amazing turns of events was in our reception at the hands of the custodian. At first he thought that we were Russian and he was very sulky and discourteous. As soon as he found we were Americans, he became very warm and responsive to our requests. Our attendance upon opera was limited to light opera, but it was indeed rewarding. We went to the Vienna Woods, we saw the not-too-blue Danube and then our journeyings took us farther north. In Vienna before 269 we leave, there should be some comment relative to the other elements of the Allgemeines Krankenhaus and the Pathologische Institut. The size of classes was in some doubt in both; but I was particularly amused by Professor Chiari in the latter. When I asked him the size of his classes, he turned to the benches and said, "Count them, doctor!", which indicated that he really did not know how many stu­ dents he had in the class. At Heidelberg, the matter of class size and instructional methods came under discussion. I indicated to the professor of medicine that we were rather taken aback that the Germans continued their didactic teaching .to such a large degree. He said, "And what is your substitute in America?" I said, "In a large majority of instances, our instruction is predominately either in conference or in ward classes and demonstrations and not in large groups." He said that his father had lectured before him and his grandfather and he imagined they would continue to do so. Of course, the beauty of Heidelberg and the Neckar River is familiar to everyone and need not be enlarged upon. We were housed in the Schlosshof and had a gorgeous view of the Neckar Valley beneath. The city had been declared an open city during the war and there was only a minor mark of destruction. In Wurzburg there were several circumstances that I recall to mind. In the first place, Wurzburg would have been spared except that on entrance to the city the American troops were fired upon. Whereupon they were withdrawn and heavy artillery called to wreak its vengeance. In the University proper, one experience remains extremely vivid. We were taken into the laboratory of Professor Roentgen. The colonel who 270 accompanied us, opened the drawers and the cabinets where there were invaluable memorabilia, letters, photographs, signatures without endo He said, "Here, take whatever you want!" He was quite amazed when I pushed the drawers shut and said, "If I ever hear of you touching any of this material, I'll have your head, young man!" When I returned to the United States--to complete this story--! wrote to two of the prominent foundations and indicated that I thought that this Roentgen collection was an unusual opportunity to preserve for posterity, some historic materials of incalculable value. The response from both was that 'we are interested in the future not in the past of medicine!" It was quite a shock to me, I can assure youo When we came to Wiesbaden, the hospital was under the control of the Air Force and the highly competent leadership of Colonel White made itself felt. Sam White was to become a very prominent figure in avia­ tion and American medicine, but the mark was on him at that date. In Frankfurt, I had a most engaging time on the wards and found a very alert, keen staff, most attentive to its opportunities and rendering highly superior service. When I reported back to the Chief of the Medical Service, Colonel George, I remarked, "Colonel, you must have had a most unusual service in the armyo I have found that your staff is very alive and alert, that they are well-oriented to their partic­ ular mission and are discharging it with great efficiency. I should like to know just where you have done your serviceo" He said, "Doctor, it's an interesting circumstance that, if you were to view the record-- 271 to look over my 301 file--you would say that perhaps I'd be a most diversified and certainly the least stimulating, from the standpoint of medical exposure of all possible military exposures. In my book, medicine is where you find it!" I have kept Colonel George's remark on file in my mind from that time. I think it is so obviously true; medicine is where you find it. The service at Munich was conspicuous in the work that they were doing in the field of hepatitis and this center was not only active clini­ cally, but from a research standpoint in this areao In recollection Colonel Spitz was the Chief of the Laboratory Service, heading this particular studyo One very interesting incident occurred in our travels. We were going to Bremen by railo In the same coach with us was a very black Negro sergeant in an American uniform. With him was his extremely blond French bride. Obviously, Charlie Drew had something on his mind and found occasion in the course of our journey to seat himself with the sergeant. When he came back he said, "Now I feel better." And we said, ''Well, Charlie, what happened?" ''Well," he said, "I find that this North Carolinian who was a school teacher in America before he enlisted, is going to stay in France.· I think that he and his wife will be much more comfortable!" So that Charlie Drew had a deep feel­ ing for his people and had a very realistic attitude toward the climate of the United States at that timeo I would refer to the record for the official report of this tour of duty; but from a 272 personal and intimate standpoint, it was a most rewarding experience$ Not the least of the opportunities was the interchange with one of the conspicuous leaders of the Negroes in this country, Charlie Drew, who came to an unfortunate end while driving to an appointment after a heavy schedule of surgery in Washington. [Pause] In January, 1948, at the behest of Hal Thomas of Baltimore, I entered upon active duty in the Pentagon with G-lo Lt. General Paul was the Cormnanding Officer and my early impressions were the limitations imposed upon the personnel by protocolo For example, he handed to me two directives that had laid on his desk for four to six weeks that could not be advanced because the contacts within this huge complex known as the Pentagon were so complicatedo I asked him if I might look them over and he said, "Gladlyo I'm glad to see them off my desk.'' A half hour later, having a carefully laid plan of attack and having approached the individuals involved in the two instances, I came back with their signature. Clearly, General Paul was impressed, but to me it seemed to be the simple and natural thing. I had followed my instinct and not protocolo I hesitate to say that this experience might be duplicated to the advantage of the service without exception in a vast majority of instances! At General Paul's request, I surveyed the hospitals at Fort Bragg, Fort Benning, and Augusta. The last named found my old friend, Colonel 273 o. H. Stanley in corrnnand and it had an exceedingly active and effec­ tive teaching operation. The staffs both at Bragg and Benning were conspicuous by its rounded and highly efficient quality. Perhaps I was more impressed by the gynecologic and obstetrical service than might otherwise have been the case since there had been initiated---, [End of Side II, Reel 7] [Side I, Reel 8] Dr. M.: ---- the dependent care pattern of which I have spoken before. This provision meant that instead of having services at prospective hospitals involving adult white males, there were not only women with problems relating to the genital system and other ills peculiar to the sex, but obstetrics with from 12 to 16 hundred deliveries a year, and pediatrics incident to this active service. So I returned to Madison enthusiastic in the opportunities of the hospitals in this system for the very rounded internship. Among my proposals to General Paul was a pattern for merit advancement. The curves of phasing this principle meant that the individual with unusual promise and performance would come up to the top level for his rank at a much faster pace than the mine run of officers. This incentive undoubtedly would hold more medical officers in the military than existed under the current pattern. I've never known exactly what happened to this suggestion; but it still, in my judgment, has the merit that I outlined. The curves are undoubt­ edly available in the files; whether they had been utilized or not I do not know. The rank and position of the Surgeon General in the 274 organizational pattern of the armed forces has always been of concern to me. The Surgeons General are service elements to the line, but have no direct access to the Chief of Staff or to their respective elements at the higher level in the secretaries. The Secretary of Defense, Secretary of War and Navy and so forth are all removed. More important, from my viewpoint, was the detachment from the Chief of Staff or the connnand level; they must go through channels to approach such superiors. Since the service elements include engineering, supply, ordnance, sig­ nals, and so forth, I proposed to General Paul that we take into account such resistance and such objection as had been encountered when preferential consideration in salary was given to the officers of the medical department. This was to say that although I strongly supported the advance to the lieutenant general level for the Surgeons General of the Army, Navy and Air Force, I did not think it reasonable to make it as an isolated issue; but rather that these other so-called service elements should likewise be advanced to the lieutenant generalcy. This issue received favor at the hands of General Paul; but I know that my particular advice was not the basis on which a distinction was made in the instance of General Leonard Heaton. Personal services to President Eisenhower undoubtedly determined this recognition; but it has since extended to the other Surgeons General. During the period of my service with G-1, January 18 to February 20, 1948, I lived at the BOQ of Walter Reed Hospital and General Bliss gave me a lift each morning to the Pentagon. This supported not only the personal interchange that had existed for a number of years, but 275 enabled me to act as his emissary at court, if you please, when the problems of the Medical Department of the Army were under discussion. All in all the limited term of active duty was profitable to me; but it did occur that such a post would have any permanent value. However, I did feel that in the Office of the Surgeon General of the Army a reserve officer with high rating could interpret for the overwhelming mass of potential medical officers in civilian practice the problems and the opportunities of the service and vice versa. Dr. O. : May I ask is this "General Bliss," Ray Bliss, the same Ray Bliss on the Republican National Committee--because the names are exactly the same. Dr. M.: No, no. It's Raymond Bliss. No, he was a Vermonter and very conscientious, not too dynamic, successor to Norman Kirko By contrast, Norman Kirk was a puncher, a driver. For the period of the early years of the Korean affair, I was General Bliss' personal medical adviser. I went to his office once or twice a month throughout this period to advise him relative to medical affairs in the Korean conflict. On one occasion I suggested the two careers of the medical officer. Under the terms of their retirement, it was obvious that a vast majority would be separated from service while they still had twenty years of active life ahead of them. I cited to General Bliss the individuals like General Hawley who had very active useful service in the Veterans Administration, the Blue Cross and the American College of Surgeons after retirement. I pointed out that General John Rogers became 276 extremely effective in the cancer program in Illinois; General Silas Hays was active in the American Cancer Society. And so I could multiply these individuals who were to have a very definite part in the plan that I indicated as a two-career outlet. This was publicized rather widely for a period of years, and then for some reason faded. I imagine it had served its season of usefulness. I had no hesitancy in taking problems that were cited to me by the Army where I had the closest contact, to General Paul for his consideration. [Pause] Dr. M.: The conclusion of my term of service in the Central Office of the Veterans Administration March 1 or February 28, 1963, found me with a warm invitation from Dr. Stewart Wolf to become Visiting Pro­ fessor of Medicine at the University of Oklahoma Medical School for one year during his sabbatical absence on the Continent. Before I left for Madison, there came a rather unusual request that I conduct a course in physical diagnosis as Dr. Mock was involved in family matters that would necessitate his absence from the medical school for a year. The authorities at Oklahoma were quite impressed by my prompt acceptance-­ enthusiastic, I might add--with a statement that if there were one course in medicine that I would prefer to give it was physical diagnosis. This was literally true. because it is the first contact of the medical student with the patient and there will be no period of his under­ graduate medical education when he is more enthusiastic in the prospect. The period from early March to July 1, 1964, when I was to report for 277 duty, was spent to my personal profit in attendance upon the medical services at the Veterans Administration Hospital, Madison. he reception in Oklahoma City was extremely warmo Not only did we find the faculty most congenial, but the townspeople and tradespeople greeted you with a warmth that was certainly foreign to the east of our more recent period. The facilities at Oklahoma City were not ideal by any manner or means. The University Hospital had outlived its use­ fulness, was rambling, and not administratively effective by reason of the physical arrangements and the very antiquated equipment in many instanceso This contrasted sharply with the Veterans Administration Hospital across the street which was literally part and parcel of the Medical School complex. This was accentuated by the fact that in many quarters they felt that the barrier across 13th Street between the Basic Sciences and the University Hospital terminated at the eastern extremity to permit an easy access between the University Hospital and the Veterans Administration Hospital. This, of course, was a psycho­ logical barrier. The clinical staff was an exceedingly interesting one to me. In Dr. Wolf's absence, Dr. Robert Mo Bird was the Acting Chief of Medicine. I'd like to say a word about Bob Birdo Bob Bird is an engaging Virginian who has all of the charm and more of the drive than most of his fellow statesmeno He has played second fiddle to Stewart Wolf for many years, but has never waivered in his allegiance. A thorough team worker, he was bound to hold the respect and the affection of 278 his associates. John Schilling, the Chairman of the Department of Surgery, is in my judgment one of the best, if not the best, teachers of surgery in this country today. His background training is superb and his approach is unquestionably one of the soundest that I have encountered anywhere. In medicine, there was the back-up of such men as Ben Heller, the gadfly of every organization to which he has been attached, but with a fine mind and a very keen analytic approach. He was in charge of the laboratories in the renal unit, worked closely with the VA counterparts and William o. Smith, constituted a very strong nucleus for the study in this particular area. Dick Marshall, a very good man in the general field; Kelly West had returned to take up the continued study of medicine and promised well in his approach to the problem of the graduate or postgraduate area of instruction; Sandy Woods was a very keen internist with some slant in the area of genetics. One of the interesting interchanges here that ought to be related occurred when I was asked to examine a pregnant woman with an obscure hematologic problem. The staff remained outside the room as I proceeded with the examination. I turned and said, "Yes, the spleen is palpable. 11 Sandy in sot to ~ said, "Fetal or maternal!" The ground in neurology was well-covered, with some reservations on the part of Stewart Wolf, by Gunter Haase. Incidentally, one of the best teachers of organic neurology I have encountered since the days of Spiller and Mills. The loss of Haase to Temple was the latter's gain at tremendous sacrifice to Oklahoma. In X-ray there was unusual 279 strength in the recruitment of Traub, who was not only a keen diagnos­ tician and splendid leader in X-ray conferences, but very susceptible to the needling of Ben Heller and myself when we ganged on him! Dr. Carpenter supplemented Dr. Haase very effectively from the stand­ point of the practicing neurologist. So I might extend the staff to include such men as Gunn, Leonard Eliel, Schnei, Schottstaedt, Furman, Conrad, Rhoads, Hampton and others. I would simply mention in pass­ ing the backing strength of Campbell. Williams and DuVal, in Surgery, the outstanding teaching and effective leadership of James A. Merrill and Warren M. Crosby, Jr. in Gynecology and Obstetrics and Harris DeWitt Riley, Jr. in Pediatrics. Brandt had led the way in the computer field and was making a major contribution during the year of my residence. It was interesting to find Mark Johnson, a Regent of the University of Oklahoma, since he had been my intern at Wisconsin. Charming evenings were spent in his household. My schedule was rather time-consuming; but the transition from almost exclusive administrative work to clinical work had taken me into the stratosphere. If one can imagine patients from daylight to dark, no administrative conferences, no administrative responsibility, no "chits," no complaints, nothing but the bedside study of the patients and teaching, you have the Elysium to which I had been introduced in Oklahoma City. Dr. o.: Yes. I imagine that was seventh heaven for you. Dr. M.: It was all of that! The rounds were made regularly. I held outpatient clinics three days a week--afternoon hours. Physical 280 diagnosis was not too exacting, but enabled me not only to refresh half forgotten lessons, but to try new instructional methods. The Brown Derby was not reintroduced at Oklahoma; but I was mildly amused after early sessions on the wards and in the conferences to have Bob Bird's general suggestion that maybe I was a little too rough on these Oklahomans. I said, "Before long they'll like it, Bob!" It remained to be seen that the Oklahoma students were just as responsive as the Wisconsin students to the uno~thodox methods--medicine without pain, if you please! The conferences were an unending source of interest to me and the diversity which I attended and in which I participated, would appear to have no real explanation nor yet objectiveo However, I always main­ tained that I was interested in the skin and all its contents; so that nothing of human illness has escaped my interest, if my acquisitiono The Clinico-pathologic conferences conducted by Dro Jaques were interesting to me in his inclusion· of the upper three classes--second, third, and fourth. I cautioned him on one occasion about the esoteric order of his selection of subjects for their analysis. I did not score my point until, on one occasion, some 20 percent of the second year class, 80 percent of the third year class, and 100 percent of the fourth year class came up with the correct diagnosis of mucoid adenocarcinoma of the appendix. This was carrying the matter of intimate diagnosis of a rare condition to absurdity and Dro Jaques admitted so. The X-ray conferences with Dr. Traub were a joyo As I have indicated, Ben Heller and I would get together before the conferences and decide 281 who was going to ride Dro Traub. Regardless of the victor, the result was the same--a very stimulating discussion and interchange in which Dro Traub usually came out ahead. He's a keen observer and a very careful analyst, but I learned one lesson early. Vic Roher and I--Vic was a senior resident--and by the way, the residency system at the University of Oklahoma has been copied in the main from certain eastern medical schools wherein the resident is the first line of consultation and the residents during my period at Oklahoma, Houk and Roher, were highly superior representativeso Vic Roher and I had selected a remarkable instance of calcification of the aortic ring to give to Dro Traub for demonstration and he put it up before the view­ ing box while he was preparing his demonstration, and he said, "Yes, quite beautiful, isn't it?" and handed it back to Vico From that time on we decided that Dr. Traub ran his own showo The cardiology conference was not as spontaneous and this was a reflection of the personality of Dr. Loyal L. Conrad. Dr. Conrad was a very superior technician with clear insight into the intricacies, not exactly a gadgeteer, but rather devoted to the techniques and the result of the same. Hence his conferences were not as widely accepted nor as enthusiastically received by the students or staff, able though he waso Dr. Mark A. Everett in dermatology, the son of the Dean, whose father had been a friend of many years, had a splendidly organized residency and undergraduate course in dermatology. There was a singularly 282 sadistic approach to his interchanges with the students of whatever level that somewhat militated against the splendid effort that he put fortho I think that Dr. Everett would have been a much more effective teacher, had he had somewhat more of human interest and elemento In inununology, regularly, I rounded with Dr. Friou. Very deeply steeped in the principles of immunology, he conducted splendid conferences from which I gained a great dealo The most able of the teachers, in my judgment, was Dr. Haaseo Not only were his clinics extremely well­ grounded in basic neurology, but his evolution of the clinical picture gave the listener a much clearer appreciation of the pathologic physiol­ ogy that would enter into each of the respective syndromes that he was discussing. Dr. Oo: I think he was replaced by a chap from Seattle, as I remember. Dr. M.: As I have indicated, Dr. Richard Eo Carpenter, a practicing internist in the city, likewise conducted clinics in organic neurology which were exceedingly good. Basicly well-grounded, I believe that his training had come out of Minnesota or Rochester and he had the mark of a master. General clinics were regularly attended whether they were medical or surgical, whenever I could make the connection. I participated in the discussions whenever the spirit movedo Their organization was good, the materials were splendidly presented and the discussion was 283 so free as to make their effectiveness much greater than might other­ wise have been. The unusual opportunity to study the muscular system under the stimulation of a series of evening lectures by Dr. Haase was an encroachment upon our home life, but Dory did not begrudge the time. The student rapport was quite intimate. It almost approached that that I had experienced in the early days in Wisconsin. The class, it is true, was about 100. The one universal fault that struck me forcibly, when I made first contact with students as a group or indi­ vidually, was examination consciousness. I had never seen it so in­ grained in a group of students as at Oklahoma. In the short period I spent there, I did everything in my power to uproot it or to destroy its very pernicious influence on the students at large. The stunt night was the usual melange of the student in his attempt to picture the faculty foibles and idiosyncrasies. It concluded on a note that gave me the deepest concern. One of the really outstanding members of the senior class said that "they were through in about two months and then to hell with Oklahoma!" Within a matter of a few days, I was given an award at the general student-faculty gathering in the amphitheater in the medical school, for the quality of my teaching. I took occasion to thank them, naturally, for their gracious recognition of my small effort. Then I said that I would like to depart from the usual approach and express my concern at an attitude that I had felt so keenly afield at the stunt night, and I concluded by quoting from Shakespeare: ''Mud not the fountain that gave thee drink." And the lesson took. I had occasion to return there. When 284 I left, every student signed his name in the Yearbook. I was urged to remain for a second year; but the decision was made by Dory and me to return to Wisconsin. We had had a very delightful year, not only in the rather anticipated reception of the faculty, but particularly the students. We had our heavy week of professional duties, lived in an economy apartment so that we did not move our furnishings as we had when we went to Washing­ ton for the two terms. Then attending a hematologic conference every Saturday morning, I would a:>me home to lunch and we would take our weekends for exploration. We came to know more about the state of Oklahoma than any native. They have a number of artificial lakes. Of course, the artificial lakes are not to be compared with our natural lakes. We have nothing of comparison on that basis. These statewide parks and lodges at the lakes afforded very easy points of access, none out of reach of a short afternoon run, you see, from Oklahoma City. We would stay until late Sunday afternoon and return to the city. We had only one occasion for limitation on that score, and that was a storm. I was reading in the living room and it got dark without lights. We turned the light on and realized that there was this dust coming in. It was tremendous, so that it had clouded the sky. There were some accidents on the highway. Oklahoma is conspicuous for its art. I refer not only to the painting. Dory was a great lover of Charles Russell and there were museums in Tulsa and other cities that had excellent art exhibits, but these western 285 scenes interested her most of all; the theater, usually local groups were interested in the theater. For the fourth time, we heard "Oklahoma" by an amateur group. Of course, it was more dramatic because they had all the verve that went with the native Oklahoman. We were thrilled when the audience joined in the singing of "Oklahoma" in the final act. Dory had been in the habit of driving home from Washington whenever my back was turned. In Oklahoma my back wasn't turned, but driving from Washington to Madison, about 860 miles, she'd do it in two days alone. The least number of times was three times in one year and the most was nine times in a year. She had complete confidence, a splendid driver, but complete confidence in that she'd go to the same motel; got to know the people and I think she knew all the patrolmen on the road, too! She drove only once from Oklahoma City which was just about five miles further. Because of the strangeness of the road, she did not feel as secure with the patrol as she had coming from Washing­ ton to Madison. We had a holiday at Christmas and took off for the west. Drove out through the Panhandle to Amarillo, Texas and then on to New Mexico and Taos. Let's see, we had Christmas dinner in Taos, and then went to Santa Fe, Albuquerque and Flagstaff. From Flagstaff we had hoped to go to the Grand eanyon; but on advice that there was snow and threatened weather, we turned south. We went to Phoenix and Tucson and then turned east to El Paso. At Abilene, Texas we awakened in the morning with heavy snow and we thought we were for it. Instead it melted very shortly and we went on to Dallas without any difficulty. 286 In Dallas I had made arrangements to buy the best clothes of land; but Dory didn't find anything but a pair of shoes. We then came north from Dallas to Oklahoma City. It was a very beautiful trip and a very enjoyable one. The year was a complete success from a personal as well as a profes­ sional standpoint. However, the decision to return to Madison was not one that we would regret. There were opportunities to go to six other locations--six locations in all--three of which included teach­ ing opportunities, two in foreign service otherwiseo The decision of our return was made with every considerationo The design was to live in our own home again and to resume any activities that might evolve. It was rather interesting that aside from the invitation to remain at Oklahoma for another year, the Class of 1965 invited me to give their Commencement Address at Norman, Oklahoma. I naturally acceded because they had been my clinical clerks the year before and our interchanges had been most rewarding to me. [End of Side I, Reel 8] [Side II, Reel 8] The date is November 14, 1968, Madison, Wisconsin. Dr. M.: The American College of Physicians had its inception in the observation of Dr. Heinrich Stern of the proceedings of the Royal College of Physicians while on a visit in London in 1913. Accordingly, greatly impressed, when he returned to his foster home in New York, he inquired as to the possibility of starting a similar movement in 287 Americao There was little encouragement. However, he finally enlisted sufficient support to obtain the legal incorporation of the American College of Physicians, May 11, 1915. It is interesting to observe the purpose as designated in the first constitution of the College: "to promote the advancement of science and practice of medicine; to further the study of biologic medicine among its members; to elevate the standard of preliminary education of physicians and standard of medical education, and secure the enactment of just medical laws by state and federal government and of a federal law providing for a national medical license; to attain the establishment of a National Board of Health; promote friendly intercourse among physi­ cians; to enlighten and direct public opinion in regard to great problems of health and medicine and to afford recognition to distinguished achievement in medicine." Naturally these objectives in different accent reflected the Royal College of Physicians of London's academic, administrative and medical prerogatives. The colloquialism of the membership at first threatened its success. The efforts of many of the individuals so interested eventually led to a broadening of the base and the incorporation of the American Congress of Internal Medicine into the American College of Physicianso The existence of the two independent bodies had threatened the ultimate success of the College. With varying periods of acceptance and rejection through the country at large, there was eventually, through the good offices of Dr. Alfred Stengel, of Philadelphia, and Dro Charles F. Martin, of Toronto a statesmanly reconstruction of the rather tenuous organization of the 288 College and a movement of its central office from Chicago to Philadelphia. With the impetus given by these two medical statesmen, the College was off to a reincarnation and the sustained growth in effectiveness that has marked its later career. The change in the constitution and by-laws, 1926, affected only the basic principles of the scientific objectives of the organization. In the statement, "the object of the American College of Physicians shall be to establish an organization composed of qualified internists of high standing who shall meet from time to time for the purpose of considering and dis­ cussing medical and scientific topics and who through their organiza­ tion shall attempt to accomplish the further purposes of, a) maintain­ ing and advancing the highest possible standards of medical education, medical practice and clinical research, b) perpetuating the history and best traditions of medicine and medical efforts, and c) maintaining both the dignity and efficacy of internal medicine in its relationship to public welfare." The Royal College of Physicians had throughout its existence entered upon the broader aspects of social responsibility in medical legislation and the operation of the government. For years, the American College of Physicians eschewed these special areas of activity. My personal affiliation with the College as a Fellow dated from 1929. The College was to afford a natural outlet for interests that have persisted through my professional career. In my absence from the United States on active duty in the European Theater of Operations, I was made a Regent of the College in 1944--quite a surprise to me-- 289 and I continued in this official relation until 1948. In November 1945, as a Regent, I was appointed by President Irons to chair the Committee of the Regents on Survey and Future Policy. The Committee was composed of the further members, James E. Paullin, George Morris Piersol, Wallace Yater, and Georges. Lathrope. In the intervening years to the conclusion of my regency, we were engaged in matters involving the qualifications for membership, in the main, and en­ countered much debate from the Regents, governors, and membership on the basis of their insistence on one side that general practitioners be given consideration, and on the other that certification by the American Board of Internal Medicine should be considered as the pri­ mary step or detail in qualifying candidates. The latter position prevailed largely through the influence of George Morris Piersol who, for many years, was the Chairman of the Committee on Qualification. In 1946, the appointment to the Committee on Educational Policy gave wider responsibility in the establishment of policy as to the formu­ lation of the annual program. The advice at the early date being that there be greater attention to the inclusion of clinics, panels, round tables, and clinical pathologic conferences. The graduate courses had developed to a point of considerable influence in American medicine and in the judgment of our committee, this growth was a tribute to Dr. Edward Bortz of Philadelphia. This committee, furthermore, rec­ ommended the increase in the support of research fellowships, a venture that had an early beginning with the College. The influence of the Annals of Internal Medicine was beginning to be widely felt in medical 290 circles and the Committee highly commended the editorship. The thought of involving the College in the certification of the hospitals for fellowship and residency did n9t find universal favor. It was the judgment of our Committee that this function was adequately covered by the Council on Medical Education and Hospitals of the American Medical Association, and that the College might well avoid this venture. In 1947, our Committee cited the courses in cardiology under Chavez in Mexico City, and ventured the recommendation of extending invitations for attendance upon our annual session to the several English-speaking colleagues distinguished in foreign countries. In 1948, the Committee on Education Policy rerommended the reappointment of Dr. Alexander M. Burgess and Truman G. Schnabel to the American Board of Internal Medicine. Dr. William S. Mccann had resigned and to his vacancy three names were offered to the Regents and among these Dr. Chester M. Jones was selected. In 1948, Dr. Reginald Fitz was made President-elect and I was made First Vice-President. In 1949, as President-elect with Dr. George F. Strong as First Vice-President, I was still on the Educational Committee and recommended to the Regents the extension of graduate courses to Hawaii, but it was the judgment of the Committee that this particular function could not include Australia and New Zealand as had been suggested. At this time, there were ten graduate courses cited for the Spring of 1950 and five for the Fall in 1950. This program was obviously one to enhance the usefulness of the College. 291 The meeting in Boston in 1950 found my induction as President at which I conducted the last meetingo At this time, I took the opportunity to express my distaste for the extension of the so-called scientific exhibits which really were commercial exhibitso I used the expression that "I would cast the money-changers out of the temple." This par­ ticular element in my acceptance speech obviously did not find favor among the exhibitors. Mro Edward Loveland communicated the reaction-­ the adverse reaction--of this group of supporters and indicated that our annual sessions were largely dependent upon income from this source for their continuance. In our interchange, he suggested--and I agreed-­ that a survey should be made of the reaction of the members. Some two­ hundred members--fellows and associates-, that is--were approached. I have not been able to obtain the original copy of the communication; but to my dismay only three of the members of the College supported my position. Even to this day, I feel that the dignity and prestige of the American College of Physicians would be greatly enhanced were exhibits of commercial houses to be limited to those with an educational outlet or demonstration and to the publishers; I feel that the meetings of the College have, at this date, attained such stature that the responsible pharmaceutical and instrument houses would perforce meet our high standards, were they so approached. The fact remains that I was properly beaten. The Boston meeting was shattered by the death of our very strong representative from Salt Lake City, G. Gill Richards, a forthright and outstanding member of the American Board of Internal Medicine with whom I had worked closely. 292 November 12, 1950, I presided at the Philadelphia meeting of the Board of Regents where there were a number of details of administrative im­ portance discussed. The preparation for the annual meeting in St. Louis found my friend, Dr. Ralph A. Kinsella, Professor of Medicine at St. Louis University School of Medicine, General Chairman. There has always been some difference between Washington University and Sto Louis University, and I could scarcely anticipate a measure of mutual cooperation with the Chairman of the Department of Medicine at St. Louis in the responsible post of General Chairman. However, Dr. Kinsella and I saw eye to eyeo I was not able to put over my appeal for clinics, clinical pathologic conferences and round tables such as I had anticipated from the earlier recormnendations of 1946 when I was serving as Chairman of the Committee on Educational Policyo However, the meeting although low in attendance was high in spirit. It was my feeling that we had a successful operation. The high point, in my judgment, was the Convocation Address by Sir John Parkinsono My friend, Sir John, was at his best in developing the subject of the patient and the physiciano My Presidential Address was directed toward the future of the College, entitled "The Destiny of the American College of Physicians." In this presentation, I built on the background of the historical development of colleges of medicine and particularly stressed the chronicles of the Royal College of Physicians of London, of which I was, incidentally, at that time a Fellow. I had made some study of its history. In conclusion in this address, I played upon the peripheral activities of the College, having developed the 293 tremendous impact of the annual sessions, and of the regional meetings, the growth of the influence of the College through its educational efforts in the postgraduate courses, and especially gave attention to the increasing influence of the Annals of Internal Medicine. This relation I quote from the concluding paragraph: ''Mere material advantage does not suffice. The American College of Physicians of tomorrow must be a spiritual force that permeates every city, town, and hamlet on this Continento In Gloucestershire, late in the 18th century, five physicians banded themselves together for social and professional interchangeo Their gatherings at Fleece Inn, Rodborough and Ship Inn, Alveston, were convivial occasionso Yet from these meetings of kindred spirit came the first account of vaccination against smallpox (Jenner) and an early association of angina pectoris with coronary atherosclerosis (Jenner; Parry). Their example is a challenge to everyone of us. With the blessing of American College of Physicians, and without stultifying protocol, small informal groups under the guidance of inspired Fellows and Associates, may well bring a resurgence of clinical medicine and human service in our day. ''Make no small plans, they have no magic to stir mens' souls." Burnham The succession in the American College of Physicians is to have the retiring president become a Regent of the College. With strict per­ sonal reservations in the direction of the tendency for such bodies 294 to develop cliques and groups that were deemed by the members at large dominating in policy, I refused to serve as Regent even though my interest in the College never waned. In 1951, my successor, Dro Maurice C. Pincoffs, appointed me to the Joint Connnission on Accreditation of Hospitals. The other members of the College in this venture were Dr. Leroy Ho Sloan and Dro Alexander M. Burgess. In 1952, an unusual honor was accorded me in Mastership in the College. In 1962 I was granted the Alfred Stengel Memorial Award by the Collegeo In 1953, I wrote a formal reconnnendation of the payment of expenses for full time faculty members who appeared on the annual programo While this received very kindly consideration, I do not know whether it has ever been adopted as a policy of the College. My interest in and attendance upon the annual meetings and the regional meetings of the American College of Physicians has continued to this dayo One of the very significant developments of the recent period has been the initiation of the Regency Club, the brainchild of Irving Wright. This group meets for luncheon at the annual session and discusses matters of policy and operation of the College at large. I personally would hope that it did not enter actively into the proceedings of the College since this would interfere with the primary function of the officers, Board of Regents and Governors. However, there is always a tendency, when such a group gets together, that its boundaries will not remain clearly defined. Dr. O.: I would think a group like this could be very valuable as the "senior statesman" of the organization and internal medicine in this 295 country and perhaps it could be known and accepted that any recommen­ dation they might make or have would always be taken under consideration without anything binding or obligation attachedo Dro Mo: I think that your position is entirely soundo I would agree completely that as long as it remained advisory and not operational, it would have a very salubrious effect on the activities of the College. I so believe it will operateo Dr. O.: I think there obviously is a wealth of background there that should be drawn upon and yet you don't want to enter into the situation of a group of "young Turks" saying, ''Well here's a senior statesman still running the show even though out of officeo" Dro M.: Right, and that, of course, was one of the circumstances and the idea that I did not wish to perpetuate--the thought of a limited group politically motivated who would keep control. Dr. o.: Leaving the Presidency and becoming a Board of Regents member. Dro M.: Righto In other words, I thought I had had my turno Dro O.: May I ask, Dr. Middleton, what other groups were formed either as splinter groups or, very candidly, as has happened certainly in surgery, tried to set up their own specialty organization which really infringed upon internal medicine with the thought of setting up their own certifying boards and so on? 296 Dr. M.: We're in an entirely different area there, and I wouldn't enter upon that here. However, when the American College of Chest Physicians was inaugurated, the Regents of the American College of Physicians connnunicated to this body their objection to the adoption of an official title so similar to that of the American College of Physicians, and a seal long since used on the College medals. From the American College of Chest Physicians came the sustained legal right to retain its name and seal. No further steps were taken in this matter since it seemed inappropriate to engage in legal contro­ versy over an issue of relatively minor significance. The original decision was borne out by subsequent events and the American College of Chest Physicians had grown to greater stature and is a more digni­ fied organization. Dr. o.: Is it now essentially looked upon as a more limited group, in other words, do people belong to both the American College of Physicians and the American College of Chest Physicians? Dr. M.: There are quite a few who do. I will say, that being of the old guard and having gone through this period of controversy when there was invitation and indeed pressure made on me to join the American College of Chest Physicians, I declined. When I went to Washington as the Chief Medical Director of the Veterans Administration, Honorary Fellowship was offered me and, again, with this old controversy in mind, I declined. I realized that the organization is now on a sound basis. Many of the very aggressive and climbing group of men who were 297 active at an early stage, had been overridden by a more conservative and stable group. One of the most rewarding of my experiences in the presidency of the American College of Physicians was the opportunity to visit with groups in every section of the country. Up to that time, I attended more regional meetings of the College than had any previous president. At these meetings, in general I spoke on a clinical topic of my own choice; but the mission of the College was always brought into reliefo This unusual opportunity of a College President to see and to meet at firsthand the respective groups in their native setting, to exchange personal and professional experiences and to really visit in the homes of the members, whether they be Associates, Full Fellow, Regent, Governor, meant a great deal to me Over the years, these associations have grown into warm friendships. The American College of Physicians has held itself aloof from all mundane matters. The details of fees and political relations have not been considered a function of the College. It was natural that the American Society of Internal Medicine should be formed with a basis of concern for the socioeconomic changes of the period. With high ideals, the group established its constitution and bylaws in 1957, and has grown in influence in the intervening periodo To bring the matter into personal focus, my good friend and former intern, Dro Maurice Hardgrove, of Milwaukee, proposed a Wisconsin Society of Internal Medicine to pattern after the long-lived Minnesota Society of Internal Medicine 298 that was founded to further scientific gatherings of men of like minds and interests. With all the force I could exercise, I attempted to have Muzzy (Dr. Hardgrove) direct his attention to the Regional Meet­ ings of the American College of Physicians. He prevailed and the Wisconsin Society of Internal Medicine was initiated without primary thought of the objectives of the American Society of Internal Medicine which had, frankly, as its primary interest the socioeconomic situation as stated in their constitution and by-laws. The growth of the Amerian Society of Internal Medicine was such as to raise some question in the minds of the American College of Physicians as to the divisive force that might be exerted, were the junior group to extend its activities into the clinical and scientific field that appeared in certain of its meetings. The participation of the two bodies in joint conferences has resolved many of the differences at high levelso At local and state levels, this is not always the case; but it is a source of great gratification to me to find the two Wisconsin groups meeting conjointly with appropriate time given to the interests of the respective bodies. In the last analysis, I believe that there will be a meeting of the minds, and the American Society of Internal Medicine will discharge the provisions of its by-laws without infringement upon the mission of the American College of Physicians. The American Board of Internal Medicine was the natural outgrowth of the post-World War I period, although its initiation was delayed some time thereaftero The postgraduate outlets in Continental Europe and Great Britain had been disrupted by World War I. The wide range of 299 exposures and the absence of standards for controls gave serious mis­ givings as to the validity and effectiveness of such irregular trainingo At this period, the medical centers in the United States were not pre­ pared to absorb the shock of European medical disruption. Accordingly, educators and thinking physicians in this country turned to the experi­ ence of the American Board for Ophthalmic Examination, which later became the American Board of Ophthalmology, for guidance. This group had been established in 1916 and interesting in-their formulation was the statement "each certificate granted or issued does not of itself confer or purport to confer upon any person any degree or legal quali­ fication, privilege, or license to practice ophthalmology, nor does the Board intend in any way to interfere with or limit the professional activities of any duly licensed physician." This general thesis was to be followed in the formulation of the plans for other specialty boards. On June 11, 1933, at a conference in Milwaukee, there were delegates from the four existing Boards of that period--Ophthalmology, Otolaryngology, Obstetrics and Gynecology, and Dermatology. The repre­ sentations from these existing boards were supplemented by appointees from the American College of Physicians, the American College of Surgeons, Association of American Medical Colleges, the National Board of Medical Examiners, and the Federation of State Medical Examinerso Dr. Walter Bierring represented the American College of Physicians at this conference. On December 3, 1933, he reported to the Board of Regents of the College the deliberations of the Milwaukee conference. He reconunended that the College follow the European pattern of inde­ pendent examinations for admission to the College rather than 390 participation in the certifying body in internal medicine. After a general discussion a decision was derived to defer action for more comprehensive study. President Piersol appointed a connnittee under the Chairmanship of Dr. James A. Miller to make such a survey. April 17, 1934, Dr. Miller reported adversely to the proposal for the establishment of an independent board at that time which followed Dr. Bierring's suggestion and led to a discussion of the establishment of an independent examination to strengthen the admission policy of the College. In May 23, 1934, President Jonathan C. Meakins set up a connnittee on examinations of which Dr. O. H. Perry Pepper was Chairman. December 16, 1934, Chairman Pepper reported the Committee's favor of an oral and written examination for all candidates elected to the College after April, 1935, before advancement should be made from Associateship to Fellowship. The Conmittee was, at that time, in­ creased by two and the report accepted without action. April 30, 1935, Dr. Perry Pepper reconnnended to the Regents the establishment of an "American Board for Certification of Internists." This was confirmed and a juncture was made with the Section on the Practice of Medicine of the AMA with financial support assured from the College at the rate not to exceed $10,000 for the first year and until the Board should become self-supporting. On February 16, 1936, the Joint Committee of the Section on the Practice of Medicine of the AMA and the American College of Physicians met with the Executive Committee of the Advisory Board for Medical Specialties. With minor changes a favorable action on the application for recognition was obtained the following day, 301 February 17, 1936. Drs. Bierring, Irons, and Middleton represented the American College of Physicians at this time. The Articles of Corporation were to be executed in some court according to the advice of the Advisory Board of Medical Specialties and Dr. Bierring under­ took this assignment in Des Moines. May 10, 1936, the entire Advisory Board approved the application for the said American Board for the Certification of Internists and the title was changed to the American Board of Internal Medicine. May 12, the Council on Medical Education and Hospitals of the American Medical Association approved the action of the Advisory Council. The first Board was constituted as follows: from the American College of Physicians on the recommendation of President James A. Miller, Drs. Barr, Meakins, Middleton, Pepper, and Richards were named; on the reconunendation of the Chairman of the Sec­ tion on the Practice of Medicine in the American Medical Association, Dr. William J. Kerr, Drs. Bierring, Fitz, Irons, and Musser were named. So was constituted the first American Board of Internal Medicine which convened in Chicago, June 14-15, 1936. At this time, Dr. Bierring was made the First Chairman, Dr. Meakins, the Vice-Chairman, and Dr. Pepper, Secretary-Treasurer. To expedite matters, Dr. Bierring asked that Mr. P. M. Hutchinson, of Des Moines, be made the Assistant Secretary­ Treasurer and this was a detail to which we will call later attention. The initial discussion was largely directed toward the mission, the manner of approach, the basic requirements, the regulations. The stress was largely upon the detail of the graduate training in basic sciences. It was indicated that in any fellowship or residency there should be particular attention given to this circumstance. 302 As to the objective, one of the newly appointed members who might better remain unnamed (I don't mind telling you myself) indicated that the highest level of achievement should mark the objective of the new Board. For example, he cited the fact that in his judgment by his criteria there were only three outstanding internists in the country, namely, Henry Christian, James B. Herrick, and David Riesman. Naturally, there was very little adherence to these lofty ideals. The original brochure of "Directions to the Prospective Examinees" con­ tained such expressions as "broad general principles for training, however, may be outlined although such suggestiona as are made must, of necessity, be subject to constant change reflecting the dynamic nature of the specialty." Reference was further made to "practical experience under the guidance of older men who bring to their clinical problems ripe knowledge and critical judgment." Then too, "the Board does not consider it to the best interests of internal medicine in this country to specify rigid rules as to where and how training is to be obtained; medical teaching and knowledge are international." Finally, "the responsibility of acquiring the knowledge as best he may rests with the candidate, while the responsibility of maintaining the stan­ dard of knowledge required for certification devolves on the Board." Much of this language was suggested by Jonathan Meakins and his clear delineation of the function of a certifying board has never been im­ proved upon. There were many personal characteristics of this original Board. From among the several I would refer to the attitude of Dro Meakins and his analysis of candidates; for example, when an 303 individual had an untidy mind or when an individual handles his material with such precision that he realized that his mental processes were very accurately meshed. Perry Pepper with his brilliance and his keen analysis of every situation that arose; Reg Fitz with his down-to- earth practical approach; and then John Musser with a remarkable capac­ ity for analysis, remaining entirely quiet throughout a heated discussion perhaps and then, having made notes, to turn up at the con­ clusion of general discussion with a careful analysis of every telling point, and with conclusions that were frequently accepted by the group as a wholeo As I view this association, it was one of a widening grasp of the workings of keen minds and of the dedication of men with many interests to a common purpose, namely, the improvement of the quality of care to the American citizen. The meetings were always attended well. The participation was unin­ hibited, and I think that the mutual respect of the several members of the Board meant that there was never carried from the Board any animosity or feeling of discrimination. As has occurred with all certifying boards, the question of the impact of certification was given due consideration at an early date. We had the important pre­ cedent of the American Board of Surgery, which states in its delibera­ tion, "the prime object of the Board is to pass judgment on the education and training of broadly competent and responsible surgeons, not who shall or shall not perform surgical operations. The Board especially disclaims interest in or recognition of differential 304 emoluments that may be based on certification." This situation was to plague every Board throughout its existence, and particularly did the American Board of Internal Medicine disclaim any discrimination in favor of the individuals who had been certified by them. [End of Side II, Reel 8] [Side I, Reel 9] Dr. M.: Particular stress was laid on the denial of any protective device in the appointment of certified internists to hospital appoint­ ments, and conversely, serious condemnation of any movement that might lead to the resignation or dismissal of an individual who did not have certification, were he appropriately qualifiedo In a word, certifica­ tion was not to be used as an instrument of appointment or of discharge. The most important early decision of the American Board of Internal Medicine was in the direction of the subspecialties. The Advisory Board for Medical Specialists had been established in 1934 with a very important function in guiding the foundation of new Boards and in establishing principles of procedure. The Advisory Board was being approached by two subspecialties with the idea of establishment of new separate subspecialty Boards. The position of the American Board of Internal Medicine was clear-cut and largely directed by the repre­ sentations of Dr. Reginald Fitz. The Board stated that no subspecialty certification in medicine should be considered except in individuals who had demonstrated a grasp of the basic principles of internal medicine. In a word, before appearing for subspecialty certification, 305 such an individual, whether it be in gastroenterology, cardiology, allergy, or pulmonary diseases, must first have passed his examina­ tion in internal medicine. This firm expression of policy gave to the subspecialties a dignity and a position in medicine that had never existed before. Upon reflection the representatives of these subspecialties realized that by this policy the American Board of Internal Medicine had done more to elevate the subspecialty than had ever existed before, when so commonly, the acquisition of an electro­ cardiographic apparatus was tantamount to the establishment of a specialty, or the gastroscope to another specialty. In a word, by requiring certification in the basic field of internal medicine before admission to the examination in a subspecialty, an individual had proved his mettle. The period of the earlier examinations found some division relative to the requirements for admission. The conventional three years of residency plus two years of practice of internal medicine after the completion of the medical course in a recognized grade A medical school obtained. Later there was some leniency. For a time the recognition of certain individuals as preceptors obtained in substi­ tution for the residency. This proved to be an inoperable procedure both as to the quality and the nature of the exposure that could not be appropriately evaluated. Eventually the Board withdrew this type of preceptorial recognition. Dr. O.: Was this primarily after World War II that this came into being? 306 Dr. M.: No, it was before World War II because you see I was out of the Board in 1944. Dr. O.: I see, because I know in surgery they made this allowance for those people who were in service and had to drop out of their residency to go in service and come back and spend time in a preceptorshipo Dr. M.: The actual examinations were a source of considerable interesto The first written examinations were of the essay order, and obviously entailed a great deal of time and study on the part of the Board mem­ bers for their correction. The oral examination was a bedside exam­ ination with a member of the Board and a guest examiner--a qualified internist. In my judgment, after the first hurdle was cleared, the latter hurdle gave a much clearer idea of the candidate's eligibility on the basis of his clinical performance. The early handicap which in small measure weighed against the great advantage of certification to the ailing public, was ''working for the Boards." In my judgment, there is no more serious psychologic indict­ ment of the specialty boards than the attitude of certain candidates who assume that the mere passing--the certification by reason of suc­ cessful completion of the examination--constitutes the ultimate objectiveo Actually, it has been my experience that the thoughtful candidate, successful or otherwise, will use his performance in such examinations as an incentive to further effort. It is to be hoped that ''working for the Boards" will become a relic of the past. Cer­ tification by a formula is a means to the end, not the end itself. 307 Unless it is a stimulus to sustained effort, it becomes a specious and hollow objective. Dr. O.: It's the same sort of thing that you found and were alarmed about in medical students working toward the examination. Dr. M.: Yes. The "grandfather clause" which was operative at the outset followed the lines of experience of other certifying boards and gave recognition in the main to men in academic medicine and to inter­ nists of stature. The early acceptance of the effort found expression in the improvement of the residencies, the quality of training, and in the quality of service to the patient which was, in the last analysis, the objective. April 6, 1938, Dr. Bierring was reelected Chairman, Dr. Barr, Vice­ Chairman, and in my absence, I was made Secretary-Treasurer in that Dr. Perry Pepper was then President-elect of the American College of Physicians and pled overwork. Jonathan Meakins had called me by phone from New York after I returned to Madison, and informed me of the action of the Board. I told him that I would not give him my answer until I had talked to one man. We realized that Mr. Hutchinson had proved very inept and ineffective as the Assistant Secretary­ Treasurer and as they had recommended a physician successor, I desired the cooperation of Dr. William A. Werrell as my Assistant Treasurer. When I had his assurance, I was doubly fortified to undertake the arduous task. Before Dr. Werrell's death, I had written a note in 308 respect to an item on Walter L. Bierring and the American Board of Internal Medicine which read, ''Members of the Board come, faithfully and effectively discharge their duties for set terms, and retire with a gratifying sense of a substantial contribution to the common weal. Dr. Werrell is the golden thread of continuity. Deeply steeped in the mores and traditions of the Board, he is more than a stabilizing administrator. His idealism, vision, and perceptive grasp of the mis­ sion of the Board have won the universal respect, high esteem, and affection of his associates." This association was to continue through­ out my tenureo The Board examinations that were conducted on the two bases--the written examinations circularized among a number of centers for the accommodation of candidates, were universally well-done; the oral examinations required a great deal more organizationo First of all, the sites had been selected by the Board and then came the arrange­ ment with the local hospital authoritieso Without exception, during my tenure [1944], there was never a lack of complete coordination at local levels with the Central Office in Madisono All of this leg work depended upon the dedication, insight, and the administrative capacity of Dr. Werrell. Actually, when I offered my resignation on assuming active duties in the military service in 1942, you will recall that this was rejected by the Board. In my absence, Dro Werrell took over the complete responsibility of the office and of the operation of the Boardo The finesse and dispatch with which he directed the overseas examination of physicians in the armed forces, is a matter of considerable significance. I have cited my own activities in the 309 European Theater of Operations. These examinations obviously could not have been given official recognition nor could they have moved smoothly, had it not been for Dr. Werrell's personal efforts. After 1945, with the cooperation of the Surgeons General and the State Department, the privilege of overseas examination was extended to candidates--military and civilian--the world over. One of Bill's last efforts on behalf of the Board was his negotiation with the office of the Surgeon General ef the Army for examinations in Baghdad, Heidelberg, Seoul, and Tokyo. In the transfer of the office from Des Moines to Madison, we encountered certain difficulties. The action of the Board had given Dr. Bierring and Mr. Hutchinson some leeway; but this movement was dated April 6, 1938. Not until December 1, 1938 were the records made available to us. This lapse was most embarrassing to Dr. Werrell and me. The bank account which was to be kept in a very small detail in Des Moines was not transferred to Madison until June 3, 1939; but in the end with Dr. Werrell's diplomatic and executive capacity all of the rough waters were ridden and we experienced a very healthful period of growth from 1938 to my entrance into military service in 1942. In the period until my official separation from the Board in 1944, the matters were carried over in regular order, as I have indicated, by Dr. Werrell. The termin­ ation of my duties as Secretary-Treasurer (1944) meant a transfer of the office of Secretary to my successor; but Dr. Werrell was continued as the Assistant Secretary-Treasurer and was given not only moral but material support. I paid tribute to Dr. Werrell in the editorial 310 column of the Annals of Internal Medicine, January 1965, from which I quote the following paragraph: "In a broader sphere, the American Board of Internal Medicine increasingly engaged his attention and energies. His unobtrusive guidance materially affected its course and action. Its present preeminence among qualifying boards of the medical world in a material measure reflects his vision and his perspicacity. Through its influence upon practice, Bill Werrell may appropriately be accorded a notable position in American medicine; but were he to have been consulted, he would have preferred the assured place he holds in the hearts of so many of us on whom he bestowed the blessing of friendship. 'He was a veray perfit gentil knight!' (Chaucer)" Dr. O.: Can I ask you just a couple of questions? One, going back really to the very early period around 1935. I gather there were several bodies other than the College who expressed an interest or felt that they were more appropriate to become the certifying body. I base this on one letter that I found--correspondence between you and Dr. Eric in 1936--in which he refers to the fact that the Interurban Club felt that they should take the initiative in forming a certifying society for internal medicine. I was wondering whether a number of bodies felt at that time that they were better suited to do the job. Dr. M.: No, I think that it had a local flavor. I do not think that it had any general impact. Dr. O.: I see. Part of this colloquialism that you referred to at the beginning. 311 Dr. M. : Right • Dr. o.: Along these same lines, I found another statement which I found rather fascinating. In a letter to Dr. Werrell you say, "as you recall Baltimore was one of the centers of serious resistance to the Board of Internal Medicine." Now Dr. Blalock, I have learned, was quite resistant to the formation of the American Board of Surgery and I am wondering what was with Baltimore? Dr. M.: This was a very interesting situation. Dr. Boggs, when he was President of the Association of American Physicians, took very pointed objection to the ability of any group of physicians to qualify an individual for certification. He indicated that it was rather beyond the range of human intelligence, for the one individual or group of individuals to pass on another who was perhaps his peer or their peer. The feeling was rather general and Louis Harrnnan, I don't know whether you knew him---- Dr. O.: I didn't know him but I certainly know of him. Dr. M.: ---- was elected to the American Board of Internal Medicine, not as a gesture but because of his eminent position, I think he was one of the outstanding clinicians of that period. In his first appear­ ance with the Board at examinations in New Orleans, he was assigned to me and I said, ''Will you proceed with the candidate, Dr. Harrnnan?" He said, "No, Middleton, I want to see you work!" I was being examined; I realized that. I went along at a natural pace and I hadn't gotten 312 through the second candidate before he said, ''Middleton, you and I think alike. Let's get on with the other six men." So that he came in wholeheartedly and I think that he really was the first one to break the ice in Baltimore. If Louis Hamman felt that this was a worthy mission, there was no one in Baltimore in Internal Medicine who would stand against him. I have always credited him with breaking the ice. The fact that we have had continuing representation there. The last one was Sam Asper, meant that men of stature in the Hopkins faculty have accepted the Board. It came from a psychologic standpoint; a resistance that I felt was not carefully thought through. The lack of appreciation of the basic philosophy behind all of this--Hopkins was receiving just as much benefit as the other institutions in the c0untry and yet they were not willing participants at the outset. Dr. Oo: It was apparently exactly the same story in surgery with the American Board of Surgery and the Hopkins. Dr. M.: I had never any misgivings, as you recall in my discussion this morning. I put the ideal at high level and I always maintained that to me certification could mean--if you have to have a cut-off point--the recognition of an individual whose clinical capabilities were those of a consultant. And a consultant to whom? Well, I put three men who were so far above me that I would recognize them as my superiors. I would go along with my peers up to that point. This amused my associates on the Board no end when I claimed that there was not one of them that I considered other than my peers. [End of Side I, Reel 9] 313 [Side II, Reel 9] Dr. O.: The date is February 10, 1969. This is Dr. Olch of the National Library of Medicine visiting with Dro William Middleton here in Bethesda at the National Library of Medicine rather than in Madison, as in the past. This is Side II, Reel 9, Side I having been recorded in Madison in November. We're to begin our discussion today of Dr. Middleton's experiences with the Veterans Administration. I'm not sure really how you wanted to approach this. It might be of interest, if you'd be willing, to give your views or your feelings about the historical development of the VA to the extent, say, from the period of General Hines up to the time that you arrived because my impression is, on the basis of my reading, that some of the policies started during the time of General Hines' administration, hung over and did have some effect actually on some of the things you were faced with when you first entered the VA. But if you'd rather wait and do this when you come to it in the course of the way you find approaches it, it matters not. Dr. M.: The policy of veteran medicine had undergone distinct changes in the inter-war period from 1918 to 1942. The actual participation in veteran medicine on my part was of an early period as a consultant in chest diseases for the Central and Southern Wisconsin areas. This situation was not one of policy making, but rather of service in patients who were referred to the University or to me personally at the Office of the Veterans Bureau of that period, 1922 on, for decision as to the 314 status of the pulmonary disease. Not until the period of reconstruc­ tion after World War II, was I intimately connected with policy forma­ tion. During the inter-war period, there was on the part of medicine­ at-large the feeling that the quality of service had not been maintained, in spite of the fact that there were dedicated physicians regularly employed by the, then termed, Veterans Bureau. Perhaps the real secret of the deterioration of service lay in the manner of control. In this respect, they--laymen at high level--dictated not only policy but the organizational delivery of medical service. Accordingly, there was not an incentive nor support from the general medical profession to improve the quality of care. This situation was entirely changed after World War II in the passage of Public Law 293 which was signed by President Truman on the 3rd of January, 1946. The story of this particular executive action is one of extreme importance to the ultimate develop­ ment of veteran medicine. However, only by the last minute intervention of strong political forces, and led in some measure by Dr. Paul Magnuson, was President Truman induced to bring the change of organization of the Department of Medicine and Surgery into effective operation. Significantly, the strongest opposition to this reorganizational pattern came from the Civil Service Commission. This position could be explained by the fact that under Public Law 293 physicians, dentists, and nurses fell without the purview of Civil Service. Obviously this agency was loathe to see such a large segment of important personnel pass out of its control. The actual development of the Department of Medicine and Surgery under this new public law was an amazing about-face insofar as 315 professional acceptance is concerned. With the assurance of advance­ ment and preferment by qualification rather than bureaucratic control under Civil Service Conmission regulations, it was possible to recruit staff and personnel beyond any predictions that had been proposed before. The Policy Memorandum 2 which was enunciated on the 30th of January, 1946, constituted the ''Magna Carta" for professional care in the enlistment of medical schools to work in association with the Veterans Administration Hospitals. This memorandum, at one step, gave to the medical schools a place in the recommendations and operation for the care of veteranso The Dean's Committee program gave to the faculty of the medical school a definite responsibility for the nomina­ tion of all members of the medical staffs of the affiliated hospitals with the clear understanding that these recommendations were, of course, coordinated with the chiefs of the respective services of the hospital and that the hospital manager, later director, had the ultimate right of veto. This prerogative was not commonly exercised since informal discussions between the contracting parties gave little ground for difference when an ultimate decision was madeo In my personal experi­ ence, this informal meeting of minds has been extremely important in averting last minute divisions that might lead to serious conflicts of interesto By the same token, all residents in a given service accepted by the Veterans Administration were subjected to the similar interchange between the Chief of Service of the Veterans Administration Hospital and the chairman of the affected department in the medical school. Obviously~out of hand, this arrangement meant a meeting of minds and a 316 sharing not only of responsibilities but an imneasurable improvement in the quality of veteran care. At first there was some question as to whether this circumstance might lead to the suggestion of veteran patients becoming guinea pigs. Certain of the veteran organizations raised this issue, but in general it early became apparent that the attendance of students and interchange of staff meant for much better care for the affected veteran. The total idea of affiliation between the Veterans Administration Hospitals and the medical schools was a product of Dr. Paul Magnuson's fertile mind. He had early comnunicated with General Hines on this point. At a later time he had with Dean J. Roscoe Miller, of the Northwestern University Medical School, proposed the affiliation of the Veterans Administration Hospitals with Northwestern University Medical School. This proposal was not favorably received by General Hines and his advisers. It is a matter of personal knowledge that Dr. Roy A. Wolford wrote the letter of rejection of this plan; but it is impossible to locate the said letter in the files of either involved party. The affiliations at the Hines Veterans Administration Hospital near Chicago and at the Fort Snelling Veterans Administration Hospital, Minnesota, were the first to be consummated and they have been most effective from the outset. The total program will be enlarged upon later, but this was the breakthrough that determined the success of the Dean's Committee arrangement. The Special Medical Advisory Group was established under the Public Law 293 to bring together the men representing the various departments 317 of medicine and the duties of this group "shall be to advise the Administrator through the Chief Medical Director and the Chief Medical Director direct relative to the care and treatment of disabled veterans on other matters pertinent to the Department of Medicine and Surgery." The organizational meeting of the Special Medical Advisory Group was in Washington on November 25 and 26, 1946 under the chairmanship of Dro Charles W. Mayo. Its functions were clearly defined and the challenge was an extremely great one. There had been a very desultory attempt in this direction under General Hines; but it had met only three times before he left office. The leadership of General Paul R. Hawley as Chief Medical Director was most effective and lasted for the duration of his tenure, some two years. The crossing of interests of the Board of Chief Consultants and the Special Medical Advisory Group will have occurred to any serious stu­ dent of the organizational pattern. It became obvious that the Board of Chief Consultants dealt primarily with professional matters and the Special Medical Advisory Group with administrative matters; but the crossing of the lines eventually led to the combination of the functions under the Special Medical Advisory Group in my tenure. Dr. O.: May I ask a question? I have the impression from reading through some of the papers that really some of the questions the Special Medical Advisory Group was faced with at this early·period--'46 on-- were some very basic factors in medical education or medical postgraduate education dealing with the residency programs, even for that period 318 reasonable salaries for house staff and so on, things that really the VA had never been faced with before. Dr. M.: You are quite correct that at this time the Special Medical Advisory Group was charged with attempting to place the graduate medical education on a sound basis and into this picture, of course, came the question of monetary return. We, first of all, did not wish to be placed in the position of the arbiter of the salary scale for resident positions, and, by the same token, it was our judgment that they were being exploited for service without proper financial return. Dr. O.: There wasn't 24-hour coverage either, was there? I remember something about its being almost Civil Service--an 8 to 5 job, the positions at the hospitals at that time. Dr. M.: In the early period there was the question of coverage and the 40-hour week schedule of the Civil Service Conmission carried over into our particular responsibility. However, it became the policy that the man receiving consideration under the Public Law 293 was a 24-hour, seven day employee, and was on call regardless of whether he was in actual residence or noto This policy was to carry over to the physi­ cians and dentists; but the nurses were never extended beyond their 40-hour week pattern. The meetings of the Special Medical Advisory Group were extremely stimulating and brought into a sharp relief certain of the differences that were developing between the then Chief Medical Director, Dr. Paul 319 B. Magnuson, and the Administrator of Veterans Affairs, General Carl R. Gray. To indicate the sharp difference that was developing beneath the surface, I might state that I was a close friend of both of the principals and was amazed to find such a sharp schism between them in personal conversations; whereas in our meeting of the Special Medical Advisory Group, all appeared to be very calm and serene. Having ex­ pounded his philosophy on one occasion, March, 1949, General Gray indicated his primary responsibility for the medical care. I took occasion at this meeting to ask him just how he would place himself in the military organization since I had first had my contact with him in this capacity in the European Theater of Operations. Well he said, "Bill, of course I am the Commander-in-Chief and I am the Surgeon General." I countered this argument by asking whether he did not re­ call the situation under which we had both operated in wartime. Since he did not enlarge on his position, I said, "General Gray, it is my personal opinion that you are Chief of Staff and that the Commander­ in-Chief is the President! In the actual military operations, one General George Marshall issued the commands for the Commander-in-Chief, the President. In turn these orders were carried out by the several echelons of command until you came to the Chief Surgeon in the European Theater of Operations. Hence, I would place your position as Chief of Staff in our organizational planning." He rather reluctantly admitted that this was the case! Realizing this strained situation that existed between Paul Magnuson and Carl Gray, when I learned that, with a ghost, Paul was writing his biography, I appealed to him to play down the 320 differences that existed between them. I realized Paul's personal animosity, but I did not believe that it could do veteran medicine any good to 'wash our linen in public." On an earlier occasion I had refused to participate in a radio program that he had arranged---- Dr. o.: Yes, there's a letter in here from Dr. Magnuson requesting you to do this. Dr. M.: The letter of April 27, 1951 indicates that my unwillingness to appear on the American Forum of the Air had as its background the impact of such an expressed difference of high levels on tlE public image of veteran medicine. In this letter I clearly stated that "the difference is so deep that I do not anticipate its resolution without change of personnel. While I sympathize with the several communications from the consultants and the representatives of the Dean's conunittee, I feel that they have aroused doubts without settling the issues. Least of all do we wish to make Carl Gray appear as a martyr and this very end is in sight in certain areas of important influence. I'm not poli­ tically minded nor diplomatically adroit enough to know how to meet this issue. I am convinced that the American people will prevail as soon as they are convinced that there is a clear issue in which the inalienable right of sick and disabled veterans is in jeopardy." At that time, I expressed my regret and inability to serve Paul Magnuson in this relation. "Ring the Night Bell," the title of Paul's biography, was taking form I used my utmost influence to have Paul delete any reference to the 321 difference with Carl Gray. At least he might play it down since, as I said, Carl is dead. Paul's response was characteristic; he said, "He is as dumb dead as he was alive!" And so "Ring the Night Bell" contains a very extended discussion of the differences that arose between these two strong and faithful servants of the American veteran. Dr. O.: Am I correct, there a number of similarities between Paul Hawley and Paul Magnuson? Dr. M.: You're right in one respecto Paul Hawley was impulsive. He hit hard and strong and then regretted at his leisure when he had time to contemplate. Very impulsive; very quick of action, he felt that he had to make these prompt decisions. I think that in our discussion of the relationship in the European Theater of Operations, I made it clear that I always had contact with his secretary or his executive officer before I made my approach! Paul Magnuson was more pugnaciouso He was never so happy as when he was in a fight--! mean to say that he'd go and look for it; .he'd not avoid it. He would not conciliate on any point. As you will have gathered in this Gray-Magnuson affair, he was absolutely unapproachable--he just would not give an inch! Dr. O.: I gather that they both had little use for red tape and if they saw something that had to be done they had the feeling you did it; you didn't worry about.notifying a, b, c, and d down the chain of com­ mand as it were. Dr. M.: Right, exactly. But because of Paul Hawley's military up­ bringing--see all his professional life until his retirement had been 322 in the military--he was more apt to follow protocol. Paul Magnuson looked upon protocol and red tape as something to be avoided. Dr. O.: Magnuson, Paul Magnuson. Dr. M.: Paul Magnuson, yes. Paul Magnuson had very clear ideas on not having anything interfere with him. The Booz, Allen and Hamilton Report had been the result of a desire on the part of the government, the Comptroller's Office in particular, to derive a clearer idea of the organizational pattern of the Veterans Administration and its recommendations for correction or improvement. It was a very extended affair, carried over several years, a most ex­ pensive operation, and in my judgment one of the most ineffective instruments I have ever seen delivered. It was largely derived from the pattern of interviewing the people who knew the problem and its solution better and then the reconciliation of these views of the various individuals interviewed into a composite that had very little functional usefulness. If out of the large sum that was expended there could have been a tenth of its value translated into actual implementa­ tion, I'd say that I was exaggerating the take on the project! I might add, too, that if I had one observation after continued federal service, the tendency to have recourse to surveys by various---- Dr. O.: Consulting firms? Dr. M.: consulting firms, yes, is one of the least effective of all media. I realize that there comes a time when an outside opinion 323 is desired or is required by the Executive or the Legislative Branch of government. In my personal experience, it is one of the greatest wastes of public funds that I have encountered! With the retirement, and Dr. Magnuson insists that he was not retired, but he was fired, Admiral Joel To Boone was made the Chief Medical Director, and throughout his term of service there was a distinct con­ solidation of the professional front. Dr. O.: He succeeded Magnuson in 1951. Dr. M.: Right. Admiral Boone was a retired naval officer with a distinguished career. One of the few holders of the Congressional Medal of Honor, among medical men, he carried not only a conciliatory presence but a sympathetic attitude toward the problems of the veteran. As a career medical officer, he had the presence and the attitude of acceptance of protocol with a thought single to the welfare of the veteran. Unquestionably, his personal punctilio led to certain rulings that brought much amusement if less perfection to the physical plants under his supervision. His associations with the Administrator, General Gray, and later, Harvey Vo Higley, were very closeo His capac­ ity for friendship brought every force within and without government to his ranks. The matter of his insight into veterans' affairs led to his continuance as consultant, working particularly with the Special Medical Advisory Group for the entire eight years of his successor's tenure. 324 Dr. O.: You were on this Medical Advisory Group during his tenure, were you not? Dr. M.: I was on the Special Medical Advisory Group from '46 to 'SO. Dr. O.: When you took over the presidency of the---- Dr. M.: That's right, the American College of Physicians. So that you see that I did not overlap there. Dr. O.: Yes, here's a letter that states, a letter of December 20, 1949 you said that you regretted that you must drop out of the Special Medical Advisory Group because of your becoming President-elect of the American College of Physicians. Dr. M.: I think then I'd better go directly to my appointment. Dr. O.: May I just ask--I gather during Admiral Boone's tour as Medical Director, whether it was the first evidence of this or it came to a peak then, but I know it carried on for awhile after; I gather there was some degree of criticism from organized medicine directed toward the VA in the area of nonservice connected medical care. Dr. M.: Well, now, I'll bring that up right here then. Two matters of policy confronted Admiral Boone insofar as the hospital admittance was concerned. The first relates to segregation by racial differences. Actually, there had been certain hospitals constructed with bath, toilet, and other facilities for each of the two major races. This circumstance 325 was a very serious one in conflict with humanitarian as well as national policy. Having served under General Eisenhower in the European Theater of Operations, I realized that this was scarcely in consonance with his attitude, and President Truman had carried the policy of desegregation to the last degree in the Armed Forces. Segregation of sick veterans was, in the minds of the Veterans Administration in general and Admiral Boone in particular, an anathema. They extended every effort to follow through the policy that had been laid down in the Armed Forces by President Truman. With Admiral Boone's complete support under Adminis­ trator Higley's direction, there was developed a plan by which all discussions of racial differences would be handled by a single person. It fell the lot of Dr. Herman D. Kretzschmar to handle this delicate task which was particularly important in some 47 hospitals, largely in the deep South. With utmost insight and discretion, Dr. Kretzschmar achieved this high ideal by a rather interesting approach. No direc­ tive was written. No published policy appeared. The attitude of the staff in all echelons was established by informal personal interchange. Where questions of departure from the stated executive policy existed, immediate measures were taken to correct the same by telephone or personal interchange. One very graphic example occurs to my mind as it affected me shortly after my arrival in Washington, 1955. The Special Assistant to Administrator Higley came to my office--a Mr. Holland-- to pay his respects. In the course of this conversation, this polished, well-educated Negro stated that two instances of apparent discrimina­ tion had come to his attention in the recent past. He cited the 326 situation and I immediately called Dro Kretzschmar into the office. Mro Holland indicated the two situations that had appeared to him under the affidavits of the complaintants; whereupon I said, "You two will take the first train or plane to these stations.~' Mro Holland objected and said, "Of course, there's no need for action of such prompt order." I indicated to him that I did not think that these situations could exist or persist without attention, and immediate attention. They followed my direction. To Mr. Holland's credit upon return he said that both proved to be invalid by reason of falsification or false represen­ tation. Until later in my stay in Washington, there was only a single departure from this clear record. A veteran with a return appointment for a checkup on a peptic ulcer was placed in the bed next to a Negro in one of the wards of a southern hospitalo He protested vigorouslyo The nurse in charge indicated to him that the only bed available elsewhere was in a closed psychiatric ward. Obviously, neither the Negro patient with a broken arm nor the white patient with the peptic ulcer could be moved to this location. She told him that if he would be patient and wait until morning, she was certain that readjustments would occur with the daily interchange. He, however, preemptorily demanded his clothes and withdrew from the hospital. Our first response to this overt action on the part of the self-discharged patient was to have notice that the Louisiana State Department of the American Legion had entered protest and had even gone so far as to charge me with being a Communist! The complaint was taken to the National Convention of the American Legion 327 and, to the credit of that organization, was ruled out of order! In a word, Dr. Kretzschmar's work at the base with the support in every echelon of the Veterans Administration and the Executive Head of Government has borne rich fruit in the record of the Veterans Adminis­ tration in the care of all veterans regardless of sex, race, religion or politics. The circumstances of my appointment to the position of Chief Medical Director of the Veterans Administration, Department of Medicine and Surgery have been clearly defined in the Remembrancero I do not think that there '·s any occasion to enlarge upon that. Dro Oo: Fineo I meant to bring that in actually, I forgot to; I'll bring it in this afternoono Dr. M.: I'm certain that all ground has been covered there; but it should be clearly stated again for the record that the ultimate issue raised by General Howard Snyder was that of dutyo Since I had no design or desire for administrative work, I was most content to see out my last years before retirement in the classroom and at the bedside of patients at the University of Wisconsin. The ''Medical Care of Veterans" which was prepared by my administrative assistant and dear friend, Robinson E. Adkins, is rather overcharged with a laudatory and exaggerated estimate of my service. If I were to use it as a text, it would be merely to discount a number of the itemso There are, however, certain details in this section of Bob Adkins' 328 account to which I would refer. The teaching has been a great source of satisfaction to me. As a teacher with some years of service behind, I can say that it is the most rewarding human endeavor that any indi­ vidual could seek. The circumstance of departure, whether military or veteran, has never brought a block to this instinctive reactiono I can say in all candor that it is a consuming passion that will out regardlesso Dr. O.: I think you're rather famous for that. I've heard tales of you going over to the VA Hospital at Mto Alto once a week. Dr. M.: So that actually as Dr. Osler said whatever the occasion, I've found the opportunity to teach. As a matter of fact, my contention is that I can walk but cannot think without a stethoscope! The magnitude of the Medical Department's responsibilities did not appall me since I had had the years of connection, first, with the Veterans Bureau as a consultant from 1922, and then the intimate contact with Central Office in my function as a member of the Special Medical Advisory Group for four years--'46 to '50. [End of Side II, Reel 9] [Side I, Reel 10] February 10, 1969. Dr. M.: The opportunity to survey the Canadian Research Program in the hospitals of the Canadian Department of Veterans Affairs in 1953-54 had afforded me an added basis of comparison and a very definite incen­ tive to the improvement not only of the Canadian opportunity but the American outlet for research and educationo The latter circumstance 329 found an interesting interchange in Congressional meetingso The Sub­ corrmittee on Appropriation of the House was the final arbiter of recommendations for our budgetary requirements. Under the highly intelligent and searching chairmanship of Representative Albert Thomas, we were required to justify every step of our wayo The only amusing outlet was the tremendous attention paid to travel expenses when, in our hearts, we realized that our inquirers were the rawest offenders in their junketing. The point of research was always under fire at the chairman's handso And I recall vividly his insistence that the Veterans Administration should get out of the research businesso Dr. O.: This was Congressman Thomas? Dr. M.: Yeso When I indicated to him as calmly as I could under the circumstances that not only was medicine advanced, but the veterans' care was irrmeasurably improved under these terms, he always countered with the statement that "It was not the intent of Congress to set up research institutes in every hospital in the land." His position was not tenable on sound logical basis; but Mr. Thomas attempted to pare appropriations down to the bone! Respecting his responsibilities, I nonetheless was interested to have his reaction when our first increase from some six million to ten million dollars for research occurred. Almost immediately upon the announcement of the ultimate figure, he called me by phone and said, "Now, Doctor, you won't squander this money by sending it around to a lot of hospitals, I hope. I'd like to see you just put it on three or four. Just put a lot of,money down 330 in Houston and build something that's worthwhile!" Realizing his rather chauvinistic approach, I tried to mollify him and indicate that unfortunately we could not hold Texas as a model nor yet as the total recipient of funds. I would be guided by men who were better qualified than I to see that the money was not misspent, and thanked him for his interest and support. An entirely different angle to this problem--appearing before the Bureau of the Budget. We had been given our guidelines, then the Subcommittee on Appropriation of the House had indicated what would be their ulti­ mate recommendation. We were called before the Finance Committee of the Senate. Senator Hayden, infirm with yea.rs, rarely chaired his Connnittee; but the Subchairman, Senator Magnuson, of Washington, on frequent occasions was in the chair. This time when we had had a mate­ rial increase in the recommendation by the House Subcommittee, I gave what to me was a lucid presentation of our needs. We had, fortunately, projected the plan over a ten-year period and by phases hoped to in­ crease the research activities both from the standpoint of their use­ fulness in the care of the veteran sick and disabled, and for their contribution to science in general and to humanity at large. I was quite taken aback when Senator Magnuson said, "Doctor, with your back­ ground, I'm amazed that you bring in such a miserable exposition of the needs and opportunities of veteran medicine. I have been advised that industry and business assign ten percent of their operation to research. At that rate, you should be asking for sixty million instead ·h.:".r~ o f ~ ~ million dollars!" Fortunately, my wits were with me and I 331 realized that Mike Gorman, legman for Mary Lasker and her group, had gotten to Senator Magnuson. I was not stampeded. I indicated to him that were the Senate to approve the reconnnendation of the House and were we to be given these sums, I would appear before him the next year and give him a clear accounting of every dollar that was spento I furthermore stated that I felt that we could use intelligently the in­ crease that was requested and that the American public could be satis­ fied by my explanation. Were we, however, to be given sixty million rather than fifteen million dollars, I knew that I could not build up the organization to make such a grant effectiveo By the same token, no man in an administrative position responsible for a research program could build on a fluctuating level--sixty million this year, fifteen million next year; fifteen million this year, thirty million next year. "I could not, Senator Magnuson, give a clear accounting of budgeting after this pattern. It has to be a planned, steady growth. Then I can t~,,h give you a clear accountingo" We got our rifteen million dollars! Interesting was the ability to insert into the mandate of Congress under Section 4101, Title 38, U.S. Code, a simple phrase "including medical research 0 after the earlier mandate of Congress to the VA, for complete medical and hospital serviceo This gave a legal tone to our research program and the growth from that time, of course, has been very steady and appreciable, but Mr. Thomas never forgave meo I introduced that particular phrase without his knowledge and he took his "pound of flesh" from that time on. 332 Dr. O.: Would he specifically ride you at budget hearings about the research programs or would he not be that obvious? Dr. M.: No, he did not ride me. He was always very courteous and considerate because he knew that I would never rile back. But one of the instruments that he used was--there are two, really, I think I should cite in this relation. I, first of all, felt that the Depart­ ment of Medicine and Surgery was miscast when it was held responsible for the cemeteries. I tried to get our own agency through the Admin­ istrator's action--he was then, John Gleason (whose wealth by the way came through a mortuarial activity in Chicago and I was up against a stone wall there), to define a veteran. I was all for the soldier's cemeteries; but I did not feel that it should be a medical benefit and I thought that it should be moved from the Department of Medicine and Surgery. I realized that I was creating a situation that would mean a tremendous relocation of funds and so forth; but I still and do now maintain that this would be a perfectly logical area for the reassignment of responsibilities within a given agency. The VA yes; benefits, yes; Department of Medicine and Surgery, no. I was beaten on my own ground. Mr. Thomas, I do not assign to him any personal advantage; but at a time of financial stringency he had the VA buy a tract of land for a cemetery outside of Houstono Dr. O.: Yes, I remember seeing correspondence about thiso 333 Dr. M.: And I could not agree. And in my absence, the Deputy signed off. I would never sign release because we were hard pressed for money. This purchase took money that was actually reassigned by the Bureau of the Budget from patient care funds--one million dollars! It was high cost and I think they had enough ground or land to bury many more Texans! I had taken into account the distance of transpor­ tation, the call for the burial lots on an actuarial basis, you know, that would occur in that area, and it was far excessive to our n~ed even if I had had to sign it which I would not do. The second point of departure was the one where Mr. Albert Thomas and I regularly clashed. He felt that the organizational pattern of the Veterans Administration was not sound in that you should have only a cadre in Central Office. "You have too many in Central Office, Doctor, too many in Central Office, and you should have the hospital director running the show in the field with nothing between." I had stood out strongly for the organizational pattern that followed not only agency policy in--we'll say the FBI, or the Department of Agriculture, and so forth--but the policy that was followed in business and industry, where if there are multiples, they would have regional representation. The table of organization I supported was to have the individual at Central Office with an area office in the fieldo The Area Office had a series of hospitals, so that you could conununicate with an Area Office and have dissemination without going through this whole 170-odd hospitals-- 173 when I went there; 169 now. The cost of this was higher. I 334 admitted there was a cost--! think it was five hundred thousand dollars, just to put the figure out grossly--to run all of these Area Offices; we'll say there were seven. Booz, Allen, and Hamilton had interestingly reconnnended twenty. We had gotten it down to a point where we felt that we could effectively operate. Under Mr. Whittier who was rather loathe to accept this position, it was proposed that we would take one area and set it up as a model, he would see how it w0rked. We took the Sto Louis area with its widespread responsibility and it did a beautiful job with the counter­ parts of the Central Office, responsive to the field. So the innnediate contact was not to a huge Central Office. It did diminish the number of people you had in Central Office, by the same tokeno Mr. Whittier who had succeeded Mr. Higley as Administrator, was not convinced; so he sent his Deputy, Bob Lamphere, to Sto Louis. He spent several days going over the Area operation. He reported the pattern perfect. There was no question but that it was the answer. There was a little drag­ ging of heels. Mro Thomas was fighting it tooth and nail. I knew that we would have no show there. When Mro Gleason succeeded Mr. Whittier with the change of Administration, the decision as to decen­ tralizing to the Area Medical Directors' offices was in the air. Mr. Gleason was acquainted with the military--! had brought a military chart--he was a major general in the reserves--so I spread that out before him and I said, "Now, Jack, what do you want; Mr. Thomas' pat­ tern which is purely a matter of innnediate economy not ultimate service, or do you want a system you can work with?" "Let me think 335 about it for awhile, Bill." Well, he thought about it for awhile until it drifted off. Finally he admitted to me that the pressure was such that he just could not give way with the idea of the greater need of the Veterans Administration. So I lost that contest, but I lost it to Mr. Thomas not to Mro Gleason. Dr. O.: This is very interesting because in the correspondence one sees and the correspondence you get from the field at that time, from some of your area medical officers who were quite distraught, obviously, at the thought that "what the hell's going on in Washington; we're being wiped off the map." I get the feeling everybody's blaming it on Gleason and this is the first I was aware of it. As you say he being pressured by Thomas. Dr. M.: Yes, that is exactly the situation and I am very gratified to have it a matter of record because it was Mr. Thomas' contribution to mismanagement from the ultimate standpoint of organization. Dr. O.: Well, there had been a field study tooo Hadn't the Central Office sent down or the Bureau of the Budget or somebody with a team of interviewers which had done a rather unsatisfactory job? Dro M.: Right. And at the present time----first they brought all the Area Medical Directors into Washington where they sat just getting reports and handing them around to the people in the Central Office for action. The next formula followed the misguided plan of the Veterans Benefits Division of the Veterans Administration in that they 336 have now some more control. I do not know just how that is working. As a matter of fact I do not meddle in Veterans Administration affairs. The next question that I should like to discuss has to do with the Tobacco Merchants Association interchangeo Oscar Auerbach, at Orange, New Jersey had done some very revealing work on the effect of cigarette smoking on the lungso His technique was to take out the lung, remove the bronchial tree and then wind up the mucosa of the bronchus in a solid form and section it. Histologically he found that the changes were first, to hyperplasia, then to metaplasia, then to neoplasia. I had only one point of departure with him personally in our discussions. I could not get his differentiation of the carcinoma in situ from the neoplasia. In other words, to me this was just simply shaving the distinction a little bit too thin; I would have merely said neoplasia. This work created a tremendous lot of discussiono Undoubtedly it's fundamental in the sense that it was taking the histologic section of the bronchus in which he could read the changes of individuals who had smoked a certain length of time and gone beyond that, and then come back to the individuals who had stopped smokingo In the latter the regression of the changes in the bronchial epithelium could be demon­ strated. As a scientific contribution, it was quite outstandingo From the time of the earliest observation of Alton Ochsner, no unbiased student of the field doubted that there was some connection between cigarette smoking and bronchogenic carcinoma, that they would find some histologic correlation that was undeniable. So it was Oscar Auerbach's work that afforded the proof. Of course, the fact that it evolved in 337 the Veterans Administration, afforded a target. I'm very proud of this letter that appears in response to their inquiries (on p. 264 of Medical Care of Veterans); I sat up late nights writing it. Out of hand, you and I realize that if an agency were to set itself up in judgment saying ''Well this is good; this is bad; this is indifferent," you'd not only have a stultified set of workers, you'd ultimately have nothing. No research worker would stay with any organization under those conditions. This philosophy, in a sense, is what I attempted to convey. As a matter of fact, the historical sequence is a little bit more dramatic than we anticipated, since we have the recent action that cigarette manufacturers will no longer advertise in a national media. Dro O.: Yes, things are really beginning to move, I think, at long last. Dr. M.: An interesting circumstance, of course, was that the people who promulgated this--Tobacco Merchants Association--had approached me as Dean to instigate studies at Madisono Murray Angevine took over from them and I think he is still on the committeeo So that they were not attempting to justify or condone; at that time, they apparently were after the trutho The next item of note relates to the educational program and I might anticipate a little bit by commenting on the fact that when President Kennedy was gracious enough to have me over to the White House to pay his compliments to my efforts on my retirement, he said," "Did you not 338 find it very trying to get away from teaching, Dr. Middleton?" I said, "Sir, I think you understand that I have continued to do a little teaching; but that's not the important detail. The Veterans Adminis­ tration has the largest graduate program in medical education in the world!" He said, "What do you mean?" I told him about the residency program and the association at every level with the medical students. I said, "I did not move out of education completely." That I think is perhaps an epitome of what one can say about the Chief Medical Director's part in this particular relation. An exaggeration in ''Medical Care of Veterans"--at the time that this was written, there were 73 medical schools conducting some portion of their training in 93--not 193 [see p. 265, Medical Care of Veterans]--of our hospitals. Eleven percent of all the residents in this country are in the VA in some portion of their training. It's between eleven and twelve percent. So that it takes on a very important aspect of the total question. We have ex­ tended programs for the clinical psychologists, for the dietitians, for practical nurses and for various technicians now. Some of the graduate nurses, or those candidates for graduate nursing, have come into our hospital for special courses; but the number has fallen off in tuber­ culosis which was the area of their primary interest--and psychiatry. Of the two, the decrease in the incidence of tuberculosis limits the utilization of this area. The question of the undergraduates--! give you my daily schedule which is a brief for what we do. I have a group of clinical clerks at 7:30 in the morning--7:30 to 8 they recount what they have done as the duty 339 man of the night. Then I have rounds with clinical clerks, interns, and residents, and the conferences and so forth that I attend. In the afternoon, once a week, I have a class in physical diagnosis. So you see that they are second year students; third and fourth year students with whom I work throughout the day. I think that it's a cross-section of what is being done in medical education by the Veterans Administra­ tion. Apparently, and this is not to make invidious comparisons, the accessibility of the full time men, whether they be at the resident or staff level, to the clinical clerks is what they notice more than any­ thing else in the Veterans Administration Hospital. If the staff men are doing research, they are doing research on the ground; they're not moved out and they're not in another inaccessible area. Dr. O.: Yes. When the student compares this to their university hospitalo That's right. It's a very interesting point. Dro M.: So that it makes for a very distinct feeling of closer rapport with our staff than with their own institution. This reaction is a little disturbing in one sense, but it does show what is being done from an educational standpoint. I'm going to come to that in an entirely different relation. The students conunonly raise the question of an entirely different order that relates to the status of the patient, i.e. compensation or pension. They do not realize that these are two different things. Compensation represents the government's responsi­ bility for injury or disability incurred in action or if in peacetimes, some illness that has disabled the individual, so that he receives a 340 monetary return. Pension relates to age. There is a ruling that the veterans of the Spanish-American War, for example, receive a pension. They are entirely different. It has a distinct bearing when you come to the veteran patientso We have had a Congressional ruling that the patient who is receiving compensation, service-connected, for medical care, must be admitted on application. The patient who has service­ connected disability will be admitted regardless of service relation for any other intercurrent medical condition. For example, you lost a leg in combat and receive compensation then you developed mastoiditis; you'd be admitted for the mastoiditis without question--by law you are eligible. The third group comprised the veteran with the nonservice­ connected disabilitieso The nonservice-connected disability is in an individual who has no compensation, yet he is eligible if he has a medical condition requiring hospitalization and signs an affidavit that he is unable to stand the medical costs. I can cover the ground againo If a millionaire comes in, and this is the one question that faces the public so often, "Oh I know this banker, why he comes to your hospital without cost. Yet he could pay any price; he's worth a million dollars." If he has some service-connected disability, you cannot refuse him admission--he must be accepted. In the second place, if he has service-connected disability and some other medical problem, he can come in for an appendectomy or a herniorrhaphy, for example, regard­ less of his wealth. Now the third, nonservice-connected disability of course is another issueo This obviously didn't occur as a result of his war service or service between wars--just how can he come in? 341 Only if he signs an affidavit that he is not able to pay for medical care. Then he must be admitted if a bed is available. What does the record show? In my time there have been five different surveys by government and nongovernment agencies. We'll say the non­ government approach might be a little biased in the case of a service organization. The General Accounting Office--the GAO--has made its own study; we have made our own. There have been five in the period of my knowledge. The one that I was responsible for was on a given day in Octobero All of the nonservice-connected patient records were referred to Central Office for analysis; all of the finances were listed, assets and liabilities together with the diagnoses. One of the amazing circumstances was the discrepancy in insurance coverage. At that time it was generally stated that 85 percent of the population was covered by hospital insurance. Actually, when we looked into it, only 18 percent of our studied group had hospital insurance. Eighty­ two percent were not covered. I do .not know where they got their figureso There is of course a wide coverage, but the coverance is quite variableo Our survey disclosed what was found in each of these other four surveys. Less than five-tenths of one percent of this group could, by the strictest criteria, have been financially responsible for their medical care. What conditions did we have in this survey of ours? I recall them vividly, patients with rheumatoid arthritis, cirrhosis of the liver, cancer, psychosis, anyone of which would be catastrophic. So that it comes down to a pretty slim margin. My own judgment is the -· veteran is just as honest as the general American public. There is no 342 real abuse if you bring the situation to the ultimate analyses. And these, as I say, were the GAO, the veterans' organizations and the VA surveys. All came out with this singularly uniform figure of four­ tenths or five-tenths of one percent deviation. I think this situation should be generally known to the American public. Dr. O.: Quite remarkable. Yes, and it really isn't well-publicized because again, most people from the private sector of medicine; if they are in the vicinity of a VA hospital, at least on one occasion will "lip off" about how the VA steals some of their patients. Dr. M.: Right. The utilization of the hospital has concerned me greatly, as you know. We were able to put two patterns into effect, the "prebed care program" and the "completed bed occupancy." Obviously, the "prebed care program" is designed to effect the same gain in time for the veteran as is observed in a civilian hospital by laboratory and other devices that may shorten his hospital stay. The completion of bed occupancy care is actually the introduction of outpatient care that had been denied under previous regulations. This had been largely effected through the influence of the House Committee on Veterans Affairs under the leadership of Representative Teague. Dr. O.: Olin Teague. Dr. M.: Olin Teague--"Tiger" Teague! Dr. O.: Yes. We should have you make a corn:nent about him before you're through. 343 Dr. M.: This is an extremely important circumstance in that the CBOC has been succeeded and augmented by the posthospital care which is, in truth, the outpatient care which of itself determines a tremendously increased service to the veteran. By the same token, there is some expansion in the home town physician program which has been extremely extensive. In both instances, the thought of the economy was in mind, not only the economy of government but the personal adequacy or self­ sufficiency of the veteran patient. This has been measured in dollars and cents; but I think that from the moral standpoint that it is a responsibility of government to protect both ends. The matter of hospital placement and hospital construction are details that deserve separate consideration. The old idea of the pork barrel location simply out of the political expediency upon the pressure of certain elements, has long passed out of the scene. We had in Wis­ consin a notable example of that type at Tomah where an Indian school had been abandoned and, for the local economy, a Representative in Congress made pressure enough to have a hospital built a hundred miles from the University of Wisconsin. When surveyed by General Paul R. Hawley, then Chief Medical Director, it was listed as the worst pork barrel that he had encountered! Eventually, through the local coopera­ tion and the support of the University of Wisconsin Medical School through consultants, it has functioned as a hospital for the long-term mentally ill. Without doubt, it is one of the conspicuous examples of misplacement of a hospital facility for the care of the mentally ill. In general then, beginning with General Hawley in post-World War II 344 period and under Public Law 293, hospitals have been placed strategi­ cally as close to medical schools as possible in the hope that the cooperation of the Dean's Committee arrangement will enhance recruit­ ment of a qualified staff and the quality of medical care. I've often remarked that good medicine can be practiced anywhere, better medicine where there are adequate laboratory facilities, and the best medicine where there is research as well as physical and professional support. This will hold true invariably in the closely knit complex of the Veterans Administration Hospital in the university hospital medical center where there is an intimate relationship. As a matter of fact, in many instances it is hard to tell where one begins and the other ends. There is a very strong design to bring these relationships ever closero The location of hospitals brings up an amusing incident because the Chief Medical Director is occasionally invited to participate in the choice of site. In this relation, I was asked to review the several sites for the replacement of the Oakland, California Veterans Adminis­ tration Hospital. After great care and scrutiny of four or five sites, I finally said in a very convinced tone of voice and mind that this was it. When the engineers went over the land, they found that I had picked out the San Andreas Fault! Absolutely right on the dot! I couldn't have missed! Dr. Oo: That's fabulous. It was probably very scenic and looked fine. 345 Dr. M.: Oh, it was perfect. So that there can be errors of judgment rising from ignorance of fundamental geographic details. The circumstance of the type of hospital underwent distinct changes during my tenure. It can be explained in the first place by the change in population. The named hospitals, tuberculosis hospital, psychiatric hospital, general hospital all fell into the last named category because the incidence of tuberculosis fell sharply and we should devote just a few moments to that later. In actual figures, from 15,960, when I went into Central Office in 1955, to 6,900 in 1963--eight years later, at the end of my term. In 1955 there were 21 hospitals devoted exclusively to care of tuberculous patients. Five were of that order in 1963. There are, I believe, now only two. The major contributions to this phenomenal advance were, first, early recognition and care of tubercu­ losis passing through the surgical phase to the medical phase; secondly, the retrieval of a great many patients by the newer antituberculosis drugs who would have had longer residence and longer care without them. Which is to say that the need for independent tuberculosis hospitals had diminished, and it was only logical to make them a component part of an all-purpose general hospital. The same is happening in the area of mental illness where the newer hospitals all have their units for the care of the mentally ill. I might cite that within the past week, they have just opened a section of a 1951 version of the Veterans Administration Hospital in Madison for emotionally disturbed patients. It was originally constructed for the care of tuberculosis. There are now fifteen patients with tuberculosis and they occupy only an isolated 346 section of one ward. The idea of an all-purpose hospital has risen first from the logical utilization of space and then, at an all-purpose hospital you will have all of the personnel--all the facilities for the patient whether he be mentally ill, tuberculous, or with other forms of illness. So that it works to the advantage not only of the administration, but more important, to the advantage of the veteran patient whether he had one or other illnesses. He has accessible care in all areas. For a long time I had been concerned in the utilization of hospital beds. This situation became very much more apparent when the responsi­ bility for a large system of hospitals fell my lot. In this respect, the average civilian, voluntary or other, hospital had a pattern of the five or five and a half day week fitted into the accustomed 40-hour schedule. This arrangement meant that for one to one and a half days there was only a skeleton crew for the emergent subject that might be admitted on Saturday afternoon or Sunday. This circumstance was com­ pounded when one dealt with the Veterans Administration system with its 169 hospitals at an estimated capital cost of three billion dollars. From a material standpoint, it was inconceivable to me that the American public could stand quietly by with such a large investment idle for one to one and a half days of the week. Extending this proposition to the hospital situation of the country at large, the magnitude of the loss in human service became the impelling force that led to a closer scru­ tiny of the subject. The patient is ill twenty-four hours a day, seven days a week, and three hundred and sixty-five days a year in my book. 347 I have never tolerated professional neglect in the system that con­ fronted me in academic as well as governmental service. However, I had learned at first hand in Madison that the highest hurdle to clear was the nursing service in the operating room and had met my first rebuff at their hands. Turning to the situation in the Department of Medicine and Surgery, matters came to a sharp focus when the waiting list at Coral Gables Veterans Administration Hospital reached 700 who were eligible but for whom there was no vacant bedo The word had spread among veterans that led many eligible sick and disabled to seek help elsewhere. Since the bed capacity of this hospital was 450, I turned to the pressing question that had occupied my attention for so long a period and asked the Hospital Director, Dr. Earl Gluckman, to undertake a review and correction of this situation by establishing a seven-day operation. It was interesting that the phases and stages of implementing such a plan should have first found obstacles in the clerical and laboratory areas. This corrected, there developed need for nurses and other para­ medical help such as in the laboratory. Confining the work period to forty hours, it was possible by staggering the actual working day to effect a perceptible improvement in the utilization of beds. Obviously, this circumstance was in no small measure improved by the prebed care program and the posthospital care program; but in the last analysis the expenditure of three percent increase in the total funds allotment resulted in a fifteen percent increase in the turnover of patients. These circumstances are sununated by the factors involvedo However, 348 it should not be assumed that one could repeat the experience of a single year each year, as one would catch up with the total need of the local demand for hospital beds. It is my firm conviction that in the period when medicine is pricing itself out of the field largely through hospitalization costs, some device for the better utilization of hospital beds may be a partial answer to the question. Certainly the American public deserves a broad trial of some such device. Dr. O.: I gather this was the only hospital in which this was tried in the VA. Dr. M.: That's right. I couldn't tell you whether it has been applied since because my term ran out. Dr. O.: But it was continuing at the time you left? Dr. M.: That's right. Dr. O.: Do you know of any application of a similar program in any civilian hospital? Dr. M.: No. And I think there's a crying need. I think that one should look at the picture as it affected other countries. The period of our residence in Britain--1942 to '44--was marked by the release of the Beveridge report, the ''White paper." The National Health Act was not put into operation until somewhat later. The fact remains that the occasion for the collapse of the British system of medicine, while it had had its origin with Lloyd George in 1910 and '12, a~~ually came to a crisis in the war period through the withdrawal of support from the 349 landed gentry. Taxation had been confiscatory in Britain since 19140 The voluntary hospital had depended entirely upon these wealthy sources for support. Since that fountain was diverted into government channels by taxation, the hospitals fell of their own weight. It was the hospital that brought the profession down and determined the actual National Health Act in its ultimate terms. Not generally understood is the fact that this was under a coalition government with Winston Churchill at the helm and not under a Labor government. So that if one may read the "handwriting on the wall," this is where the trend may be determined in this countryo Hospitalization costs rather than direct professional costs. [End of Side I, Reel 10] [Side II, Reel 10] February 10, 1969. Dro M.: The interchange with Congress was not always at the committee level. Not infrequently members of the Congress sought advice or offered the same relative to our programso One of the most helpful among these men was Representative Olin Teague of Texas. Himself a war casualty who had spent some two years in Veterans Administration Hospi­ tals, he was a worthy champion of superior medical care for the veteran. His very effective chairmanship of the House Veterans Affairs Conunittee gave a forum for the discussion of all problems relating theretoo I have frequently commented on the patience and forbearance of Mr. Teague in listening to innumerable witnesses for various causes affecting the American veterano Coming away from one of these sessions where there 350 had been an unusual representation from obviously lowly levels, I cormnented to one of my associates, "It could happen nowhere but in the United States!" Mr. Teague was most courteous and understanding throughout. Insofar as our personal relations are concerned, I realized that he had very strong back-up in his administrative assis­ tants. Mr. Patterson and Mr. Meadows, both highly competent individ­ uals, gave me a better insight into the support that is necessary for our law makers in this complicated societyo Both of these men forti­ fied Mr. Teague's public position and image by affording him extensive informative reports of their studies at first hand. Such studies involved routine procedure within the Department of Medicine and Sur­ gery, for example, and on other occasions specific areas of problem advice. In general, Mr. Teague and I saw eye to eye and I have the highest respect for his judgment and integrity. However, on one issue, in spite of repeated personal and public interchanges, we did not agree. Mr. Teague realized with the Department of Medicine and Surgery that there was an area in which the veteran did and would require increasing attentiono This attention related to nursing home care. With our problem in recruitment and in the maintenance of highest quality of medical personnel, I objected to the introduction of this element of medical care into the existing programo My objection reflected the reaction of a high percentage of the most desirable medical personnel in the system who foresaw that were the camel to get its nose into a tent, the first thing we knew we would be dealing with a system of nursing homes. Certainly no physician could link his future career to this prospect. This circumstance was conmunicated to Mro Teague and 351 his administrative assistants on every possible occasiono Dr. O.: In a way (I don't mean to interrupt) but this would almost be reverting to the pre-World War II situation where your Old Soldiers' Home, so poorly named, but Old Soldiers' Homes were essentially a series of nursing homes. Dr. M.: You are entirely correct because we had foreseen the deteriora­ tion almost to the point of disintegration of veteran medicine prior to World War II; a situation that none of us viewed without serious concern for the future of the care of American veterans. I am certain that Mr. Teague realized the sincerity of my position for we exerted every effort under the sun to not only improve the quality of local nursing homes, but utilized them and where possible gave support to the individual veteran assigned to such institutions. Furthermore, in the field of psychiatry, we had developed half-way houses and intermediate zones of care usually with the prospect of restoring these individuals to their homes, but the half-way house is not the problem with which we are confronted here. The development of restoration centers was, in my judgment, a reasonable extension of our program of acute and chronic medical care designed to rehabilitate those individuals who had longer than average hospital residence. At Hines, Illinois and at East Orange, such institutions were established during the period of my tenure. However, the judgment of Mr. Teague prevailed and after my retirement certain beds, now up to a level of 4,000, in the hospital system were assigned to nursing home level of careo In~ system of over 352 110,000 with a ceiling of 125,000, perhaps this is not a dangerous level. Furthermore, the 4000 nursing home beds have not been sub­ tracted from the ceiling figure of hospital beds--a Bureau of Budget device that I feared. Dr. 0o: Are these scattered amongst the general hospital facilities; they are not isolated nursing homes. Dr. M.: No. And your connnent relative to isolation of considerable segments of this 4,000 will perhaps not prejudice the total effort. However, there is in this concept, if there be no strong effort to maintain conmunity rather than Veterans Administration responsibility, a threat that cannot be overlooked. The circumstance of the recogni­ tion of this responsibility, of course, is now much wider spread than previously. The standards of our nursing homes are improving at a pace that will justify wider government recognition on this score rather than prejudicing the high quality of medical care in our Veterans Administration Hospitals. Which brings up an interesting circumstance that when the Veterans Administration was underwriting the care of the veteran in the nursing home, we had to be very cautious that there was not a divided interest that the personnel of our hospital were either involved or actually running these institutions. In fact we encountered occasional incidents where apparently there was proselyting and the movement of veterans to hospitals or nursing homes in which our personnel had an interesto This relationship we could never condoneo Speaking of personalities, perhaps the most powerful man in Congress during my period in Washington was Speaker Sam Rayburno My encounters 353 with him had been cited in the Remembrancer; but for the record I would like to indicate one very characteristic one. Mr. Patterson, then the Deputy Administrator of Veterans Affairs, called me and told me that Mr. Thomas had asked us to come to the office. So we went up on Capitol Hill and Mr. Thomas excused himself. Across the table from me was Mr. Rayburn who fixed me with a piercing eye. Mr. Thomas ex­ cused himself and we engaged in a little bit of idle conversation. Mr. Rayburn was the object of our attention and we were the object of his attention. He said, ''What are you going to do with McKinney?" and I said, ''Mr. Speaker, we're going to close it .. " He said, "But Doctor, you can't close it; it's a going hospital." I had visited the hospital twice to survey it from a professional and physical stand­ point .. It had a good staff, it had excellent support from Houston (Houston was 38 or 40 miles away. It was within striking distance.). The Speaker said, "I don't see how you can possibly----." I said, "I've gone over it physically. The hospital requires a tremendous lot of rehabilitation--built in wartime--all the plumbing; all the wiring; the roofs are beginning to sag; it is not fireproof, all of the window jams and doors, floors are combustible, and it would be prohibitive to try to rehabilitate the hospital even if it were necessary." But he said, "It is necessary." I said, "I'm sorry; it was my understanding that on the addition of Unit 2 to the Houston Hospital, McKinney was to be given up." "Oh," he said, "I don't know about that." Mr. Patterson said, ''Maybe you'd like to see this letter." Mr. Truman had signed the authorization for the construction of the Houston No. 2 Unit on condition that McKinney be abandoned. 354 Dr. O.: No. 2 now is the unit which is right in near the University of Texas Medical Center. Dr. M.: It is a part of the Center, yes. Unit 1 had been there for some time; but this was new construction and built on the condition that we give up McKinney. (Of course, we'd made sure that we had this letter back. I had had a copy made in case.) He was a little taken aback---- He said, "But you know the land's worth $3,000 an acre." I said, "I'm sorry." "Closer to town it's worth $5,000 an acre." I said, "I'm sorry, but still.~-' He said, "Doctor, you just can't." I said, ''Well, I'm sorry, Mr. Speaker, it's a fait accompli. We just have to do it, it's in the books, of no use any longer, a matter of policy, a matter of planning. Every bed has been accounted for and is replaced in Houston." "But you will find some use for it." He concluded (we'd talked about a half hour), "I have another appoint­ ment, then I am going home. I'll be back after the first of the year. By that time, Doctor, you will find some use for it." I said, "I'm sorry, Mr. Speaker, but I can't." He went out of that room, put two million dollars into the budget. If President Eisenhower had wanted to cancel, he would have had to wipe out the entire budget. It had been placed in such a way that you'd have to reconstruct the entire budget and he kept the hospital open! Dr. O.: You kept that hospital open! Dr. M.: He was a good one! 355 Dr. O.: How in heaven's name could he do this though. I mean this is my own ignorance in political matters obviously, but by just investing more money in the budget? Dr. M.: The Speaker put the money i~ the budget for the express pur­ pose of rehabilitating that hospital. So you hadn't any choice! The hospital director who had been universally acclaimed as highly superior was running both the hospital at Houston and at McKinney at that time. The newspapers had cartoons of him, you know, putting "Locked by order of" and so forth. I made it a policy, Dr. Olch, never to maintain a hospital director in a place where he was under fire. I'd look at the matter as carefully as I could from traditional standpoint, his position against political forces, community and so forth. If the community gets against a hospital director, his usefulness is done and he will never have a happy existence, however effective he is. So we moved this hospital director and named in his place one of our outstanding men who was excellent in conciliating divergent forces and meeting situations however serious they had been. The union of employees got on him after some trivial matter. While things were still in turmoil in the interchange, Mr. Rayburn called my deputy, Dr. Roy A. Wolford, he demanded that the hospital director be moved at once. Dr. Wolford said, "You know Dr. Middleton has screened the entire roster. He has picked Dr. Hobson out of all of the available men. He has had the trial of fire; he's been in tight places before, to resolve problems. He was sent to McKinney for this express purpose." He added, ''We'll move him, 356 we'll move him right ·away if you say the word. I'm sure Dr. Middleton would accede if you feel that it's an impossible situation." "Oh," the Speaker said, "don't move him. Don't anyone touch him. Keep him right there. We'll take care of those people who make a disturbance· down at McKinney! " Dr. O.: What a reversal! Dr. M.: But, he was a strong man! He gave our recent president most of his political lessons, and Senator Lyndon Johnson was the next strongest man on the Hill when I was in Washington! Dr. O.: Well, I guess there was quite a relationship there, there's no question. Dr. M.: But he was adamant about McKinney. In spite of the fact that we had a letter dictated by President Truman that he did not know about. So that took care of that! There is a large area that I would like to touch on about which I have brought these (I'll leave them with you) three different documents. They all have to do with the relocation of hospitals in the event of a national emergency. Dr. O.: You had an interest in this. I noticed that in your papers. Dr. M.: These are some of the papers that you probably have encountered. It was naturally called to my attention by the situation in Britain -- where there had been the necessity for relocating their preclinical work 357 as well as their clinical work. Having had this contact that I cited to you in the Task Force on Reserve Medical Affairs for the Department of Defense, this matter was very closeo The first thing I did when I came to Washington was to get a listing of our commitments to reserve programs which brought out some very interesting information as to the Ready and the Standby Reserves in our hospitals. The policy was affirmed that we would not protect any ready reserve. He was on call~ Furthermore, we would depend on whichever agency was responsible for the assignment of functions in case of a national disaster, an all-out attack, the function of the Standby Reserve. Which was to say that you would have the chance that a hospital could lose 40 percent of its personnel and still operate. However, this movement could affect cer­ tain critical personnel like a laboratory man or an X-ray man--the loss of one man might be disastrous--so it had to be reconciled among these hospitals in the VA. My administrative assistant, Ralph Casteel, made the survey of all our personnel; so we were in perfect position. He was a long standing reservist. Then we went to the British situation. In correspondence with Sir Francis Frazer who had been the Director of the Emergency Medical Service in Britain during the war. We reviewed their experience of the war period. As I said before, they moved the preclinical students out and I have the list of the assignments where they were relocated. Insofar as the clinical years were concerned, they were still given in London with some reassessment of the hospitals. The location of our hospitals I have given here (I think you've seen that before)o 358 Dr. O.: I've seen that chart, yes. Dr. M.: It tells you the type of hospitals that were in existence at this particular time. The landing of a bomb on the strategic points-­ the primary targets--would mean that 58 hospital systems would be destroyed or rendered inoperable for varying periods of time. The beds would be reduced from the 250,000 as we had projected before, to 176,000 in the remaining 113 hospitals. Of the professional staff, we listed 3,684 positions--299 dentists and 6,763 as casualties. So that under these simulated conditions, remaining physicians numbered 1,208, dentists 126, nurses 6,769. All of which is to say that if we had these hospitals wiped out, it was estimated that in the same attack 55 of our medical schools would be doomed and 21,379 people would be denied education in these 55 medical schools. You were taking out big medical centers all over the country. A large overlaid map was prepared and it is somewhere in storage in the VA I hope. This map showed exactly what would happen and where there could be a relocation of hospitals and of medical schools within these hospital units. Preferred were the Veterans Administration Hospitals with the experience of the Dean's Committee so that it would be a simple transfer of that function in medical education. This cru­ sade of mine began in about '58 and I presented this material to five different organizations. And at the end of that time--1961--I said, on five different occasions, four different groups, including the Association of Military Surgeons, 1958, had been apprais~d of the 359 necessity for planning a relocation of medical schools to assure a continuity of production of trained medical personnel. In this pat­ tern of relocation of medical education, the utilization of Veterans Administration Hospitals and personnel has been repeatedly recommended. One does not willingly assume the role of a prophet crying in the wilderness; but a grace period of fifteen years has been granted the American public and the American medical profession. To this date, not a single constructive movement has been made to correct a vital flaw in our armor. To me, this is a very serious crying need. It simply means sitting down and planning to get these responsible heads together. Dr. Oo: And nothing has been done. Dr. M.: Nothing done. Now, you know what happened here (World War II) with the acceleration of medical education, the needs and demands of medical and paramedical personnel, the shortening up of the residencies and so forth. I have a very strange feeling that in the national emergency--an all-out war--perhaps it will be of such short duration that it will destroy or obviate the need for all of this, but there should be a pattern. First of all, the relocation of undergraduate medical education and of paramedical personnel training. Second, that there should be a program that assures a flow of trained men in spe­ cialties--surgery and otherwise. I think that it should be a matter of planned attack rather than hit or miss or wait until the bomb falls. Dr. O.: Yes, which is about the way they're approaching it, it seems. 360 Dr. M.: Right. I have a great deal of confidence in planning. I know that some men as Gehrig in Public Health have done basic work in this area--! know that things have gone ahead; but there has been no pinning down of responsibility. The Veterans Administration Medical System comes under Civilian Defense for the first phase, and from there the Army is to take over, but not pinpointing on production of essen­ tial personnel to carry on. And my interest is in education and pro­ duction as it is represented by the turning out of physicians, special­ ists, and health personnel. Dr. O.: Yes, I know. I must admit, it's something I had never really given a moment's thought to until I saw reference to this in your papers. Dr. M.: Turning to the reserve, I don't know whether you had access to or whether you followed up my point relative to this Task Force on the reserve---- Dr. O.: I have the folder. I have yet to go through it. Dr. M.: Well, sometime when you've gone through it---- Dr. O.: I'll go through it and then we can chat about it, this week. Dr. M.: Fine. I think that we should because it ties in very closely with this problem. I think that a strong reserve is essential. I have been in touch with the local situation, and just last week they told me what difficulty they're having holding a reserve unit together be­ cause of lack of the officer interest. They can keep the "noncom" and 361 the enlisted personnel in order. Their 44th General Hospital, of course, is based on the University Hospital in Madison. Dr. 0.: I'm sure this is a universal problem. Dr. M.: I'm sure it is. And the more peace we have, the more dif­ ficult it is. The Cuban situation is an interesting one and I have had occasion to refer to it in another respecto When my attention was called to the number of Cuban refugee physicians in Miami, Florida, my immediate thought was that, if possible, we should utilize them insofar as they could find a place in our system. This was discussed with Administrator Gleason who had a very sympathetic turn of mind. He indicated that he would waive the citizen requirement for the enlistment of Cuban refugee physicians if they met our standards. I added that if they had a work- ing knowledge of the English language. So that the University of Miami School of Medicine, by rotation of residents through the university program and by forced draft insofar as their knowledge of English was concerned, worked very closely with us. It was interesting that 200 Cuban physicians were screened in Miami by the University of Miami School of Medicine and by our Coral Gables Veterans Administration Hospital;working very closely together. The Professional Standard Board at this early period, 1961, had screened 167 of these men and 74 had been Boarded and 39 had been placed in our hospitals. There was a real grasp of this problem and the plan worked quite effectively. I am .. interested that with very few exceptions, they not only appreciated but 362 responded to the generous gesture of the Administrator in making this particular outlet possible for them. These physicians have rendered splendid service. The waiver of a citizenship policy would not be applied across the board; it was only for the refugee Cuban physicians for this period. It will interest you that to get the entire picture, I asked our local authorities to approach the Florida Board of Health for temporary licensure for these men, working only in the VA hospitals under our terms. The Florida Board of Medical Examiners wouldn't give us an inch! Dr. O.: No, they're about the toughest in the country. Dr. M.: I was really trying them out! They didn't bite, or at least they didn't grant that if the Federal Government was willing to waive a long-term fixed policy and then went to the State Board of Medical Examiners and asked only temporary licensure for the term while such physicians were in our hospitals and responsible to us primarily, they might have made a gesture. But none such! One interesting diversionary move was the dedication of the Veterans Memorial Hospital, Quezon City in the Philippines in November, 1955. Naturally, we flew. The hospital was built with funds appropriated by the Congress of the United States. Of course, being a sovereign country a free hand was given. They did not have the skills and could not get ahead. So the Veterans Administration in Washington furnished the skilled and architectural engineering advice where it was necessary. Mrs. Rogers, Congresswoman from up in Massachusetts, quite a character 363 was, in the main, instrumental in getting the funds for this project. The structure itself was built with certain very obvious flaws--a splendid building, more stainless steel than in all the east together, I think, but at a cost considerably below the appropriation and lower than costs in this country. There was one fault that immediately occurred to me. Their morgue was in a small building removed from this hospital which had a very large tuberculosis population. The outlook of the various vehicles carrying the dead out to the morgue was in direct view of the patients! I said at least you might keep them at home! Shortly after we left, there was an incident of their hauling one of the deceased veterans in a cart under view of these people. Of course, it burst the newspapers wide open! I was much impressed by the spirit, the drive, the interest of these people--the Filipinos. We were entertained at the President's home--Magsaysay was the President then. Magsaysay was about your build--just a little shorter than you-­ but well over six feet tall. Dr. O.: Which was somewhat unusual for a Filipino, wasn't it? Dr. M.: Yes. Very erect. Very alert. Very keen. And one thing (you remember very trivial matters) when they were playing the march for the review, I was standing right alongside of the President, who was keep­ ing time with his hands as he stood at attention! (Laughter) A very human, hard driving chap, and his death was a major tragedy to that people. You recall that he was killed in a plane crash. It was an interesting experience. I can see how some of these ju~~eting trips 364 are attractive to the Congressmen. I had very little reason, except a hospital dedication, for being there; but when you speak about that, Mr. Teague was with the same party! And one or two of his men! [Break for lunch] Dr. M.: The research program of the Veterans Administration Department of Medicine and Surgery was largely related to the diseases that con­ fronted the agency. The age and sex distribution of the veteran pop­ ulation determined many of these changes in the realm of degenerative diseases. It was generally recognized that over half the beds of this country are occupied by patients with mental diseases. It was obviously one of the prime targets of our research program; but singularly it was difficult to establish the tasks in mental disorders as well as the men to meet the tasks in our systemo The intervening years have remedied somewhat this dilenma; but still there are not the objective measure­ ments in this field that admitted of such an effective approach as applied to the case of tuberculosis. To digress for a moment, this particular problem had confronted the Veterans Administration with the advent of the antituberculosis drugs. In conjunction with the Armed Forces, the Veterans Administration set up a protocol of study that effectively measured the efficacy of streptomycin in a relatively short period of time. The format of the therapeutic research--the chemo­ therapy of tuberculosis--was developed by Drs. John Barnwell and Arthur Walker. Both of these men were proteges of Professor A. N. Richards of Pennsylvania and his fire hand can be judged in the sound­ ness of the proposed approach. Utilizing double-blind methods and 365 random sampling of the subjects, it was possible to resolve the answer to efficacy of streptomycin in a relatively period of timeo Naturally, we relate this to the objectivity of the patient's condition, the X-ray findings, and the bacteriology of the sputum. Such data were not avail­ able to the psychiatrists; and when we attempted to resolve the problem of the tranquilizers, a group of some 13 psychiatrists was called to­ gether from the country-at-large, and after a debate of some several hours, the second day of their meeting, a subcommittee approached me relative to the four or five different approaches that might be had. Obviously, no protocol of any value can be derived from such diverse approaches. The psychiatrists had approved, beyond a peradventure, that the use of tranquilizers made patients in our institutions for the mentally ill more accessible to a well-recognized formula of approach. Quite vividly I had in mind a conference of group therapy that met in one of our institutions in the Middle West, and I was impressed by the reaction of the patients. Dismissing the psychiatrist, I sat in with these men as they related their reactions. When they turned to me, they asked whether I was one of them!--which rather flattered-me, in that I had been able to completely disguise my identity. However, in another encounter of this type--Coatesville Veterans Administration Hospital-- I was impressed by the suggestion of one of the group who stated that if patients who were coming into balance were assigned conferences with luncheon or service groups through the irrmediate area there might de­ volve a much better rapport with the uninformed civilian--a thought and a suggestion that, in my judgment, was worthy of conside~ation. On 366 another occasion, I was attendant on a group of staff members who were, as a team, discussing the future care of a patient [Marion, Indiana]. The patient had been withdrawn from all of his connnunica­ tion with fellow patients, the staff, and visitors for a period of 12 to 15 years. Schizophrenic, there appeared in my superficial ob­ servation little prospect for improvement, as first the physician, then the psychiatrist, then the clinical psychologist, the nurse, the occupational therapist, the clergyman--in all some six or seven dif­ ferent staff members--discussed the picture presented to the team as a whole. I was rather taken aback when the psychiatrist, having listened to all of the others, said, "I'll take him," and I inquired, "For what?" He said, "For intensive care." The rest of the group having agreed to this disposition of the patient, I awaited conference with the psychiatrist. I said to him, "Just why would you pick a patient with schizophrenia, withdrawn for 12 to 15 years as a likely subject for intensive therapy?" He said, "I just have a feeling that he'll come back. Give me two years." "All right, two years." He shunned me at meetings for the next year or so. Then after a little over two years he came up very brightly and I knew he had news for me. He said, "You know the patient you saw at Marion with us that time?" I said, "Yes, he's been very much on my mind." He stated that he had been rehabilitated insofar as we think it is possible to rehabilitate a patient with schizophrenia. I said, "As I recall, he was over 12 years withdrawn." He said, "Yes." ''Well," I said, "now there's been some brainwashing and something a little heavier than I understand." 367 ''Well, we learned at first hand that he was interested in music. We never let an occasion pass that there was not some musical instrument around. He played the piano, and someone would be playing the piano when he came through. 'The first thing we knew he would sidle up to the piano as he went by and strike a chord and move on. Then pretty soon he sat down and started to play. He would get up as though startled and move away. Eventually he came to the point that he participated in patient musical affairs. He has for six months been out of the hospital. He is now gainfully. occupied, lives with his sister, and I have a monthly report from her saying that all is well!" To me it was oneof the most marvelous responses I had encountered in this field. The question of the withdrawn state of the mentally ill has always been an enigma to me, because I do not know what babies think and I know much less what the adult mentally disturbed patient thinks; but I have made it a point to keep contact. I was heartened by an experience of Dave Boyd. Dr. David Boyd was in one of the groups of psychiatrists meeting in Central Office and he said, "I've had a most unusual expe­ rience, a most unusual experience!" ''What is this, Dave?" several asked. He said,"A schizophrenic who had been out of contact for a number of years, was dismissed as well under control and competent to go to his normal environment. He said, 'Doctor, I want to thank you for something that you said that is responsible' for my being well as I am today.'" ''What was this? What did you say, Dave?", everyone was asking. He said, "Good morning!" To me, that is one of the most poignant comments I have ever heard. When you work in a·community, an 368 institution, that is dealing with the mentally ill you will find a considerable percentage of the patients first, deserted by shopmates, and then by friends, and finally by family. We have literally thou­ sands of such patients in these institutions who have not seen friend or family for 20-25 years. It is little wonder that we have an element of population that cannot be rehabilitated. You can't get them back unless they become a part of you. In one of our hospitals for the mentally ill these men, who were sit­ ting around doing nothing and apparently could not be rehabilitated, were on a recent occasion taken in busses to a county fair. Every one of them properly dressed, every one of them returned to his normal environment insofar as clothes were concerned. Not a single man soiled himself. Not a single man was out of order. These minor matters, if brought into the aggregate, may add up to a very appreciable contribu­ tion to the patients' care and rehabilitation. That's my position regarding the tranquilizing drugs. It isn't what they have done in themselves, but they've made these patients, in so many instances, so much more accessible to the commonplace details of treatment. One of my uncomfortable experiences was at the hand of a psychiatrist. I was invited to address the American Psychiatric Association in Chicago. At great inconvenience, I was able to fit it into a crowded schedule of movement that took me to the Middle West. I listened to a tirade by Mr. Albert Deutsch who was, as you know, one of the con­ spicuous pseudo-science writers----- 369 Dr. o.: Yes, he wrote a history of mental health in this country. Dr. M.: -----who took extreme umbrage at the pace at which we were moving in psychiatryo I afforded them the picture as I had encountered it; my intense interest and deep sympathy with the movement. I was not emotionally involved; but I felt that this was the area of greatest promise insofar as advances were concerned because they had such a dis­ tance to go. I indicated to them the proportion of our research funds that was so committed. It wasn't half, but I showed how it had in­ creased over the years of my tenure. I told them that I regretted that my schedule meant that I had to leave. I would certainly be responsive to any questions I could answer. I had to make a plane and I'd be off as shortly as I could. After I left, a chap by the name of Raines, who was a naval officer--George Raines was his name I think. [End of Side II, Reel 10] [Side I, Reel 11] Dr. M.: George Raines took the floor and attacked me personally on the score of my slipping out instead of standing by to explain to them the position of the Veterans Administration in this important field •. This was reported to me on my return to Washington, and I communicated imme­ diately with the Surgeon General, Admiral Bart Hogan. To him I made it perfectly clear that I had never avoided any discussion and I felt that the attack was not only unjustified but most discourteous and without basis in the evidence. I know that Dr. Raines never retracted his 370 comments; but Bart Hogan was incensed that any fellow officer in the Navy should have taken such a vicious position. My tour of duty in the Veterans Administration ended in 1963--February 28, 1963--and the Central Office was very kind in the reception afforded me. Mr. John S. Gleason, Administrator of Veterans Affairs, had a special edition of Vanguard issued and distributed to all employees of the Veterans Administration. The tribute was a very heartwarming one and I treasure it highly. The invitation to the White House to receive President Kennedy's hearty felicitations was entirely unexpected. A measure of his warmth and consideration of his associates is embodied in a letter afforded me several days before--February 23, 1963u On this occasion, two circumstances arose in the very hurried conversation necessitated by the President's manifold duties. I have related the first in the matter of my separation from an academic environment and participation in a very involved administrative post. When I told President Kennedy "I am still much involved in the field of education. As a matter of fact, the Veterans Administration has the largest grad­ uate program in medical education in the world," he was obviously surprised. I indicated that in this direction the support of medical education in the Veterans Administration could and should materially improve the output of physicians and the quality of medical care in the United States, which apparently impressed him on the moment. He indi­ cated some interest in the areas of our research activities and I told him that I felt that the Veterans Administration of all agencies in the ,. country was in the best strategic position to attack the problem of 371 aging. We had, for example, a controlled population; a population that was aging and that was regularly under observation, both from a physical and a socioeconomic standpoint. In my judgment the Federal Government was losing a great opportunity by not capitalizing upon and, in a sense, exploiting this particular area of inquiry. President Kennedy's preoccupation was manifest by the coIIm1ent, ''Well, here .comes a photographer. Let's get on with that!" Dr. o.: And down the drain it goes! Dr. M.: But it has occurred to me in the intervening years that ob­ viously President Kennedy was a highly intelligent, interested individ­ ual; but here were two key matters the discussion of which he had invited. I suspect he was preoccupied with other vital questions and was playing the courteous host to me; so my observation did not go beneath the surface! Dr. O.: Yes. They didn't register, I wouldn't imagine. Dr. M.: The reaction to the period of service in the Veterans Adminis­ tration as I have indicated on several previous occasions, administration was neither my ambition nor my forte; but I felt that there was a job to do. I knew my basic interest, I believed that I could make a con­ tribution at the level of the iIIllllediate focus of our effort, namely, individual patient care. As in the Army, here in the Veterans Adminis­ tration I wished to get at the level of delivery of that care, and I did not believe that I could do so by sitting in a chair in Washington 372 and simply pontificating! You will have gathered, I'm a great believer in direct action--action on the scene. From my varied con­ tacts, I feel that I can judge human nature, I do know quality of medical care, and I know who will pull best in the machine. The great disappointment of my service in Central Office was the failure to put over the Area Medical Director Plan in its completeness. I still see it as the logical solution of situations as they arise, by individuals in contact with the scene of action. These staff men can either dele­ gate the authority or irrnnediately investigate and correct the problem. You can never do that, Dr. Olch, from a removed position. Dr. O.: Sitting thousands of miles away looking at a memo! Dr. M.: A most rewarding experience. The hundreds of medical men, ancillary or paramedical staffs--! prefer to call them co-professional services--the dedicated personnel that I have indicated are measures of a team that I think is without equal in the country. I was warned by certain of my predecessors that I should beware of the service organizations. As you may have gathered from reading, Paul Magnuson was particularly chary of their association. I think among men of good faith that you play the game above the board; indicate to them the wisdom or ill-wisdom of their position and it has been my experience that they will see the light. I told them when I came into office that I would regularly attend four major service organization meetings every year that I could. I religiously followed that formula; " entered into their discussions as adequately as I could, and they knew 373 I was always accessible. I did not curry favor. I put all the cards on the table. Then let them see with what I was confronted in the same light as I was expected to see their problems. By and large they are dedicated men. I would say of the Congress that, with rare excep­ tion, I found them most helpful and cooperative. It was a rare circum­ stance where an individual asked for favor out of line with what, in my judgment, was reasonable. I had some very acid exchanges; but one that was particularly interesting in retrospect was on the surrender of the Minot, North Dakota, Veterans Administration Hospital to the Air Force when it was apparent that we no longer could justify its continuance--we came from 75 to 50 to 25 patientso We said that we just could not operate such a hospital. The while I was attempting to negotiate--Dr. Horace Copp was my representative--with the Air Force since they had a big installation near Minot. They would take over and would assign to us 25 beds, if needed up to 30 beds. While that was under negotiation, Senator Young got in touch with me. We had sent one of our old-time special operators, a physician (Dr. Frank Brewer) who had been an area medical director at one time and later on the staff in Central Office, to make a survey. He had brought back this word, "Chief, we just can't justify the maintenance of this hospital. The support that we get, is from the town physicians who are very devoted to the institution, but this is not the final answero" The per diem. cost of operations was rising alarmingly, because you've had to main­ tain a certain standard to have the quality of medical supervision that we required. When I conveyed this information to Senator Young, 374 he was most abusive, almost unbelievably abusive. I said, "Senator Young, it's only out of consideration to your position that I am giving you this conmunication; I did not expect abuse!" He said, ''To hell with your consideration!" I knew the Senator was talking with someone in his office when he was doing this. You can usually tell when you get that line on the telephone. I said, "I am making other provisions. I'll send another man out there, another staff man to review the situation. Dr. Brewer is a very trusted associate; but Dr. Zink is a younger man. He may have a different viewpoint." "Let him see such and such individuals. I will make the contact in Minot." "Fine," I said, "all those names are down now and he will see them personally." So the time came for him to go--he was to go Saturday and this was Thursday--! told Senator Young, "Now, Dr. Zink is all ready, final priming. Are there any other individuals----" "Oh," he said, "Doctor, you can forget it; it is all settled now!" Just as soft as he had been harsh before! Of course, by that time he knew that we had made the arrangement for the transfer to the Air Force and that they were going to have their hospital. They had a more assured future for that matter. As I told him before, all we ask is that there be protection for our veterans. We were asking for 25 to 30 beds. That is the sort of human nature which you must endure! Dr. O.: Well certainly there's little question that veterans' medicine in this country today is a totally different ball of wax or ball of string than what one used to hear or read about in generally misinformed 375 publications that they were poorly staffed hospitals, by innuendo if not actual statement implying that the physicians manning these hos­ pitals were those that could not make the grade elsewhere. During your tenure as Director were there not some instances of medical centers or regions which did not welcome the association with the VA hospitals? Dro M.: That was the next point I was going to discuss, a very impor­ tant one. The Dean's Committee arrangement was, as you will realize, a voluntary arrangement. It became an arrangement that was coveted. For example, in La Jolla, at the present time, in California---- Dro Oo: Oh, La Jolla, righto Dro M.: La Jolla, yes. You're speaking like a Californian now! The VA Hospital delayed its location in that center until they knew where they were going to establish their new medical school. In the case of Stonybrook, Long Island, we had all sorts of temptations. They wanted us to take 30 acres of an airfield removed, we knew, some distance, from where we thought the medical school was going. Westchester County was hoping to get the medical school and so there was a feud among these New York counties. We had information Stonybrook probably had the inside track. So we were subjected to serious criticism that we were vacillating. We were not doing anything; that was all the vacil­ lation we were doingo We were awaiting their decision. When they decided, we had our plans to move in and have moved in on planning at Stonybrook. 376 So that Coral Gables--we planned to move across the street from their downtown hospital, the county hospital--Dade County is it? That is the hospital down in Miami proper. At Nashville, when we moved from five miles out, it was to a location directly across the street from. the Vanderbilt University Hospital. Every single movement of recent date has been to come close to the medical school with this interchange that exists under the Dean's Committee Plan. Now I suppose, Dro Olch, I have gone to 25 or 30 Dean's Committee meetings with the express pur­ pose of meeting some issue that had arisen locally. In the ideal of medical education, the university hospital is built as the clinical laboratory--the laboratory for clinical medicine for the medical schoolo That's the only reason we have a university hospital next to a medical school. There are very few medical schools that do not now have their own university hospital which was in contrast to the British system. They cannot quite understand our arrangement. The design of the medical school is the education of physicians; we assume that is its natural product. There is some question in certain quarters about this. You have then, teaching, research as an essential for the advance­ ment of teaching and of knowledge in general, and service comes last. I think I told you before that when I appeared before the Joint Commit­ tee on Finance of the Legislature in Madison, I told them this, not once but every time I went. I made it clear that we only have a medi­ cal school hospital or university hospital on the campus because of its teaching responsibilities. All right 1, 2, 3. So the service comes last and it's very hard for some of them to understand that service is not the primary function of a university hospital. 377 When you come to the VA, as when I would encounter some question of staffing and function, then I would say, "Now, it has only been a little while since I was a dean and I know what you're talking about. The VA hospital is built primarily for serviceo I could not go before any committee of Congress or any body of responsible citizens and say that it was built for teaching. Then your teaching comes second and research is a bonuso Let's not get this priority out of line, gentle­ meno We will understand each other if the Veterans Administration Hospital starts off with a different primary mission from the university hospitalo Service is your subsidiary purpose, yes, and it is excellent, perhaps the best in the community. With us, service is our first func­ tion." Now, that philosophy I had to preach and repreach. The next issue was the allotment of salarieso I insisted that our physicians were full time men and they might not improve their income by moonlighting. Dr. O.: Yes, they were straight full time, not geographic full timeo Dr. M.: Not geographic full time. Now this situation, of course, was one that put the VA position under a handicap. There were many well­ wishing friends in the medical schools that wanted to help us over this hump--''We'll give him such and such salary." We said, ''There was one loophole that we afford; we will pay a man up to a five-eighths basis and what he does with the other three-eighths of his time is his own business. What you pay him is none of our business; but he's a part- ,. time employee and therefore is not eligible for the fringe benefits 378 of the VA. He doesn't have insurance, he doesn't have any of the things that go with tenure and so forth--retirement. You can take care of that on your side if you wish to; but this is all the further we'll go." You'll be amazed at how frequently they came to me--friends-­ and asked for a 14/16. "Bill, can't you give us a 15/16 arrangement? You take 15/16 and we'll take the l/16th?" It may seem out of character that I should have taken such a firm position; but I found that the resident who saw his chief getting a hundred dollars for consultation, or going off on a lecture tour and getting four or five hundred--! said, "Gentlemen, none of this, you're writing a book; you're not get­ ting an honorarium; you're not collecting anything on the income of this book--a lecture, an honorarium or the textbook income." Within the hospital family, you know, all these are small circles. If a laboratory man could not enhance his income and the surgeon or the internist could, the wife said, ''Well, Mrs. Jones has a Cadillac and we have a Ford. What about that, John?" "She's wearing a new mink coat!" To the credit of the Department of Medicine and Surgery they bought the policy right down the line. Where there were defections, we closed in and we closed in hard; we did not mince any words. It's an interesting circumstance that since I have left, the order has changed and they have gone back to the system used by the Armed Forces. If there's a requirement or need in a community they may have consul- tat ions. Dr. O.: In other words, if they're in an area where their services can be utilized without "competing with the private sect~r?" 379 Dr. M.: Well, that was theoretically so, but I mean to say that it now goes anywhere. Dr. O.: They can practice; they are geographic full time. Dr. M.: No, they are full time; but they can do consultation work. They may not take responsibility for the care of patients. It's my judgment (this ought to be off the record); it is not a sound philos­ ophy nor a sound practice because there's always someone who's going to cut corners, perhaps not intentionally but the pressure is so great. Dr. O.: In the Public Health Service, this past year they started what they refer to as "continuation pay." Very frankly, I think it has been misapplied. I'm delighted to get a little extra money each year, but it's based on a rather unrealistic situation. Everybody whose chief says, "Yes, he is essential to the service; if we lose him it will be a loss" will get continuation pay. You have some people getting it who are literally treading water prior to retirement and they're getting twice as much as the young buck who's flirting with all sorts of outside offers for positions and so on with a higher income. I'm wondering if this sort of thing isn't being justified now with this same idea that while we have to do something to make more income avail­ able to these people to try and hold our good people, there is the realization that, yes, there will be some people who will take advantage of it. 380 Dr. M.: First, we were competing with university salaries, at least up to the associate professor level. Now they have gone out of line with us in many instances. One of the strongest appeals came from the south from a man who was chairman of a department who made strong representations as to what this would do if he could get such and such, to get this for his men. And I said, ''Naturally no, doctor." (I had all the information relative to salary scales in the university posi­ tions.) "Do you mind telling what your salary is?" His was $10,000 and he was getting whatever else the private traffic would bear above that. I said, "Our men are considerably above you in chief grade, you know, and there can be no question as to the adequacy so far as your university salary level is concerned." The university was not infre­ quently rather conscience smitten because they were having the services of a VA physician, sometimes what would be equivalent to their own teaching load and yet not paying him anythingo The only way that, in our terms, they could have gotten by, was for us to put him on as a 5/8 basis. This pattern worked out well but it did not free the con­ science of the medical school that felt that they should pay him. The added circumstance that I encountered in one school--it was a western school. They said that "Your staffing isn't on a par with ours." I said, "But ours is full-time staffing; we have excellent coverance in this hospital." "But we should like to have this modification. If we don't have this improvement we think that quality of teaching and care will be deficient." I said, "You have your own standards and these happen to be ours." They said, ''Well, unless you _iµeet our level, 381 we might as well close out." I said, ''That can be done very readily. We will not jeopardize your standards." It is a matter of historic; record that Dean Hyman, the University of Tennessee Medical School, tried to lever General Hawley into a position that he would not accept. Dro O.: He wasn't the kind of man you could do that to, I would imagine, would he? Dr. Mo: I said "Old Pinky" should have known his man, but he didn't. General Hawley didn't budgeo As a result Hyman said, "We can't go along with you." Hawley said, ''That's all right; we'll start our own program!" So what he did was to move his strongest men to key posi­ tions at Memphis--Chief of Surgery, Chief of Medicine and so forth. So that they were getting the residents and interns. Dr. Oo: Ah, so that in that community the VA Hospital was the better of the two. Dr. M.: Oh, it was the strong hospital! Dr. O.: Yes, it was pulling from the university. Dr. M.: There was no question at all about it. When the western Dean became very obstreperous I said, "Now this is ground where I can see we're coming to parting the ways. If we (meaning the Veterans Administration) are detracting from your educational program and you cannot see your way clear to our point of view, our responsibilities-­ service, education, research--in such a measure as we c~~ afford, we 382 should break relations now. I'd be the last man with my background to pull down a medical school. We'll go our own way." He knew that I was deadly serious, he retracted. Actually I had a team all set up to move in on him. I'd have done exactly what was done in Memphis. They would have had to fold up so quickly, because we have great strength in the staffs of the system. I could have picked half a dozen men at least as good, if not better, than his own staffo Dro O.: And he knew it! Dr. M.: Yes, he knew it. So that this is one of the uncomfortable situations; but by and large there is agreemento John Nunnemaker, at one phase (you've probably encountered in some of these accounts), made a survey of the reactions of the Dean's Committees to a continuance or change in the system. Actually, I think that Policy Memorandum No.2 which has had some minor revisions in late years, was remarkable in its simplicity and its understanding. I was called before the Board of Regents at the time of the agreem~nt with the Veterans Administration for cooperation with the new VA Hospital (1951) and asked just how much this was going to cost them. I said, "Not a penny, and you're having approximately 450 beds turned over to you for exploitation in education for which you have no monetary responsibility." "But isn't there a contract?" "No," I said, "there isn't any contract. This is a gentle­ man's agreement. If we're not satisfied, we can pull outo If they don't like what we're doing, they can pull out. This is an area in which we need tremendous improvement in facilities. Af~~r this hos­ pital has served its function as a tuberculosis hospital, it will be 383 converted to a general hospital and we can't lose! It's just as though the largess of the federal government was pushed to your front door and you take it. It's something where you can't lose." They saw the light when there was no money involved. That was the detail in which they were particularly interested. This tacit agreement that I speak of has been resolved in recent months--or just the last couple of years--to a written agreement. Now I can see all sorts of flaws in it. There was no trouble with the gentleman's agreement before. Dr. O.: Yes, really all based on that first original document drawn up by General Hawley. Dro M.: That's right. Policy Memorandum No. 2. As I look at John Nunnemaker's survey, there were no institutions that wanted to withdrawo There were minor changes that should be made and would be made; but it bespeaks the attitude, the climate, in which two different groups are working. I have always been intensely gratified that in no instance where there was an issue and I went to the scene and sat down with the Dean's Committee was I forced to capitulate on basic policy. I mean to say that we saw the light in our mutual advantage. At times there were changes we should make; they had definite areas of doubt that we could resolve without compromise of principles. So that it has been an eminently successful arrangement. The credit, primarily, goes to Paul Magnuson for the idea. Paul was dynamic and driving and had friends in high places that helped. His original proposal did not receive favorable consideration. It was when Paul Hawley became the 384 Chief Medical Director inmediately after World War II that he came upon this document and I think the principle had also been enunciated to him by Elliott Cutler. Elliott Cutler, whether he got it directly from Paul Magnuson or whether he had some other light, probably did more to sell Paul Hawley on the idea than anyone else. Then Paul Magnuson came into the office, as you know, and took over so that it was an extremely fruitful plan. Dr. Diamond has lately referred to it in certain articles he has written about the future of medical educa­ tion where the Veterans Administration facilities should be used to greater advantage. Undoubtedly in any federal hospital system, this will prove to be the focal pointo Dr. O.: Yes, it certainly makes sense. It's really the only unified federal hospital system scattered throughout civilian areas. We have military bases here and there, but not right in the center of your civilian population--right at your medical centers. Dr. M.: Right. I want you to go over carefully, if you will, the area of the relocation of hospitalso I feel that it is one of the basic philosophies that I've tried to sell, and so ineffectively. If you will get hold of Ralph Casteel, he would have knowledge of where that big map with the location of the hospitals and the strategic primary target areas. As you will have gained, the composite effort is a result of long staff studies in relocation exerciseso We assembled at points removed from Washington to carry out our mission in Civil Defense. But the while, I was thinking of what was gain~ to happen to medical education in event of total warfare. 385 Dr. O.: One person we haven't mentioned. I'd be interested in any comments you might have on the role of Omar Bradley. He, of course, brought Dr. Hawley in. Dr. M.: That, I think, was his major contributiono Dr. O.: Yes. I gather that other than that he was a--I don't mean this in an uncomplimentary way--but he was primarily a "big name" that would connnand the respect of the veteran population and give assurance that things were going to be handled properly. Dr. M.: I think that is fair. See, I know General Bradley, but I had no irrnnediate contact with him in veteran affairs. General Hawley was my contact. I had been his Chief Consultant in Medicine in the Euro­ pean Theater of Operations for three years, so that I knew him intimately. But Bradley picked Hawley; Hawley had the advice of Elliott Cutler in the early period. Elliott Cutler had carcinoma of the prostate and diffuse metastases at that time; so that he was only shortly active. It's a tragic picture. I did not save the letters, I believe, that--­ I think I've told you he would write first about "being carcinomatous, Yours, Elliott." Dr. O.: Yes, you mentioned this off tape actually, when we were driving back to the hotel one day, in Madison; that was a moving thingo iiiiiiiiiiiiill 386 Dr. M.: That's right, I did. "Living on codeine and milk, Bill" and then, "If you have anything experimental and would like to use me for a guinea pig!" [ Pause] The natural question that arises is as to the accessibility of medical care to the eligible veteran. In emergency or upon recognition of need by the appropriate authority, the patient may be cared for in his own conmunity and his physician reimbursed. This circumstance is one that is not too well understood. It nevertheless gives the patient full choice of physician so long as the physician is recognized by the agency. Dro O.: And only when there is not a VA facility in the immediate environs. Dr. Mo: If transportation be impossible--too difficult--this may be authorized even though the facility be at hand. As a rule, it is the policy not to extend this privilege where there's ready access to a Veterans Administration Hospital. The extent of this is quite large, into the tens of thousands of the physicians who are so reimbursed, but it does mean that special consideration must be given to the assignment of this privilege to the veterano Dr. O.: This started did it during your tenure? Dr. M.: No, this had been in effect for some time. Dr. O.: I hadn't realized that. ii 387 Dr. M.: The rules that applied to admission and discharge are interesting. They're somewhat at variance with the general civilian policy. I have maintained that when in doubt, admit. When in question as to the ability to take care of a patient outside of the hospital, maintain him until you are certain that he is going to be well cared for. This has some very interesting repercussions. In the first place, the Veterans Administration is seriously criticized for accepting cer­ tain patients with obvious means. The president of an insurance company in Texas attempts suicide and is brought to the hospital and dies on their hands. The newspaper headline said, ''Millionaire dies in VA Hospital." It so happens that his was one of these fly-by-night insurance companies; he had a $125,000 home, which was mortgaged to the hilt and his business affairs were in such shape that he commits suicide. If we had rejected him, what would have been the next headline? I would instruct our staff that when a question arises--should we admit; admit when you are in doubt, and make your mind up in the next 18-36 hours! The number of patients that you turn away who may die suddenly or have some serious complication is an important consideration. I have already indicated the human failing of desertion. In the first place, whether it be age or disability, the frequency with which you encounter the lack of a place of residence when you discharge a patient, is startling. Be sure of your ground through Social Service or other agency as to the ultimate disposition of the patient. It is scarcely human to turn him out without a place to light. Dr. O.: Literally out in the street! 388 Dr. M.: Right. The matter of responsibility. We attempt to impose such an attitude on the family from the day the patient comes into the hospital. Do not ever let them feel that they are freed of responsi­ bility. In one direction, your maintained interest transmitted to them that when he's ready to go home, this and so will be carried on. Make things possible for a transition. Always keep in mind that they are the responsible individualso Otherwise as soon as you release them, this build-up of irresponsibility emerges and you have an added job in getting that patient properly returned to his own environment. I've maintained that the hospital is not the normal habitat for any healthy individual. There are circumstances which make maintained residence in a hospital necessary and more desirable, but do not make it a habit. Dro O.: This point of preparing the family is so very well madeo I was just thinking back of my experiences as intern and resident. You're so wrapped up in what you're doing there. It is something you seldom gave thought too All of a sudden, "Yes, he can leave tomorrow. He no longer has to be here.u There really is no plan to prepare the family and their responsibility in looking after the patient. Instead you say, "OK, we've done our bit, now you do what you have to do with himo" Dr. M.: The problem that confronts us as an agency more than any other at the present time--now I'm speaking as though I belonged to the VA, but I'm still intensely interested--is alcoholismo About 35 percent of our patients at the present time in the hospital in Madison have 389 some alcoholic factor in the background, either undercurrent or the complete swell. I'm speaking now of the individuals with cirrhosis of the liver, alcoholic gastritis, peripheral neuritis, central ner­ vous system involvement--what you will. You'd be amazed at this because I made this statement when I was in Bronx Veterans Adminis­ tration Hospital--probably 10-12 years ago. They said, "Oh, Bill, you're going wild!" I had just gotten through saying that it's a much more serious hazard than tobacco. ''What!" "All right, bring out the records of all your patients with bronchogenic carcinoma, emphysema and chronic bronchitis and I'll bring up these others with alcoholic gastritis, cirrhosis of the liver, peripheral neuritis, central nervous manifestations." And, of course, it just sunk them; they hadn't stopped to count! The fact that alcohol is an insidious and conventional form of drug addiction, had excaped themo It is the most insidious of all the habituations known to man. When they brought this label out on the cigarette package, I wrote to my friend, the Surgeon General of the United States Public Health Service.and asked him when they were going to put such a warning on the bottle! (Laughter) He wrote back and said that he didn't think they were 7 ready! It is a question that I insist my students deal with medically. Let someone else handle the moral, ethical, sociologic factors. Don't get tangled up in that, boy, or you're in for it! Dr. O.: If you stay in the general medical ward long enough you'll see plenty of it. 390 Dr. M.: You certainly do. The modern student interests me greatly. He's much better prepared than was I. He is serious minded, very well motivated, and dedicated to his patient. I think the interviews with these lads in sections of five to seven have been particularly illuminating in light of the observations out of Boston where, appar­ ently in the recent past--the last ten years--there's been a trans­ ition. According to these reports the lad who was patient or clinically oriented changes in many instances to laboratory or science oriented and psychiatrically oriented. I was curious because I hadn't sensed it either in Madison or in Oklahoma City. So that last year I took sections of senior medical students and asked them why they had come into medicine and whether their objective had changed in their medical course. There were some 35 last year--I've had an equal number this year. Last year of the 35, only two were science oriented. One was science oriented when he entered the medical school, the other had become science oriented since. So two out of 35. This year I had an equal number and there's not been a one who was not patient oriented. We must be dealing with a different "breed of cattle." Dr. O.: These are second and third year students? Dr. M.: No, these are seniors, ready to go out! Dr. 0.: Right. That is a surprising percentage unless, as you say, the student population is more interested in clinical practice in Wisconsin than elsewhere. 391 Dr. M.: It amazed me; this year's 100 percent! There hasn't been a one who has been laboratory or science oriented. All want to get out and handle patients. Dr. 0.: Don't you think there's some element, particularly in institu­ tions like Harvard and Johns Hopkins and others--! mean not just the "old line big league," now no bigger than any other Grade A medical school--where they see the faculty in so many instances "academically living off of government grants" to do research that there's some ele­ ment of this as far as "developing an interest in a scienceZ" Dr. M.: Well, they have gravitated. I think they have gravitated to those schools. I do not know whether I told you about the lad. For years I was designated as an interviewer for Harvard Medical School, for men at Wisconsin who wished to enter Harvard. Dr. 0.: No, I don't think you did mention that. Dr. M.: A lad came to me--bright and shining lad, one of these Ford scholars taken out of the third year of high school and brought into the College of Letters and Science at Wisconsin--had a brilliant record. I said, "So you want to go to medical school." "Yes." "Just what is your background? Is there any physician in your family?" "No." "Any associate or kin?" "No." "Has there been a serious illness in your family?" "No, sir." "You have had no contact, never been working in the laboratory, or as an orderly?" "No, I haven't." Well, this was rather interesting. "Are you interested in people?" ''Well, I think 392 so." ''What do you do by way of outlet here besides your academic work, the report of which is excellent?" ''Well," he said, "I was a manager of this theatrical company." I asked, "Did you go into the theatrical work?" He said, "No, I was just managero" ''Well," I said, "you must have had some interest that brought-----" "Oh," he said, "you know I was in Tel Aviv last summero" I said, "You've got some insighto" "Oh," he said, "they have a wonderful hospital." I said, "Did you do work there?" "No," he said, "I didn't go in." I said, ''That's very interesting. And you are taking some subjects that are not entirely science in which you've done quite well. We have here, philosophy. We have a living philosopher, Albert Schweitzer, who is also a physi­ cian." "Oh," he said, "I know him. I have his book but I haven't read it!" It's wonderful. Harvard didn't take him! Dr. Oo: Harvard did not take him? Dr. M.: No. But he is an exception you see. This brilliant youngster had a quiz-mind type of approach--snapping conclusions--but a superfi­ cial knowledge. Dro O.: Yes, no real depth to ito Dr. M.: The youngsters that I see now, are serious-minded. They have no part--medical students--no part of this turmoil, distress, unrest if you will, of the student body at Wisconsino Yet they are most alive to their social responsibilities. I think they'll become even more so. A number of them that have gone on foreign elective quar_;ers to London 393 and Stockholm. A husband and wife worked this past summer with the migrant field workers in Wisconsin; another lad spent his summer in Appalachia. Dr. Oo: You see a lot more of this these days than you did in mineo There were occasional students who did this. Dr. M.: Most of us did, I think, what I did--go into a laboratory. I elected to work in the laboratory of the State Hospital for the Insane for two sunnners; worked with Dro Ash, as I told you. I think that was much more the rule particularly since we were pathology oriented in those days. I think that they are definitely more socially alert than I was, at least. Dro O.: Oh yes, well, certainly that's true. A great change from my erao I think it has just been in relatively recent years that it's become so generalized amongst the student body. Dr. M.: I believe that the impact of my more philosophic ruminations reflected the practice of my younger days. You'll agree that the medicine has capitalized on this rugged individualism and physicians have been rather strangers at the social board. Only recently have we accepted even in the health areas people who were not physicians. Now, I think, we all realize that we are perhaps captains of the health team but not the whole show. Dro O.: Yes. That's very well put. 394 Dr. M.: I had rather a disappointing interchange with some of the other departments. There was first of all, the attempt of individuals who had come to this country on exchange basis or who had come here for im­ provement in special fieldso We had a working arrangement with the State Department that made it a matter of honor, really, to see that these people went back to their own underprivileged country. My greatest difficulty was with the Near East and the Greeks. There were a number of instances, but one I cite particularly--"Oh, Bill, but this is a man who has done a splendid job in a field where we have need. He's married an American girl and she's pregnant. They would like to have the child born here and he'll work two years for nothing!" I said, "I don't care if he'd work 20 years for nothing. He came here with the thought that he was going to return to his country for the improvement of their medical care and he's going back." I think that there has been serious pressure made on the State Department. Unless they have had a change in their philosophy, they believed--at my period--that it was a breach of faith with a sister country not to return these students for the improve~nt of medicine in their homeland. Dr. Oo: I think unfortunately many people perhaps came here saying "yes, it's for a brief period of training. I want to return" knowing full well that once they got here they were going to jolly-well try to stay. [End of Side 1, Reel 11] ii 395 [Side II, Reel 11] Dr. M.: Under existing conditions, these individuals were accepted into the Veterans Administration system for residencies only on the cognizance of the affiliated medical school which meant that they would be responsive to and accountable to the medical school for the duration and order of their training. This, of course, stems from the citizenship requirement in the Veterans Administration; but it has been a bit modified where there is not patient care. To the best of my knowledge, it has never been abrogated in case of direct patient care. The disappointment to which I was referring directly though, was in the person of Dr. Leona Baumgartner, who came with the ICA from the New York Board of Healtho I was most anxious that our facilities be utilized wherever possible in enhancing international medical relations in the assignment of certain of our personnel to foreign countries and in the exchange of qualified personnel from other countries to come into our hospital and laboratories. She referred by particular issue to a subordinate and in spite of recurrent encouragement to open the matter, never closed in on it. Rather interesting! And she's a very competent woman. [Pause] Dro O.: The date is February 11, 1969. This is a continuation of Side II, Reel llo Dr. Middleton will first have a few comments to make in continuation of our discussion of the Veterans Administration 396 and then we'll move into discussion of his involvement with the Medical Reserve Advisory Corrnnittee of the Cooper Committee which is not the formal title. In fact, the formal title is a little confusing to me. It's sometimes called the Task Forceo Dr. M.: The period of service in Central Office of the Veterans Admin­ istration would not be historically complete without reference to the splendid team with which I was associatedo Particularly would I refer to the staff immediately responsible to me, with whom I worked so intimately for a period of eight years. I found Dr. Roy A. Wolford, as Deputy Chief Medical Director, a most conscientious and effective associate. A West Virginian by birth, he encompassed within his person­ ality all of the independence and integrity ordinarily ascribed to the mountaineerso Never did I find him wanting in information relative to the medical program of the Veterans Administration and his integrity was above cavil. His retiring nature led to his withdrawal from public notice; but behind the scenes he was a most effective co-worker. My Administrative Assistant was Robinson E. Adkins. Raconteur extra­ ordinaire, who had a story for every occasion. Behind a fa~ade of easy accessibility and affability was a broad knowledge, really comprehensive in depth, of all of the actions and mores of this vast agency that we term the Veterans Administrationo His warm personality had endeared him to the entire agency. Throughout the Veterans Administration, he was the type of the ideal civic servant that is so familiar to the British and so little understood by the American public. His empathy 397 won the friendship and support of every echelon of the Department of Medicine and Surgery and even extended into the other elements of the Veterans Administration. Bob Adkins' associate was a man whom I had known intimately during my service in the European Theater of Opera-_ tions when he served first, with a general hospital at Taunton, England, and then as the Executive Officer to the Deputy Surgeon for the Euro­ pean Theater of Operations, General Charles Spruit. Ralph Casteel was a very loyal and effective co-worker who lent strength and direction to our efforts by his intimate knowledge of the various directives and organizational patterns in the Department of Medicine and Surgery. In this intimate team, there was complete understanding and cooperation. We knew exactly where each other stood and never doubted the support of our fellows in any action that might be required. The secretaries were Mrs. Billie White and Mrso Carolyn Bell. Splendid women, whose devotion to duty exceeded the call of ordinary secretarial obligationso [Pause] The reserve components of the military forces had been subject to serious study and question in and after every major warfare in this countryo After World War I when I had had the privilege of serving with the British Expeditionary Forces in France on detached duty and with the American Expeditionary Force on return to our Army, there had evolved certain fixed ideas relating to certain of the handicaps under which we worked. Having close relationships with Dr. J.M. T. Finney-- iiiiiii 398 General Finney during the service--as the Chief Consultant in Surgery in the American Expeditionary Forces, I addressed him in this matter. My particular plea was for the peacetime training of our forces, both medical and military. In the former instance, there occurred regularly on the cessation of hostilities a detachment of interest and a lack of cohesion and planning for the future. My reaction found expression in presentation before the Wisconsin State Medical Society in 19190 At that time I proposed that the medical department be detached in a military sense by the removal of rank, since behind the armies the activities were entirely professional. This proposal found no favor in the Armed Forces nor, for that matter, in the medical profession at large. The plight of reserve medical officers in World War I was one of frustration by reason of a lack of rapport between the regular medical department officers and the reserve medical officers. With the advance in the educational and professional outlet of regular forces medical officers, there was a distinct change between World War I and World War II. With the closer association between the two groups, the lines of distinction were largely abolished; but there still remained a great deal of ground for survey and reconstruction after World War IIo With the advance notice that reserve medical matters were under consid- eration at a high level, I was approached by Dro Richard L. Meiling, Director of Medical Services of the National Military Establishment in the Office of the Secretary of Defense. Eventually, Dick Meiling became an Under Secretary of Defense, Health and Medical. It is my understand- -- ing that he was the first man to occupy this position under Secretary -I 399 Johnson. Our interchange by telephone in September and early October, 1949, gave me some idea of the objective of his office. The Cooper Connnittee had been established in May, 1949 under the title of the Anned Forces Medical Advisory Connnittee with strong representation. They found that there was an area that required special consideration, since the civilian elements of medical support in event of a national emergency would carry the greater part of the medical burden. Accord­ ingly, it was proposed that a Task Force be established for the con­ sideration of medical services civilian functions. This Task Force eventually was announced in releases of October 13 and November 22, 1949. The components of this subcormnittee were Dro Winchell Mo Craig, a Rear Admiral in the Medical Reserve Corps of the Navy, who had been Chief Surgeon at the National Naval Medical Center, Bethesda from 1942 to '45 and Director of Graduate Training Program '45 and '46. As an outstanding neurosurgeon with the Mayo Clinic, Rochester, Minnesota, he was a conspicuous representative. William R. Lovelace, II, Colonel in the Air Force Medical Reserve, was a member of the Board of Governors of the Lovelace Clinic, Albuquerque, New Mexicoo His widespread inter­ est in aviation medicine had led to his rather dramatic free jump from 42,000 feet altitude as a physiologic testo Under special considera­ tion since he was at that time in government employment in the United States Army Medical Corps, Dr. James B. Mason, a colonel in the Army Medical Corps Reserve, was requested as a member of the connnittee at the time he was Chairman of the Specialty Boards of the Veterans Admin­ istration. Dr. Mason's sustained interest in reserve affairs made him 400 a logical member of the committee, but his status was as consultant since his employment on a full time basis in the government precluded his independent membership. Dr. Charles Ro Wells was the dental representative. During World War II he was Senior Dental Officer at the Naval Receiving Hospital in Brooklyn and the U.S. Navel Hospital, Sto Albans, New York. Engaged in private practice in Brooklyn, he was nationally known as one of the outstanding members of his profession in the countryo The Chairman­ ship devolved upon meo The early contacts with Dr. Meiling led to certain considerations relative to the planning of the meetings, but there was evolved a clear understanding of the range of our approach. On the advice of the Cooper Conmittee and Dr. Meiling, the Surgeons General, Chiefs of Staff, and representative civilian physicians interested in the problems of the medical reserve of the several armed forces, were invited to appear before us. Since Dr. Ravdin was one of the conspicuous reserve officers--a major general--he was given an audience that covered ground that perhaps would have a very clear bear­ ing upon our further evolution of this survey. Realizing that the situation was a tangled one, without prospect:of early solution, we proposed the following questions to him for his consideration before appearance: The losses in personnel being quite astounding, do you have tangible reasons for this movement? Have you given thought to the grounds for apparent disaffection? Have the training programs con­ stituted challenge or an obstacle to recruitmentZ In yo~r judgment, 401 would a simplification of organization help? Has Public Law 810 increased reserve interest or acted as a barrier? Have you opinions on the point system? Should the affiliated units be encouraged or discontinued? If continued, is there any mechanism by which dispro­ portional rank can be avoided? Apparently, the last named situation has jeopardized the rank of certain reserve officers in the past. Finally, our $64 question--how would you view a uniform policy as to procurement, rank, promotion, salary, training--insofar as possible-­ and separation among the Army, Navy, and Air Force? Obviously, these charged questions covered the entire problem of the reserve program. Our meetings which were oriented and arranged by a Mr. Robert M. Beers, a highly competent executive secretary, were held in the Pentagon, and the substance of these hearings is a matter of record. The cooperation of the Surgeons General was ready and effective. We were interested in the fact that the Surgeons General of the Army and Air Force brought little supporting cast, whereas the Navy brought a "squadron" with them for their presentation! However, the crying need of the support of reserves in time of action was repeated by all of these men. Most interesting, however, were the hearings with the Chiefs of Staff, who reflected, in our judgment, the basic attitude of their respective forces. The first one to appear before us was General Collins who gave a very clear picture of the dependence of the field on medical support. Knowing him quite well in the European Theater, I was not surprised to have his conclusion that, in the last analysis, the interest of the 402 line in the medical department was primarily delivery of service. They had little deeper involvement in the problems that confronted the Task Force. Admiral Sherman, a gentleman of the old school, was most considerate and generous in his approach to the problems that we had posed to him; but in the last analysis, he said after the man became a lieu­ tenant commander, he gave up his stethoscope and became an adminis­ trative officer, so that the Navy expressed its traditional attitude toward the reserve in an air of detachment! However, our real joy came in the presentation of General Vandenberg. Privately, I had attributed his spectacular rise to prominence and to station, ran~, to the eminence of his uncle, Senator Vandenberg. I was most pleas­ antly surprised to have a keenly alert, cooperative witness who wished to know what it was all about, what our Task Force was attempting to accomplish. Finally having presented the picture clearly to him, a most responsive witness, the general said, "Gentlemen, I understand your situation quite clearly. I realize the dependence of the Armed Forces on medical support in time of conflict. We are the junior service. If you have any new things to try, use us as a guinea pig!" The Task Force operating smoothly and conscientiously prepared its report with serious thought of the impact of such recommendations upon the problem of medical support in event of a national conflict. In justice to the participating members and the supporting secretariat, I would say that there was never a more dedicated group with which it 403 had been my privilege to work. Each and every member of the Task Force was completely in tune with its opportunities and responsive to its challenges. The privilege of reporting to the Cooper Conmittee-­ the Armed Forces Medical Advisory Committee--fell my lot. But before this presentation, there was the opportunity to coordinate the findings with the Civilian Component Policy Board. This occasion was a rather disconcerting one in the bland and passive attitude of the members. Mr. Faricy was the Chairman of this committee and his passivity lent nothing to our feeling of security. However, the appearance before the Cooper Conmittee was entirely a different experience. The Conmittee, alerted to our particular responsibilities since they were the parent group, manifest an intense interest in all of the issues raised and reconmendations made. There was no lack of cooperation and it was my feeling that we had a complete meeting of the minds except in one detail. Obviously, the matter of finance raised its ugly head and we realized that without training programs there could not be developed the highest level of medical care, medical officer training, morale within the medical departments, and rapport with the civilian profes­ sion. This was a circumstance that was acceded to by the Cooper Committee since they had an intimate knowledge of the military. Free­ dom from personality, fair play and interchange, and clear understand­ ings of our respective positions were the net products of our confer­ enceo I pointed out that the council represented a group of men who had lent their unselfish efforts to improvement of the quality of medical service in the armed forces in war and since World War II. 404 The training program was their own brainchild and had received their undivided support. The first notice of curtailment that any of us had had, had been in the public press and then it was actually a fait accompli. If consultants had erred in making known their reservations in the public press, they had followed a precedent that the Cooper Committee had set. Again the matter of timing and precipitous action were cited and its effects on the men in training reviewed. Certainly, all of the confreres left with a clearer understanding. There was hope that the wording of the reconnnendation relative to the affiliated units might be changed. It is my recollection that we reconnnended a restudy of the program particularly with reference to the rank of the partici­ pating medical officers which, in truth, was out of line with the non­ affiliated elements. Dr. Oo: Again, for the record, an affiliated unit is the hospital or the medical center which develops its own reserve units with its chain of connnand and so on. Dr. M.: Yeso The affiliated unit I am referring to is the complete military hospital organization that is built out of the organization of a medical school or hospitalo In World War II, as you will recall, it had been the source of highly qualified men who were badly needed in undermanned units that were sent to us overseaso I have cited the great numbers of medical officers who were withdrawn from their affiliated units to fill very thin cadres that came to us from the Zone of the Interior, the United States. 405 General Hawley took strong exception in my presentation of this partic­ ular phrase and he said, "Bill, you know that this was a source of innneasurable support to us in our operation in the European Theater." I said, "Yes, I appreciated that but this recommendation was simply a device that would attempt to maintain and to strengthen these units without differential sacrifice of rank among officers who were not so affiliated." I believe I satisfied the Chief because there was no other member of the Cooper Conmittee who took the issue at that time. The dalliance of the Faricy group and the delay in the publication of the Report gave a great deal of concern, not only to our Task Force but to the parent Cooper Committeeo While in some measure and in some effectiveness its provisions have been implemented in the intervening years, there was never a complete concurrence nor clearance at the higher levels. Dr. O.: Has there ever been a publication of the recommendations of your subconmittee? Dr. Mo: Not a release publication. It is a matter of record in the Department of Defense. The letter that I wrote to Bob Beers on July 15, 1950, "I have carefully read the comments of the Civil Service upon the Task Force reporto One basic misconception tinctures the Army and Navy resistanceo I refer to the inference that our group designated or desired anything for the medical reserve officer that should not apply to the entire organized iiiiii 406 reserve body. I'm somewhat disappointed in this lack of vision that would persist in life in the fool's paradise of a presumed reserve corps that really does not exist in fact. Obviously, the place for missionary work is not in the councils of the several services and I should have been prepared for this reaction on the testimony of the representatives. Dick Meiling's advisory relationship with the Civilian Component Policy Board may redeem some of the recommendations of our group; but you may judge from my very casual contact with the Board, I have little confidence in its effectiveness. To begin with, it is too large to be effective and to my personal observation direc­ tion seemed singularly lacking." When there was an issue drawn out of the position of the Surgeons General to their respective Chiefs of Staff, I found that in the several establishments there was a difference. The Air Force and Navy had direct access to the Secretary of their respective departments. The Army did not. The Army had to come up with the service divisions-­ we'll say Ordnance, Engineering, Supply, and so forth. I approached Dick Meiling as a friend and he said, •~ut, Bill, what can I do, this is the way it's set up and I haven't any say." I said, "You do have a very definite say, Dick, you stand with me, you believe what I say is true that until we do have direct access we are in a very compromised position." He said, "That's perfectly obvious." I said, "There's something you~ do." He said, ''What's that?" I said, "Resign!" "Oh," he said, "I wouldn't do that." I said, ''That would be the one thing that would bring them around." But Dick was very proud of his 407 military rank. He was in the Air Force, as you know, and he was just retired last month as a major general. He is now Dean of the Ohio University Medical School. He's an obstetrician turned Air Corps man! Dr. o.: I'm interested in your comment there. Your problem was trying to get your message, in a sense, to the Secretary of the Army, is this what you are saying? In other words, in the Army you'd have to go through this chain of command. Dr. M.: This is carrying the chain of communication from the stand­ point of the relationship of the Medical Department in the respective services. However, this situation was not part of the reserve problem. It carried over there because of Dick's position and we depended on Dick's advisory relationship with the Civilian Component Policy Board-­ this was Faricy's Board you see. There is where we were stalemated. We knew what the reactions of the several services were and obviously depended on them to "carry the ball." Now, as an outcome of this, they did place in the several services a reserve medical officer with star rank, and that, I should say, was about as much as we accomplished in the aggregate except in the next chapter I can continue on another phase that I think is a corollary of this situation. This obviously relates to the period when I was in service in the Pentagon with G-1. Dr. O.: It is really amazing to me that there would be such dragging of feet, but that's my own naivety I suppose. Dr. M.: No, I do not think that you're naive. I think that it is a problem of communication. You could have these men about the common 408 board and then realize that as they leave you they have to go through certain protocol for possible action. If we had had the same support in the Faricy Board that we had in the Cooper Committee, I think that we would have moved. You see, this Faricy Board was one of "across the board" responsibility for reserve programs and they were assuming that the medical department was divorcing itself from the total move ment. Dr. O.: Yes, trying to get special treatment, so to speako Dr. M.: Right. I think the point you make there is-a particularly vital one because of the experience of the Medical Department of the Army, for exampleo You see that we tried here to inject into the picture the proposal that they have a common pool and that they draw from a common pool with common points of recognition, salary, promo­ tion, and so forth. The idea that the Medical Department got the special dispensation of the recognition of their period of training in medicine and therefore not only rank but salary, irked them no end. You can't imagine what a difference that would make on a field post or in a combat unit where the man was advanced in rank and salary because he was a physician and his wife felt it too! So that it cuts right through a very natural human element that resents these discriminatory movements, and is particularly felt, as I cited yesterday, when you spoke of a hospital. Now you put this in a military context and you have even a more difficult situation. Dr. Oo: Yes, very much so. The situation on a post. 409 Dr. M.: Yes sir, that mink coat is a status symbol that goes right along with the rank! Dro Oo: This document, which is from around 1951, is I believe some­ thing approaching what you have described. Dr. M.: That has emerged from it. See, this has emerged from it on certain elements and had to do with the control of the regulations involving the medical department. Dr. o.: But it really is a far cry frcm the full program you were striving for. Dr. M.: Oh, it's a far cry. It's only one element. It is really, I think, worthwhile to get out the first report. Dro O.: Yes, I wish we had a copy of that. Dr. M.: I'm sure you can get ito I believe that the first issue that we drew was relative to the segmen­ tation of the "ready" and the "standby" reserve with the thought of availability and the necessity of immediately getting this overall view of what you really had by way of effective reserve. Until you have that, you have nothing on which to work. [ Pause] Hal Thomas, of Johns Hopkins--a close friend, called me relative to the special assignment that he had had with G-1; an assignment which he felt 410 should be continued in the interest of the reserve program within the Medical Department of the Army. I acquiesced in his earnest appeal that I succeed him and came to Baltimore for a conference and then to Washington for assignment in the Pentagon on the General Staff with the ultimate design of coordinating certain elements of the personnel re­ quirements for the Army Medical Department in coordination with the general procurement. The assignment was a very interesting and reward­ ing one since on the first day of my appearance General Paul suggested that here, for example, were two papers on his desk that had been there for four to six weeks awaiting coordination. I asked him with whom they dealt, and he told me and I suggested that perhaps I might be able to do something about it. He gave them to me and in half hour I had them both back with signatures! He said, "How did you do it?" "Oh," I said, "I was just running messenger boy and they were signed off without question when I explained their content to the responsible elements!" The interchange with General Bliss was very intimate. As Surgeon General of the Army at that time, he had arranged for my residence in Bachelor's Quarters at Walter Reed and arranged my transportation to and from the Pentagon each day. The first problem to which I directed my attention was that of our lack of a clear-cut plan for the recogni­ tion of superior ability. With this in mind, I constructed a device by which step increases could be arranged to give an individual the advantage of salary increases ahead of his class, if you will, and 411 eventually his total income over an extended period would be far greater than the man who came up by the regular steps. General Paul was the G-1, was quite impressed by this proposal. Whether he was ever able to sell it, I do not know. In early interviews with General Paul, I made it clear that I felt that the rank of the Surgeon General of the several Armed Forces should be at least a lieutenant general so that it would appropriately compare with their opposites in the British Army and other allies. He said, ''Well, there had been consideration given this, obviously, but there were objections.'' I said, '~here's no objection, General, if you will take all of the other supporting services--Engineers, Ordnance, Supply, Quartermaster--and bring them up together. I'm the last one ever to appeal for special consideration for the Medical Department." I felt that the general was quite respon­ sive to the idea; but, as you recall, it did not occur until President Eisenhower had his illness and eventually his surgery for terminal ileitis. Leonard Heaton was the surgeon and he got the third star. Whereupon all of the other Armed Forces Surgeons General advanced one step too. It's rather interesting that human nature reflects itself in a change of rank! Leo?ard Heaton, of course, is a very representa­ tive Surgeon General from a professional standpoint. The further calls were to resolve any issues that occurred with the Medical Departments. I again attempted to get the Army Medical Depart­ ment into line and at least parallel to the access that the Navy and Air Force had to their Secretaries, but without success--blocked! I 412 made two survey trips, one to Fort Benning, one to Fort Bragg. They were in the professional interests and I made rounds as usual and had a very grand time. I recall the visit to Braggo The surgeon there was an ETO friend, General Bob Hill, and they invited me to stay at their home. When I came down to breakfast Bob said, ''Were you brought up right, Bill?" I said, ''Why should you question that?" He said, "Then say grace!" So he put me on my mettle. (Laughter) The interesting outcome of those two inspections is entirely aside from my official duty. As Dean of a medical school with some difficulties in getting adequate materials in the obstetrical department, I was perfectly amazed that they had under the Dependent's Care Program the most active obstetrical services at Bragg and at Benning. I said if they'd just given me two hundred of their women to take back to Madison, we could make a bang-up service out of ours. The experience there, I think, did a great deal toward modifying my recommendation of medical students for internships and residencies in the Armed Forces hospitalso I had had a great deal of contact over the years; but this was an intimate contact with the implementation of the Dependent Care. It brought a varied service in obstetrics, gynecology, pediatrics. Dr. O.: I am curious as to what sort of position this was that entailed bringing you down for a month and then, I gather, there was somebody else brought on the month following? Was it a rotating position? Dr. M.: It was simply to bring men who were interested in the reserve to cut the line across between the Medical Departments and the personnel which was the G-lo 413 Dr. O.: That's a very interesting concept, really. Dr. M.: I do not know, I doubt whether it's longer continued, but it was innnediately postwar. [End of Side II, Reel 11] [Side I, Reel 12] February 11, 1969. Dr. M.: There's only one action to which I would direct attention in my membership on the Civilian Health and Medical Advisory Council, Department of Defense, April 1953-March 1955. This relates to the initiation of the Dependent Care Program and its appropriate implemen­ tation within the Armed Forces. At this time, there was a distinct attitude abroad that there should be no election of service. It was my contention that to lift the standards of the Army, Navy, and Air Force Medical Departments, it would serve a good purpose to place the election of a physician in the hand of the families who were eligible for such care. In other words, if the Medical Department of the Army were so superior to that of the civilian population that they choose Army over civilian, it would be a tremendous boost to morale and to quality of such service. Some of my fellows on this particular commit­ tee were not of the same mind and I was particularly concerned that the Armed Forces representatives did not share this opinion. Dr. O.: They were a little dubious at attempting this. Dr. M.: They were a little dubious about getting into competition, in other words. I feel fundamentally, from a psychologic standpoint, 414 that you'd be well ahead if you'd place them in competition. Dr. Oo: Well, at this point in time, this is not the case I don't believeo Dr. M.: Noo I think that only a question of their convenience. Dr. O.: Yes, yes. If there is not a military facility available then they can get civilian care and the military will cover the cost. Dro Mo: That's right. So that it becomes really the matter of conve- nienceo Dr. O.: Now this committee that you just cited was primarily concerned with dependent care of the military? Dro M.: No, it was overall; it was the entire field of health and medical. The Atlantic Treaty Organization meeting in May, 1954--I went to Paris on the invitation of Dr. Frank Berry who was then the Assistant Secretary of Defense, Health and Medicalo It was an interesting expe­ rience. The various representatives of the several participating gov­ ernments. Frank Berry asked me to summarize for the United States the proceedings and I initiated by the statement that "I was most happy to be received by a British confrere whose uncle had been the Commanding Officer of the 11th Field Ambulance Fourth Division to which I was attached when I came to the BEF in 19170" Then I proceeded to my own analysis of the actions or the proceedings of the conference. But that is enclosed in my effects and you have thato [Lunch break] 415 Dr. M.: The situation regarding the drug industry had received serious deliberation and study at the hands of the Commission on Drug Safety sponsored by the Pharmaceutical Manufacturers Association under the Chairmanship of Dr. Lowell Coggeshall. This very important document had recommended that there be a further study made in continuity of the problems arising out of the use of drugso Under continued discussions among the Special Assistant to the Secretary of Health, Education, and Welfare, Mr. Boisfeuillet Jones, the Chairman and members of the Com­ mission on Drug Safety with representation from the American Medical Association, Association of American Medical Colleges, and a number of societies interested in therapeutic research, it became apparent that some focal point would, of necessity, be established, were there to be a continuity of the ground breaking of the Commission on Drug Safety. The National Institutes of Health, through the Directorship of Dro James Ao Shannon, were approached by Dr. Keith Cannan, Chairman of the Divi­ sion of Medical Sciences of the National Research Council, in the prospect of material support of such a projecto In a statesmanly pre­ sentation of the picture, Dro Cannan listed the following examples of such questions as might be submitted to the established committee within the National Research Council: 1) Existing resources and needs in clinical pharmacology; 2) Training in clinical pharmacology and toxicology in cooperation with the Association of American Medical Col- leges; 3) Principles in design, conduct, and evaluation of field trials of drugs; 4) Epidemiologic and follow-up studies of drugs; 5) Intelli­ gent sy~tems for the identification of aberrant effects [in cooperation 416 with the American Medical Association]; 6) Problems of nomenclature and criteria; 7) A review of conventional methodology in animal test­ ing; 8) Comparative fetal pharmacology and metabolism of teratogenic agents; 9) Relation of drug safety to drug efficacy; 10) The impact of the Food and Drug Administration regulations on drug research. Obviously, in the initial proposal to Dr. Shannon, Dr. Cannan not only indicated possible areas of discussion and deliberation but suggested that the proposed board would be available for advice to the Food and Drug Administration and other health agencies of government and, by the same token, it would constitute a forum for representatives of the pharmaceutical industry and the medical profession. In substance, then, this proposed board, under the aegis of the National Research Council, Division of Medical Sciences, anticipated financial subsidy through the National Institutes of Health. With a meeting of the minds, par­ ticularly with the cooperation of Mr. Jones and Dr. Cannan, a working plan was evolved. In this relation, my first personal contact with the situation came through a letter of September 30, 1963. Herein Dr. Cannan, in outlin­ ing the proposal and including his conmunications with the National Institutes of Health and a statement prepared by Senator Humphrey which strongly urged such a proposed mission, recommended the creation of a drug Research Board with me as Chairman. The proposal found me as Visiting Professor of Medicine at the University of Oklahoma School of Medicine.. I first had some hesitancy in assuming new responsibilities. 417 However, the importance of the problem and the gravity of the situation as it affected the several involved parties, made it obvious that any personal reservation must be submerged to the conunonweal. The Coumis­ sion on Drug Safety report was cleared in January, 1964, but its essential content was available to me at the time of the conununication from Dr. Cannan. There was absolutely no reservation in my mind as to the need for such a common forum. After due consideration with the representations made by Dr. Cannan, I accepted the Chairmanship of the proposed Drug Research Board. The conference in Washington was had with Dr. Cannan and I expressed the judgment, in a letter of October 17, that "there could be no question as to the wisdom of consolidating the bridgehead that will have been established by the report of the Conunis­ sion on Drug Safety. We see eye to eye on the basic principles under which the proposed Drug Research Board must operate.". In the selection of the members from a panel of suggested available candidates, I was gratified by the caliber of the men therein included. My prospect of working with this group was greatly lightened by the fact that we were not operating under the governmental terms of conflict of interest. This circumstance meant that we could select any qualified individual and would not be denied the services and advice of men who might have direct or indirect activities that could be interpreted as conflict of interest. The ultimate initial group selected was a very important one; significant not only in its scope, but also in the remarkable quality represented. From the panel supplied by Dr. Cannan, supplemented by suggestions from without, the following initial Board was selected: 418 Dr. Robert w. Berliner, National Heart Institute; Dr. Karl H. Beyer, Jr., Merck Sharp & Dohme; Dr. John J. Burns, Burroughs Well- come; Dr. K. K. Chen, Indiana University School of Medicine; Dr. Jerome w. Conn, University of Michigan School of Medicine; Dr. Maxwell Finland, Thorndike Memorial Laboratory, Boston City Hospital; Dr. Alfred Gilman, Albert Einstein College of Medicine; Dr. Chester S. Keefer, Boston, Massachusetts, Wade Professor of Medicine at Tufts; Dr. Pauls. Larson, Medical College of Virginia; Dr. Carl V. Moore, Washington University School of Medicine; Dr. Carl F. Schmidt, University of Pennsylvania School of Medicine; Dr. George E. Shreiner, Georgetown University School of Medicine; Dr. Josef Warkany, University of Cincinnati School of Medicine. As will be observed, there was no thought of geographic re­ presentation nor observance of overweening academic preference. Further­ more, the inclusion of certain representatives from industry and government left no doubt as to the breadth of our design. Included in the group but absent from the first meeting: Dr. William B. Castle, Harvard Medical School; Dr. Hugh H. Hussey, Jr., American Medical Asso­ ciation; Dr. William M. M. Kirby, University of Washington School of Medicine; William S. Middleton, Chairman, University of Oklahoma Medical School. The superb staff support of Dr. Keith Cannan and the Executive Secretary, Mr. Duke C. Trexler, bode well from the outset; a prospect that was fulfilled in our ultimate evolution. The initial meeting of the Drug Research Board was called for January 20, 1964;at the Academy Research Council Building. The outline of the origin and mission of the Board were fully covered by Dr. Cannan. The statements delineating 419 national interests were covered by three individuals: Dr. Austin Smith for the Pharmaceutical Manufacturers Association, whose presentation was discussed by Drs. Beyer and Burns; Investigative medicine was covered by Drs. Keefer and Lewis representing Dro Hussey. Further discussion of this area was by Drs. Shreiner, Warkany, a.nd Schmidt; for government, Mro Boisfeuillet Jones, Commissioner George P. Larrick, and Dr. James Shannon represented the respective Departments of Health, Education and Welfare, Food and Drug Administration, and the National Institutes of Health. The Conmission on Drug Safety reported its activity through a very comprehensive discussion by the Chairman, Dr. Lowell Coggeshall. Reports of the subconmittee of the Commission received due consideration. Mr. Duke Trexler reviewed a listing of the national and international organizations with active interest in drug research. Finally, Dro Cannan proposed an International Conference on Drug Safety. The closed executive session of the Board identified problems that invited further study, suggested a. program for procedures of the Board, and indicated its support of an International Conference on Drug Safetyo In general, this executive session was organizational and these topics eventually led to a review of the liaison relationship that the Board should sustain. There is a release in my papers dealing with the Drug Research Board, a statement of purposes of January 21, 1964, that was given wide publicity and that should be noted by the reviewer as a frame of reference. In general, it should be stated at this time that the inauguration of the Drug Research Board in continuity with the recommendation of the i 420 Commission on Drug Safety had a very salubrious effect on the scientific and general public. For the first time, there was the prospect of a concerted action to bring into sharp focus the several issues that were troubling the lay and scientific public after the tragedy of the thalidomide release. An interesting commentary; that of all of the invitations for participation in this new project, there was only one rejection. When one considers the responsibilities of such a group of citizens, it is interesting that such an important task should be under­ taken on a wide fieldo Actually there were two who declined the invi­ tation, but the quality of their substitutes compensated for their losso My response to this successful appeal found expression in the note to Dr. Cannan: ''What a strong panel you have drawn. Now if we are success­ ful in enlisting support of a high percentage, we shall have talent in depth. If there's any detail in which I may add to your approach in this representative group, do not hesitate to call upon me. I am loathe to muddy the waters by premature importunities." This observation anticipated the response that I have cited. Dr. O.: Was there at this time any reaction or query from groups such as the American Academy of General Practice as to representation? Dr. Mo: Utterly none. When we came to the matter of drug efficacy study later, there was such. The scope of the Drug Research Board's activities naturally grew with increased rapport among the participating members and agencieso From the outset the Pharmaceutical Manufacturers Association maintained 421 continuous attendance as did the several elements of government. Particularly were we gratified by the attitude of the Food and Drug Administration. From the earliest period, pains were taken to assure the Food and Drug Administration and its then Conunissioner, Mr. Larrick, that we were a conunon .forum, to which might be referred any problems confronting them relating to drug therapy. To give some indication of the growing scope of interests, a listing of the conunittees, both standing and ad hoc in order, should be useful: Conunittee on the Appli­ cation of Biochemical Studies in Evaluating Drug Toxicity; Interdisci­ plinary Symposium on Immunology and Pharmacology; Workshop on Biochemical Approaches in Clinical Pharmacology; Second Workshop on Drug Metabolism. The Committee on Drug Compendium had a very sticky subject with which to deal. This circumstance became increasingly apparent when not only the agencies or elements directly affected entered the scene, but legislative action had been proposed in the Senate of the United States. The drug industry through the Pharmaceu­ tical Manufacturers Association and its representative, Mr. Joseph Stetler, had indicated a deep interest in this subject and a willing­ ness to undertake such a compendium at a prospective cost of some millions of dollars. However, they imposed a condition that the package inserts be eliminated as a useless medium of communication. Generally accepted as the existing situation, there was nonetheless, on the part of Mr. Larrick--Commissioner Larrick--an unwillingness to discontinue the ruling relative to the package insert before the compendium had been proved effective. Obviously, the industry was not willing, at the 422 early date of negotiations, to undertake the concomitant cost of both the compendium and the package insert, so that the discussion continued over a protracted period of time. The organizing conunittee on drug efficacy study will receive independent consideration. It was appointed April 1, 1966 which circumstance will be chronologically presented. The Conunittee on Continuing Education had a primary interest in attempt­ ing to establish a medium or media by which the information relative to drug therapy might be rendered current to every practitioner in the country. This committee had obvious plans which have undergone certain changes. Among the suggestions made was that of the therapeutic con­ sultant who would be subsidized under grants from the National Institutes of Health, latterally with the Regional Medical Program complexes being established as a part of this development in the continued education of physicians. In carrying this idea forward, obviously, the improvement of patient care at the periphery would keep closer pace with that at the hub of medical developments in medical centers. As a slight byplay, I might indicate that at this early date I proposed that a DEW pattern of release of adverse drug reactions be established after the National Defense Program. This plan would mean that at a given time or a given day there would be flashes of a therapeutic order, particularly relat­ ing to the adverse reactions of drugs, that could be picked up by a physician at any point in the line. The Conmittee on Teratology was obviously a reaction to the thalidomide tragedy and had a very important function from the outset. Several workshops on teratology were established. At a later date, the 423 Comnittee on Patient Consent took a very important part in the Board deliberation through its reports. It, too, will have due considera­ tion at the appropriate time. At an early date, upon the suggestion of Dr. Gilman, a registry of tissues from patients with adverse drug reactions was recommended. This proposal was to bear fruit in the active participation of the Armed Forces Institute of Pathology with a separate section of this areao The readiness, indeed the eagerness with which other government agencies lent their assistance and cooperation in this and other new fields, was a source of gratification to all of us. The interesting divergence of functions of the Food and Drug Adminis­ tration early attracted my attention. In its responsibilities for the investigation of foods and drugs, the agency acted first, as the fact­ finding element, next as the jury, and finally as the judge with capacity to assign penalties for breach of rulings or laws. This anomalous situation appealed to me as a division that did not find a duplication anywhere in our judiciary system~ On two occasions I attempted to have members of the Board discuss the divergent functions represented by the Food and Drug Administration. It was interesting that I could never get a consensus or an action that I felt was warranted by the situation. It was my thought that it would be much wiser were the general functions relative to drugs under the Food and Drug Adminis­ tration to be assigned from an investigative standpoint to a separate agency as were the biologic products. A laboratory so created would 424 undoubtedly have an entirely different status within the scientific community than an agency which carried with it the added punitive function. Be that as it may, the organization of the Food and Drug Administration remains unchanged. Perhaps even my proding of my fellow members of the Board might not have produced results. It was an interesting circumstance that the most vociferous of the group against the dual or diverse responsibilities of the Food and Drug Administration were the ones who failed me at the critical moment. Dr. O.: I would think the pharmaceutical people would be the ones who would be only too happy to jump on such an opportunity. Dr. M.: Yes, it was our own men who would not go into it. This is off the record, but Max Finland and Carl Moore were the two that I had depended on. They weren't buying, or they didn't. In our interchange with Mro Larrick, there was early a highly defensive attitude on his part. Eventually he came to respect the Board and its impartial dis­ passionate approach to our mutual problems. It was my reaction that he was a convert, in the last analysis. Dr. O.: Was there any sign of a similar attitude on the part of any representatives of the pharmaceutical industry? Did they feel they were being in any way put on the spot by this? Dro M.: No, contrary to the attitude of the Food and Drug Administra­ tion as reflected by Connnissioner Larrick, the representatives of the pharmaceutical industry apparently quite regularly accepted the design 425 of the Board as published and were free in their discussions, criti­ cisms, and suggestionso In the evolution of the discussion on teratology, it emerged in Dro Warkany's presentation that even after three years from the first reports of the tragedy of thalidomide, the manner of its action was not known. The problem passed with the dis­ continuance of the individual drugo Both the public and medicine gave little encouragement for scientific insight into the mechanism. It emerged, furthermore, that even had the provisions for control been applied to thalidomide, under the existing terms its teratogenic effect would not have been revealed, since the litter test was the last crite­ rion defined by the Food and Drug Administrationo That circumstance is not generally known. Dr. O.: I gather that is no longer the case, that the litter test is not the last evaluation. Dro M.: No, noo The participation of the Food and Drug Administration at an early date was largely in the hands of Dro Sadusk who felt that the present reference sources for drug action, largely in the hands of the Physicians' Desk Reference and the American Medical Association's New a.nd Nonofficial Drugs, were not comparable to the information con­ tained in a package insert. However, the matter was always referred back to the obvious need for a compendium. The adverse reaction from drugs received further consideration at his hands and the interchange among the Food and Drug Administration, American Medical Association, and the Pharmaceutical Manufacturers Association gave a certain 426 allocation of responsibility. The AMA obviously was not capable of giving complete coverance although the major responsibility for col­ lecting reports from physicians remained with this organization. The group of 500 university teaching hospitals--affiliated teaching hospitals and community teaching hospitals--with resident staffs reported through the Food and Drug Administration. A conmon report form had been adopted by the American Medical Association and Food and Drug Administration. The interchange of materials, punch carding, data processing procedures were an ultimate objective. Obviously, these mechanisms still fell far short of the mark. In the second meeting further, there was a discussion of the place of the United States Public Health Service in scientific conmunication. Dr. Ellis Kelsey, Special Assistant to the Surgeon General for Scientific Communication, gave the clear outline of the functions and the participation of this agencyo The United States Public Health Service expects to provide support for a National Library of Medicine Drug Information Clearing House [15 June 1964]. The comment from Dr. Kelsey aroused a question in the mind of the Chairman. He had heard a presentation before a Senate conmittee in which the Chairman, Senator Hubert Humphrey, charged the National Library with this respon­ sibilityo In a scholarly presentation, Mr. Scott Adams discussed the history and purposes of the Library with particular reference not only to its magnitude, but also to the development of a MEDLARS system--a medical literature analysis and retrieval system. In his judgment, the device in the past three years had been developed by the General 427 Electric Company to a point of efficient application. The potential for searching the medical literature was still in an experimental phaseo Mr. Adams explained that several problems would have to be solved before the National Library of Medicine could be expected to make a significant contribution to handling drug toxicity informationo Terminology, programming, effectiveness of indexers in using terminol­ ogy require several reviews. MEDLARS, of course, offers a tremendous advance and obviously the group was much impressed by the prospect. At this meeting, the Conmissioner of the Food and Drug Administration explained in great detail the responsibility of that agency in maintain­ ing a clear slate insofar as conflict of interests was concerned. He had said that "there are numerous matters in urgent need of resolution today. It cannot be resolved by science and medicine alone, nor by industry alone, or by government aloneo They require the best efforts of us all and these best efforts put forth in a spirit of mutual under­ standing and good will necessarily benefit all of us." Which was the objective toward which we were aspiring. As you will have gathered, the interest in drug metabolism was one that was attracting increasing attention throughout the scientific world. Responsive to this interest, the workshops, as outlined under the Com­ mittee on Application of Biochemical Studies in Evaluating Drug Toxicity, were to have an increasing impact not only on the activities of the Board but on the important attitudes of the scientific world. The matter of continuing education, which has been cited before, led to 428 careful reference to the studies of pharmacology training programs throughout the country. The work of Dr. Cosmides in the United States Public Health Service, the Pharmacology Training Committee in the National Institutes of Health Sciences Committee, indicated that there were 94 members of the Association of American Medical Colleges. Fifty of this group now had the National Institutes of General Medical Science sponsored programs with over 500 predoctoral and postdoctoral trainees. Some 600 members of the faculties of pharmacology and related departments are presently involved. Apparently, however, this has not been a popular area of exploitation, and the industry has regularly supported and given considerable amounts to make this possible. The Association of American Medical Colleges cited a figure of $50,000 a year for five years as an objective to which to aspire which would afford impetus to the efforts of the given medical school in stimulat­ ing a program. Dr. 0.: Here again I think is an area in which the general public doesn't realize, that tends to be critical of the pharmaceutical industry. Dr. M.: A tentative offer of $200,000 was made to Dr. Kirby of the Board by one industry group in the event that the Association of American Medical Colleges assumes the role as the administrative agent. Under these terms, there has been a definite effort to exploit this field, not only in the interest of scientific development, but from the stand­ point of the education of physicians. 429 Continuing with the Committee activities on continued education---- Dr. Schmidt had proposed the therapeutic consultant, as indicated in prefatorial remarks. This was to endeavor to infiltrate the profession by direct scientific information rather than depending on the detail man and the "throw away" notices for the knowledge of advancement of pharmacology and the therapeutics. This I think is a very important development, and it has not yet seen fruition. The design as outlined would have had men with this primary function on the faculties of the medical schools, geographically located first of all as a trial, and then going out from the medical center to communities or having the physicians of the areas coming in for indoctrination in newer develop­ ments in pharmacology and therapeuticso It was put on a rather---­ [End of Side I, Reel 12] [Side II, Reel 12] Dr. Mo: ----low plane at the outset with the thought of an initial subsidy of some half million dollars. Obviously if it were to replace the detail man insofar as actual expenditure, there would be a real saving to the producer as well as the consumer in the last analysis. The drug compendium which had been recommended at the outset by the Commission on Drug Safety, received the unanimous support of the Drug Research Board from its initiation. At the second meeting of the Board, June 15, 1964, there had been a discussion of this matter and at the third meeting, October 21, 1964, a resolution proposed by 430 Dr. Schreiner read: "Resolved that the Drug Research Board approved in principle and concept of preparing a compendium, information which is now contained in package inserts and of distributing the compendium widely on a complimentary basis in the expectation that the compendium would ultimately supersede the package insert as a means of information on prescription drugs." This is obviously a basic concept and it was the belief of the Board that it would ultimately replace the several publications of the American Medical Association, the Physicians' Desk Reference Handbook and like media. The operation of the Registry for Drug Reactions was underwritten by the American Medical Association, the Pharmaceutical Manufacturers Association, and the Food and Drug Administration. The success of this movement has been unequivocal in its contribution to our material knowl­ edgeo At the meeting of October 21, 1964, Dr. Cannan reported receipt of a letter from Dr. Martin M. Cununings, Director of the National Library of Medicine, dated 12 October 1964, requesting the aid of the Division of Medical Sciences in formulating subject headings to be used in the Library in several areaso Information only. Drugs and chemicals identified as one specific area in which counsel of the Drug Research Board was soughto While Dro Cannan indicated that it was a matter of extreme importance, he felt that it could not be generalized but would have to be referred to the several members of the Board for their personal participation and actiono 431 The establishment of an industry-wide foundation by the Pharmaceutical Manufacturers Association was highly comm.ended by the Board at the meeting of April 23, 1965. Its role in the support of consultants, scholars, and other worthy objectives was conmented upon. Recurrent among the discussions was the place of the clinical pharmacologist in the total medical picture. All agreed that development in this area depended upon ability to enlist young and intelligent workers who viewed the undertaking as a career and not as a mere stepping-stone. There's some division in this matter as to whether the individual trained in basic sciences alone was as competent as the man with both basic science training and eventual skill as a clinician. Most of the clinicians had a fixed idea in this matter, but eventually resolved that the Drug Research Board prepare and encourage an appropriate scientific society to prepare an agenda on a workshop program in which clinical pharmacol­ ogists and their associates may consider information and organizational problems important to the more effective development of this field. In other words, money alone was not yet purchasing interest. Dro O.: Am I not correct that most clinical pharmacologists today-­ those who are truly clinical pharmacologists--are pretty much limited to a special area ·of drugs, chemotherapy? Dr. M.: That's right, even more and more, and I think that it is simply a reflection of the tremendously expanding scope of knowledge in the basic scienceso 432 October 11, 1965, the meeting of the Drug Research Board (sixth meeting), Dr. Leighton E. Cluff reported that the Johns Hopkins University had conducted epidemiologic studies of hospital-acquired infections for the past five years. In this last study, a high percentage of hospital patients had had adverse drug reactions. Actually they proved as impor­ tant as infections, when the same epidemiologic techniques are used for both. The first problem was to arrive at a method of determining the total use of drugs in the institution because these data would provide a denominator for the drug incidence equation. Computer method for tabulating prescriptions filled by the hospital pharmacy developed for this purpose, and some of the findings on drug use have appeared in the literature. To me, it was most significant that they found that there was an average, in the semiprivate ward, of 14 different drugs for each person, with a reaction rate of 15 percent. This figure was thought to be incomplete because in some cases the appropriate physical examina­ tion had not been conducted to determine the adverse reaction. Per­ sonalized surveillance is clearly the most effective method of determin­ ing the incidence of adverse reaction. Adverse reaction rate for semiprivate medical service proved to be about the same as in the public medical service. The private rates were even higher; but the better cooperation of the medical staff reporting influenced these datao It's extremely significant that the rate of drug users is so high in a representative hospital, with excellent medical supervision. When we were discussing the matter of the drug compendium, the repre­ sentative of the American Medical Association cited the fact that they 433 have in mind the development of a compendium. More recently they had actually developed a publication "New Drugs." Twenty-five thousand copies have been sold; another eight thousand ordered. Apparently widely accepted, there is an attitude on the part of the American Medi­ cal Association that this might answer the need. This reaction was not acceptable to the Board as a whole. They said that if you had two hundred and fifty thousand physicians and you had 25,000 copies sold, you had only a tenth of the profession (and population) covered. Furthermore, that the question of the printing of inserts was again brought up by the Pharmaceutical Manufacturers Associationo The present cost of printing inserts is between six and eight million dollars a year. Publication of the compendium would be an additional expenditure at about six million dollars a yearo The Pharmaceutical Manufacturers Association was not in a position to support these projects concurrently. However, the usefulness of the proposed compendium as an information medium to the practicing physician is indisputableo The Pharmaceutical Manufacturers Association was glad to participate in further conversa­ tions with the Food and Drug Administration concerning the project. And it appeared for a time as though the legislative branches of govern­ ment--the Senate in particular--were going to take it out of the hands of both the Food and Drug Administration and the Pharmaceutical Manufac­ turers Association. The Food and Drug Administration was still holding out under Larrick for a dual coverance until they could accept the compendium. A purely legalistic position. 434 Dr. Keefer suggested that they let it be sent to the Food and Drug Administration affirming the interests of the Board in improving com­ munication of drug information to physicians suggesting that one means to the end was the publication of the compendium of the package insert materials. This letter would further suggest that the Food and Drug Administration meet with the Pharmaceutical Manufacturers Association to discuss the proposal to seek means whereby the compendium might be produced. Simply a continuation of the same argument, you see, but with a thought of bringing it to focus. April 1, 1966 brought Dr. James Lo Goddard as Commissioner before the Board, and indicated the change in attitude. I think that Dr. Goddard was medically oriented, not legally orientedo He was very much a man of action, rather apt to shoot quickly, without thought, from the hip and regret at leisure! The occasion was taken to assure him again of the interest of the Drug Research Board in affording a forum for all interested individuals. I shall take occasion later to relate his reac­ tion when the informed consent discussion was in focus. The Pharmaceutical Manufacturers Association Foundation had, by this time, come into very active operation and was quite warmly received by the Board. At this meeting there was a report that was extremely significant in that there had developed in the Chicago area a Midwest committee on drug investigation following the activities and success of the like committee in Philadelphia. The committee in Philadelphia, under the direction of Dr. Thomas Durant, was termed in Philadelphia Committee for Medical-Pharmaceutical Sciences and incorporated the 435 industry, profession, and the educational group of the Philadelphia area. Highly successful, the Midwest group in Chicago I visited with, extremely active and with a close rapport among the industry, the consumer, and the educational representatives. Dr. Kenneth Kohlstaedt made the representations for the Chicago group, and Dr. Durant for the Philadelphia group. There was the feeling that there might develop easier rapport among the affected groups if they were established on a geographic basis. (It's rather interesting that Dr. Durant has be­ come my successor as Chairman of the Drug Research Boardo) Dr. Oo: The date is February 12, 1969. A continuation of Side II, Reel 12 and further discussion of the Drug Research Board. Dr. M.: The discussion on the drug compendium had reached an impasse through the inability of the Food and Drug Administration to agree to a discontinuance of the package insert before the drug compendium had reached an agreeable point of perfection. On the other side of the picture was the cost involved in producing both elements which, in effect, duplicated each other. The drug industry was naturally unwill­ ing to undertake this enterprise with the prospect of having to hold to the fixed position of the Food and Drug Commission. The Conunittee on the Drug Compendium of the Board comprised of Dr. Chester Keefer, as Chairman, and Drs. Karl Beyer and William Castle, had been most assiduous in following through this particular project because of its importance to the profession at large and the ultimate consumers, the patients. Hence, the effort was a continuous one and the support of 436 the Drug Research Board unanimous. The several meetings culminated in a special session of the Committee on Drug Compendium with representa­ tives of industry and goverrunent. They included Joseph Stetler, Executive Vice-President of the Pharmaceutical Manufacturers Association; Dr. Austin Smith, President of the Pharmaceutical Manufacturers Asso­ ciation; Dro Earl Bambach, Senior Vice-President, Pharmaceutical Manufac­ turers Association; Dr. Joseph Sadusk, Medical Director of the Food and Drug Administration; Dr. Donald Levitt, Director of Information Programs, Food and Drug Administration; Mr. Winton Rankin, Assistant Conmissioner, Food and Drug Administration; Dr. Eugene Weston, Council on Drugs, American Medical Association, together with the Board Conmittee I've cited. After free discussion, the plans of the American Medical Asso­ ciation as previously cited were enunciated in which the new volume entitled "New Drugs", replacing "New and Nonofficial Drugs", was their offeringo They felt that some version of the revised version of the package insert would fill the major demand of the profession. However, the acceptance of the principle of a compendium that encompassed the content of the package inserts was again reiterated. This led to the general consensus that an acceptable format that would meet the essen­ tials of all of the parties involved without sacrifice of the basic information to the physician, would meet the requirements of the case. However, there was not yet a meeting of the minds as to the under­ writing--financial underwriting--of this effort unless the Food and Drug Administration were to accept the proposed compendium in lieu of the package inserts. In other words, there appeared no legal barrier 437 to the acceptance of this course by the Food and Drug Administration and the meeting concluded without firm decision either as to format or implementation of the proposed effort. The statement that this was actually a pilot meeting under the date of July 21, 1964, would actually characterize the proceedings. The matter of a direct revision of the Physicians' Desk Reference had not met with complete favor because of its underwriting by a restricted group of manufacturers and its obvious commercial slant. To this date, there had not been a resolution of the total effort, but unquestionably the discussion came into sharper focus on the necessity for the drug efficacy study, which will be taken up in another relationo It is an interesting commentary that Senator Gaylord Nelson, of Wisconsin, had taken up the cudgels from a legislative standpoint in the Senate com­ mittee and that at the last reading, it appeared as though the federal government at the legislative level might actually demand such a compendium. Dr. O.: If I might just ask, I gather then that at this point of time, as best I can tell from few communications you have in mid-1968, that there still seemed to be somewhat of a stalemate in that the AMA is not overly anxious to discontinue its publications---- Dro M.: I think the American Medical Association is well-advised not to discontinue its publications until there's a resolution of this point. "New Drugs" is a very excellent text. However, it is not ii 438 complete and it would not have the wide circulation on impact of the complimentary drug compendium coming from the Food and Drug Adminis­ tration under whatever auspices. The minutes of the Drug Research Board will show that this issue has been a continuing one for open discussions involving the several affected parties through the intervening years down to the present. The opportunity to scrutinize proposed chapters in the Reference Book on Drugs that is being evolved by the American Medical Association indicates that in the main the subject matter has been lifted unchanged from the volume, Newer Drugs, and will not meet with the general require­ ments of a drug compendium. I've mentioned this before and I think that the resolution ought to appear as such. Dr. O.: A note to the record. The resolution to which we were just referring is the one from the DRB in reference to the Pharmaceutical Manufacturers Association and will be found in the folder labeled "Drug Compendium. " Dr. M.: The title of the proposed volume from the American Medical Association is "The American Medical Association Handbook on Drugs," and, as indicated, does not respond to all of the requirements for drug information as will be encompassed in an appropriate drug compendium. In the Federal Register of August 30, 1966, Commissioner James L. Goddard published, or promulgated, a proposed ruling for consent in the use of investigational new drugs on humans. The statement of policy i 439 dnder Title 21, Para. 130.37, indicated the necessity for greater stringency in the release of drugs and the use of investigational drugs in human subjects. Dr. Goddard called attention to Section 505 [l], the act that the use of investigational new drugs on human beings, the condition that "investigators obtain the consent of such human beings or their representatives except where they deemed it not feasible or in their professional judgment contrary to the best interest of such human beings." Interpretation of this official section of the act led to promulgation of the principle that patients to whom investigational drugs are administered, primarily for the accumulation of scientific knowledge, such purposes as studying drug behavior, body processes in the course of disease, must be obtained in all cases and only in excep­ tional instances could this procedure be waived. Carried further, interpreting this ruling under treatment was qualified as applying to the administration of such drugs for either diagnostic or therapeutic purposes.wherein responsible medical judgment was required, taking into account the availability of other remedies or drugs and the circum­ stances applying to the patient under consideration. The exceptional case was interpreted as an instance where it was not possible to obtain the patient's consent or the consent of a representative, or in an unusual situation where the professional judgment must be exercised in the best interest of the patient concerned, as it would be contrary to the patient's welfare to obtain his consent. All of the details of the ruling led to the ultimate position of the Food and Drug Administration that consent or advised consent, means that the patient involved has 440 legal capacity to give consent and is able to exercise free power of choice and is given a fair explanation of all material information relative to the drug under advisement. Its possible use is controlled so that he may make an understanding decision. The ultimate issue arose in a concluding sentence of this administrative ruling: "Said patient's consent shall be obtained in writing by the investigator." The hue and cry that was aroused by this statement of policy or inter­ pretation of the act can hardly be overestimated. In the first place, the clinician entrusted with the care of the patient, was placed in the position of an arbiter whose judgment was sub judice and whose integrity was actually under some question--quilty until proven other­ wise--if the issue be raised. In the next place, the time-honored position of consent for surgery, or the so-called permit---- Dr. O.: Operative permit. Dr. M.: Yes, operative permit, was obviously under some question since it hardly held that the surgeon who was contemplating a thyroidectomy under ordinary circumstances would indicate that there were certain risks. He would scarcely be expected to say, "If I should just move slightly in one direction I might sever your recurrent laryngeal and you might be hoarse for the rest of your dayso On the other hand, I may take out too much of the thyroid gland and have to give you substi­ tution therapy for the rest of the way. Or, in the last analysis, if I went deep enough, I might get your parathyroid glands and then you would have the serious effects of metabolic calcium disorders." The 441 conscientious surgeon will have given the surgical risks, the anes­ thetist will have indicated that there are certain hazards, but the patient is scarcely in the position to evaluate these and under ordinary circumstances would, in all probability, interrupt the sur­ geon or anesthetist and say, ''Well, after all, I have to depend on your judgment, doctoro If this is your advice, we will follow through." At least that has been my personal experience when I have tried to extend the level of hazard whether operative or medical. Turning to the question of the informed consent as it has applied to surgery. By tradition, therefore, there had been ultimately dependence upon the integrity of the individual surgeon involved to give a clear understanding of the hazard, but not to extend the discussion to a point that no patient would be able to understand. By the same token, the patient would scarcely tolerate such an arraignment before a sur­ gical procedure. So that when this became applied to the investiga­ tional drugs, the physician was the first one to indicate that obviously there were circumstances that could not be predicted and circumstances that, for example, attended the use of certain drugs in which alopecia might be anticipated, but an occasional hazard of adverse reaction insofar as the central nervous system is concerned. In the area of investigational drugs, the first responsibility of the physician is to afford such details of hazard or risk as are known. There may be to him certain areas that are either problematic or else not ascribed to the use of the drug in human beings but noted in animals, for example. 442 As the discussion extended there was a great deal of stress placed upon the use of the alkylating and the antimetabolic drugs in the treatment of neoplasmso Their hazards in the area of depression of the marrow were quite widespread. They were made known to the patient, particularly in the area of use of investigational drugs. Yet the underlying disease was of such devastating order that in the judgment of the physician the hazard of drugs was less than the progress of the disease which had not been arrested. The impact of the FDA announcement on the man in research as well as the clinician using the drug for investigational purposes was of a different order. There could be, and certainly if this ruling became generally applicable, might be the threat of a legal action. Certainly no physician wishes to put his professional future in jeopardy or to incur the displeasure of the law as well as the public by the liability to malpractice suits. It early became apparent that the workers in the research field were beginning to back off from highly promising areas of a therapeutic approach to the more serious problems in medicine be­ cause of this threat. When this situation was brought to the attention of the scientific and medical community, the media of communication to these groups were literally flooded with protests. The pharmaceutical industry naturally responded in kind since workers in the laboratories of industry were confronted with the same problem as their academic fellows in the laboratory. The paragraph that I read from a letter of October 11, 1966 from Mr. Stetler to Commissioner Goddard is certainly in consonance with the general reaction: "The August 30th statement in 443 our opinion and the opinion of many physicians and scientists imposes conditions upon the investigator with which he is physically unable to comply. It requires a subject or patient to make medical decisions which he lacks the capacity to make. It produces an unwarranted inter­ ference with the doctor-patient relationship. It prevents the conduct­ ing of meaningful double blind studies. It will increase the number of medically unfounded professional liability suits. It makes it more difficult to obtain U.S. and foreign clinical investigators. It will lengthen the time required to get new life-saving drugs to the public. It will increase the cost of new products and, because of its ambiguity and inconsistent use of terms, many questions are raised as to its mean­ ing and purpose." And so, from a legalistic standpoint, there arose many issues that had to be resolved about the common table. I will not burden the record with all of these issues; but there was finally called a meeting of the Drug Research Board on November 7, 1966. The presence of Commissioner Goddard made this meeting much more effec­ tive. His presentation was a very detailed one of his design and pur­ pose in promulgating the ruling as outlined above, under date of August 30, 1966. Dr. Cannan had, in the meantime, conferred with the Food and Drug Administration on the 12th of October, 1966. A free discussion was made more effective by the participation of all affected parties. A subcommittee was constituted with the title of Committee on Human Experimentation to which the assigned Chairman, Dr. William Castle, objected. His substitution of Committee on Clinical Studies was 444 accepted. He strongly objected to any suggestion of human experimen­ tation. As a result of our deliberations, there is an interesting interchange that occurred at the conclusion of the November 7, 1966 meeting, when I was approached by Dr. Goddard. Dr. Goddard thanked me for the courtesy of the audience and for the very free discussion that was afforded. The response, I believe, should be a matter of record. I said, "Jim, you came to your present position through pre­ ventive medicine. It is my understanding, and I believe you realize, that the Drug Research Board is an impartial body to afford a forum for discussion of problems involving science, industry, and government. Under the circumstances, we stood ever ready and had indicated to you and your predecessor our willingness to advise in any matter that affected the American public. The policy of informed consent was clearly in this area." Jim responded, "Bill, I know exactly what you mean and certainly I shot from the hip!" Obviously, this was a cir­ cumstance in which the Drug Research Board was not only competent but stood ready to afford advice that would have avoided the turmoil that arose from Cornmissioner Goddard's premature release. On November 10, 1966, Dr. Keith Cannan addressed a very comprehensive letter to Dr. Goddard including the several recornmendations of the Drug Research Board relative to the modification of the proposed release of the Food and Drug Administration through the Federal Register. You have already in the record a brief comment relative to the August 30th version. I would like to have included in the record the paragraphs of Dr. Cannan's communication to Dro Goddard between the ink marks, and then 445 the response of the Food and Drug Administration through the proposed revision of November 18, 1966. [See Appendix] Dr. Oo: Fine. Why don't you give me those two and I'll keep them separate as we type the transcript. Dr. M.: Fortunately for the meeting of minds and the peace of the many individuals involved, there was a reconciliation and modification which did not meet the full requirements of Dr. Castle's committee. At least it indicated a conciliatory mood on the p~rt of the Food and Drug Administration, albeit somewhat legalistically modified from the orig­ inal intent. In conclusion, it is my firm conviction that the air cleared. The pro­ fession at large and investigators, laboratory and clinical in particular, were put on notice that a more careful scrutiny of the use of investi­ gational drugs was gained out of this interchange. The responsibility of the physician or investigator is basically moralo Regardless of the law, the unscrupulous or heedless worker could proceed without hindrance to take unwarranted risks with patients under their care. In modern society, one would question whether this were possible; but the horrors of Buchenwald, Dachau and other concentration camps, where physicians recognized in the medical world participated in atrocities beyond human expression, and even in our own country the revelation that certain studies were made upon subjects not capable of judgment, ---- [End of Side II, Reel 12] 446 [Side I, Reel 13] Recorded February 12, 1969. Dro Mo: ----lend force to the necessity for careful scrutiny in this areao The responsibility of the physician cannot be discharged even by the knowledge that the legalistic approach is not humanistico It is interesting that the Declaration of Helsinki came into increasing promi­ nence during this period of controversy and the acceptance of its principles has dictated the attitude of government as well as the medi­ cal professiono In the rapidly evolving picture as it involves trans­ plantation of viscera, a new facet of this total question has emerged so that the treasured code of medical ethics will continue to undergo reinterpretation and revision as the horizon of science extends medical practiceo However, it is still a matter of individual conscience that will determine the conduct of the clinical problem as it presents in the specific patient. I think that's enough on that. Dro O.: Fine. I'd just like to ask you, do you feel that it would be appropriate for a group such as the Drug Research Board perhaps another body brought together by the National Academy of Sciences to set up some sort of a committee dealing specifically with transplantation? Dr. M.: That has been done in the National Board of Medicine and that is, as you know, under the National Research Council and the National Academy of Scienceso The circumstance that has emerged in the further discussions of the Drug Research Board relate to the protection of both individual and investigatoro We realize that within government there 447 is a definite provision where treatment has gone astray or where there has been some mishap in the course of treatment that by congressional action the affected individual may receive redresso Only in courts of justice have we any redress for the civilian situation. This means malpractice suit which in certain instances is misdirected because it is an inescapable accidento If these tenets can be spelled out, it occurs to many students of the subject that there should be some form of insurance to the worker; that there should be some insurance to the affected patient, and it is obvious in the further evolution of medical science as we get deeper and deeper into the now hidden areas of knowl­ edge. The extending frontier of medical practice should not deny to the patient, the party of the first part, to the physician and the investigator the right to take legitimate chances. They accept this in the area of neoplasia. We know that this matter is going to extend, but both parties should have protection and I think that there will evolve a form of insurance that covers such risks. Dr. O.: Is there active consideration at this time for this sort of thing by anybody? Dr. M.: Yes. It's being very widely discussedo The protection of the physician is obviously against charge of malpractice. What I am trying to indicate that this is the unavoidable incident that should be recognized---- Dr. Oo: Yes, and certainly when obvious malfeasance, malpractice has occurred it will be treated as such, but to cover these many incidents 448 which you say are just unknown hazards, in a sense, that they may occur. Dr. M.: Righto From the present range of our information we would say inescapable, but they will extend our knowledge obviously and in the future be avoided. I think that the use of drugs is a very serious responsibility of physicians, particularly these embarking in the area of new drugs, the range whose action is not generally known. We realize that we cannot always--cannot in many instances--transplant from the laboratory results in experimental animals to the human species. Species difference is one thing; and within species there are sharp differences, as you know. And take the old example that morphine rarely leads to emesis in the human subject and yet we regularly use morphine to induce vomiting in our dogs for the preparation for abdominal experi­ mentation. The metabolism of drugs is being increasingly explored, and the appreciation that drugs so commonly have cross-action; the enzyme induction under which one drug may potentiate another, or in other instances drugs that will abolish the action or decrease the action. Take the increase in metabolism of such a drug as dicoumarin under the concomitant use of the barbiturates, so that your effectiveness of dicumarol is sharply decreased because its metabolism is so greatly enhanced by the use of barbiturates. It's just an isolated example, but it becomes more and more apparent that this area has to be deeply explored since we are using more. and more potent drugs and drugs and drugs tlB t may have either potentiating activity or the capacity to diminish or abolish the action. The sphere that I refer to is one in 449 which there is obviously a need for much greater information, research into basic principles of drug metabolism, and in which there is, in the use of drugs, the necessity for control. When we were discussing this matter of informed consent, it would have been impossible to advance the treatment of tuberculosis had we not used control subjects. The study on the chemotherapy of tuberculosis that was set up in the Armed Forces and the Veterans Administration meant that a certain group of these individuals were not receiving the drug, whereas others were receiving the drug--in this case streptomycin. And if informed consent meant that you were telling all the patients that "you're getting the drug" and "you're not getting the drug," you immediately are destroying one of the control elementso This becomes even more important where you are using drugs with psychogenic activityo I think that the public is informed in certain directionso Informed consent may mean one thing to one person and something else to another; but when you're dealing with human life and welfare, if you have any conscience at all, you are not going to take the risk. It isn't generally known that if you were to apply the present strictures, and if you were to have made on William Withering--1775-1785--the strictures on digitalis that are applied today, digitalis would never have cleared the deck! Dr. Oo: I imagine this is true of a number of our mainstay drugs todayo Dr. Mo: As you may imagine, the discussion here was very free and vitally important to the ultimate healthy attitude toward the use of new or experimental drugs. iiiiiiiiiiiiit. 450 Dr. O.: Well the scientific community now, I gather from what you said, has accepted this. They're still not overly happy with what they feel are restrictions and unwise policy statements, but they do find it something they can live witho Dr. M.: Yes. I might cite my own reaction when I am using an experi­ mental drug where the patient does not have full grasp of the situation. I may feel that he has some supratentorial reservations. I always have a second physician go over the record with me completely and sign his name with my name that we are undertaking this study under these condi­ tionso I feel that it's so important from the standpoint of the moral, ethical and legal issues, that you do have support at a professional level and do not undertake this trial individually. Of course there would be emergencies where you would use certain drugs that were experi­ mental perhaps without the support of a confrere; but I think that it is much wiser to have that protection. Dr. O.: Yes. It seems like a very wise way to do it. Dr. M.: I think that about covers this. [Pause] At the request of Dr. James L. Goddard, Commissioner of Food and Drugs, to Dr. Keith Cannan, the Drug Research Board took under advisement the request for a review of the efficacy of prescription drugs accepted by the Food and Drug Administration between 1938 and 19620 Obviously, this was an area of extreme importance to the American public, since under the interpretation of the congressional action, the Food and 451 Drug Administration believed that they had a mandate for establishing efficacy as well as toxicity. Dr. Cannan indicated to the Drug Research Board that such an undertaking was contrary to the policy of the National Academy of Sciences and could only be undertaken were the public requirement sufficient to overcome the existing Academy position. When the Drug Research Board reconunended that this study be undertaken on the representations of Dr. Cannan, the National Academy of Sciences waived their traditional position and accepted this contract with the Food and Drug Administration. The situation as outlined in the communi­ cation above cited is of such importance that it should be a document of permanent record with this recital. [See Appendix] The midyear report of the annual meeting of the National Academy of Sciences under date of February 9, 1968, outlines the development to that period in the evolution of the project. Since the Drug Research board had a limited membership, on advice a Policy Advisory Conunittee was established, comprised of a strong and broadly representative group. It will be noted that its scope was extended beyond the role of membership of the Drug Research Board to give broader coverage. Again, it was a source of deep gratification to the staff and to the Chairman of the Drug Research Board who had been assigned the Chairmanship of the Policy Advisory Conmittee to have universal acceptance to this new responsibility. From the outset, there was full support, as anticipated, from the Food and Drug Administration and representation from the Department of Defense, industry, and the 452 United States Phannacopeia. The membership of the Policy Advisory Connnittee is here listed. [See Appendix] The organizing conunittee for the Drug Efficacy Study was constituted in April 20, 1966 with Dr. Alfred Gilman as Chairman. Its constituency is important since it indicates the breadth of coverance and the sig­ nificance of this function. Included Dr. K. K. Chen, Dr. Leighton E. Cluff, Dr. Maxwell Finland, Dr. George E. Shreiner, and Dr. William B. Castle who could not be present at the original meeting by reason of illness. The Food and Drug Administration afforded a Conunittee on Guidelines consisting of Dr. Ralph G. Smith, Mr. Julius Hauser, Dr. John J. Jennings, Dr. Harvey Minchew, Dr. Arthur Ruskin, Dr. Howard Weinstein, and absent were two other members, Dr. Paul A. Palmisano and Dr. Robert J. Robinson. The National Academy of Sciences and National Research Council were represented by Dr. Keith Cannan, Mr. Earl Grove, and Mr. Duke C. Trexler who was to be held responsible for the executive administration of this particular function, with Mr. Grove as his assistant. The evolution of the plan included the assignment of ten medical officers of the United States Public Health Service to serve as Executive Secre­ taries for the reserve panels of the study, to begin duty with the Food and Drug Administration on July 6, 1966. The training period in drug evaluation procedures under Dr. Charles Tidwell, George Washington Uni­ versity, was arranged and the groundwork was set. The contributions of the American Medical Association, the Pharmaceutical Manufacturers 453 Association, and the Food and Drug Administration to afford drafts of guidelines were held under advisement. A Categorization Committee under the Chairmanship of Dr. Walter Riker established twenty-seven categories of drugs that are listed in the Appendix Ao Do you wish those names? Dr. Oo: I don't think so. I think we can identify where they can find these in these documents. [See Middleton Papers, Drug Efficacy Study] Dr. M.: Obviously, the coverage was broad and the soundness of Dr. Riker's judgment was to be confirmed by the experience of the surveyo The arrangement of a conference on guidelines brought the matter into sharper relief for the ultimate consideration of the joint meeting of the Policy Advisory Committee and the chairmen of the respective panels of the Drug Efficacy Study on May 17, 1967. In the meanwhile, the recruitment of the panels advanced apace. The selection of the chair­ men of the panels was made on the advice, not only of the Drug Research Board and the staff of the National Research Council, but with the cooperation of the national organizations, societies, with interest in the specific fields. This procedure assured not only a wide range of choice, but also a highly representative pool of available panel mem­ bers. To the credit of the involved agencies of government, profes­ sional organizations and industrial groups, the recruitment was remarkably effectiveo Certain ground rules were laid down at the outseto The records of the proceedings of the meetings of the panel would be limited to formal recommendations and the citation of sources from which such were derived, would be a matter of reference. The proceedings of 454 the meetings would assign opinions to individual members of the panel only by the formal action of the panel. None of such proceedings would be mechanically recorded. In an effort to maintain a strict confiden­ tiality, the members of the panel were charged with the sensitive order of the material and enjoined to refrain from communication outside the panel, the recommendations or proceedings thereof. Obviously, the divergent opinions of its members would be protected. Informal solicita­ tion of information and opinions from their professional colleagues was not denied by this provision. If, however, it became a part of the record, such communication should be formalized and proceed through the channels of communication that are observed in National Academy of Sciences procedure. In the early approach to the participating parties, the Chairman of the Advisory Committee urged the necessity for a single point of clearance of information. Since it was apparent that the entire subject was newsworthy, the Chairman advised that the Policy Advisory Committee and the members of the panels clear through a single individual, namely Dr. Keith Cannan. Where there were any conflicts of interest in the consideration of a given drug by the panel, such members as were involved, would disassociate himself from participation by reason of possible prejudicial judgment of the product of his direct concern. The Policy Advisory Committee, as indicated above, had certain readjustments from the complete representation of the Drug Research Board. While a major­ ity of its members was transferred to the second duty on the Policy Advisory Committee, the addition of nine members gave a wider 455 therapeutic competence to their judgmento The Committee provided guidance to the Division on the conduct of the study, and maintained surveillance over the deliberations of the panels. Where basic policy problems arose, the Committee was charged with their resolutiono The Committee in no sense was devised to pass judgment upon the individual recommendations of the panels, but rather to consider the conclusions and reconmendations as a whole with the possible evolution of a report that might afford guidance, not only in the current study of prescrip­ tion drugs from 1938 to 1962, but as guidance for the future. It should again be emphasized that the cooperation of professional scien­ tific societies and with members of the Board was sought in the selec­ tion of the panelso In this term of reference, much wider range and greater pool of personnel was afforded. However great as may have been the challenge, the implementation of the total effort represented not only teamwork but the tremendous capacity of Mr. Trexler to orient and to direct its actions. In the background, the wisdom of Dro Keith Cannan was regularly apparent in the smooth evolution of the plan. With the categorization in hand, it became apparent that the judgment of the panels leading to the eventual recommendation would depend upon several sources of information. First, the immediate factual informa­ tion available in the scientific literature; second, factual information available from the Food and Drug Administration through its origin in the manufacturer or other sources, and third, on experience and informed judgment of the members of the panelo After due deliberation, several categories were suggested by Commissioner Goddard as most helpful in 456 the ultimate decision making of his agency. Accordingly, the cate­ gories--the alternatives--may be listed as follows: Category A: Effective. For the presented indication, the drug is effective on the basis of the criteria stated aboveo Category B: Probably effective. For the indication presented, effec­ tiveness of the drug is probable on the basis of the criteria stated above, but additional evidence is required before it can be assigned to Category A. The recommendation to the Food and Drug Administration could be for further research or a modification of the claim or both. Category C: Possibly effective. In relation to the indication in question, there is little evidence of effectiveness under the criteria stated aboveo The possibility that additional supporting evidence might be developed should not be ruled out, howevero The recommenda­ tions to the Food and Drug Administration could be that unless it is informed that studies are being initiated promptly with the object of developing substantial evidence of effectiveness, the indication in question should be considered inappropriateo In this particular cate­ gory, there later arose a qualification, but under which the several panels might make recommendations that would modify Category C. Category D: Ineffective. In the relation to the indication in ques­ tion, the panel concludes that there is no acceptable evidence under any criteria, stated above, to support a claim of effectiveness. If there is clear evidence of ineffectiveness, the panel should cite it. 457 The recommendation to the Food and Drug Administration could be that no useful purpose is served by continuing to make this product avail­ able for the indication in question, and that immediate administrative action would appear to be justified. The number of completely worth­ less drugs is probably not large, and these are probably concentrated primarily among certain drug groups. The major use of this category would appear to relate to ancillary indications claimed for a larger number of basically useful drugs. "It is obvious from this categorization that the effort has been made to relate to law, in the matter of the effect the drug purports or is represented to have under the conditions of the use prescribed, recom­ mended, or suggested on the proposed labeling." This obviously raises the question of inappropriate or inadequate labeling of a given drug-­ a matter that was to give considerable latitude to the terms of refer­ ence of the panels. The activities of the several panels had a wide latitude. It is obvious that certain of the drugs and groups of drugs could have immediate resolution. And so in the actual operations of the several panels, the executive secretaries would have drawn such items apart for irrmediate and early decision. Were there a divisive among the panel members, it would obviously be subjected to much more radical study. Furthermore, facilities were afforded to comply with the Conmissioner's request that the recommendations where possible be supported by citation of adequate references, including the best in quality and in strength. Where the 458 scientific literature did not afford the supporting evidence, the request could be made by the panel directly to the applicant for addi­ tional information without recourse to the normal channels through the Food and Drug Administration. Furthermore, the panels were advised that an applicant might make a verbal presentation of the case for a given drug at a meeting--a stated meeting--of the panel, but the reverse of the picture was not encouraged. In a word, it was not deemed advisable to have the pharmaceutical house approach the panel; rather, on the invitation of the panel, such a firm might be asked for clarifi­ cation. Obviously, instances arose where more than one panel was involved. Indeed, there could well be several panels with whom a given drug with broad or limited indications might require pooled considera­ tion. The pooled response of the several panels, then, would be resolved by conference. The combination of drugs posed an inunediate problem. It was the decision that a drug combination could be judged effective if each active ingre dient contributed to the effect of the combination as claimed. Obviously, the safety in relation to effectiveness had to be brought under further consideration, although all of these drugs had presumably passed the original criteria of the Food and Drug Administration to remain in pro­ duction and procural. The claim of relative effectiveness raised an issue that could only be met by reconunendations relative to appropriate labeling of the drug. Unless this were the case, the panel might seri­ ously consider the rejection of the drug whose producer made extravagant claims. An interesting circumstance arose in the possible weight given 459 to the sustained position of a given drug over long years which implied an earned reputationo Such weight as was given would be relative and not easily evaluatedo Where there were sharp differences within the panel as to the rating of a drug, appropriate consultation was recom­ mended upon the advice of the Chairman of the Policy Advisory Committee. Usually this was resolved at staff level either within the Drug Research Board or more regularly members of the Policy Advisory Committeeo The listing of the members of the Policy Advisory Corn:nittee has been given already [See Appendix] and the appended list of the panel chairmen, 27 in number originally, but enlarged eventually to 30, should be supplied. [See Appendix] The forms for the Drug Efficacy Study are found appended to the Guidelines for the Drug Efficacy Study of the NAS-NRC, August 1966 (Middleton papers, Drug Efficacy Study), and with the groundwork set and the panel chairmen named, a joint meeting of the Policy Advi­ sory Committee and the Chairmen of panels on the Drug Efficacy Study was called May 17, 1967. This obviously represented a remarkable organ­ izational accomplishment at the hands of the staff and with the keen, young physicians assigned from the United States Public Health Service appropriately indoctrinated, this meeting was a most helpful oneo Productive in every sense of the wordo Dr. O.: I gather it's the deliberations of this panel--this is for the record--I'm pretty sure this is the case, but the deliberations of this panel which are the source of the frequent letters every physician in this country receives today from various pharmaceutical manufacturers stating that the FDA has stated that our claims cited in our package 460 inserts for such and such a product must be modified as follows. Dr. M.: Yes. This is naturally the result of inappropriate, let us say, labeling and the claims that had been reviewed by the panels of the Drug Efficacy Study. The recommendations made, as I have implied, did not carry the weight of legal action; but they came from such respected sources that not only the Food and Drug Administration honored them but the recommendation carried over to not only the drug acceptance but to the labeling of drugs. The tremendous impact of such recorrnnen­ dations, as you have indicated, is felt now quite regularly in the change of the labeling. Dro O.: Practically weekly mailings. Dr. M.: Right. The meeting of May 17, 1967 was not the original joint meeting of the Policy Advisory Conmittee with the Chairmen of panels which actually was constituted, A Conference on Guidelines, of July 29, 1966. At this time, Dr. Frederick Seitz, President of the National Academy of Sciences, welcomed the group. The stake of the Food and Drug Administration in the Drug Efficacy Study was outlined by Dr. Goddard; Dr. Keith Cannan and I gave the plan and objectives of the Conference on Guidelines. The groups were separated into three assemblies. One, Assembly of Study Panel Chairmen, under Dr. Alfred Gilman; two, Assembly of representatives of the pharmaceutical industry, under Mr. Stetler; three, Assembly of organizational delegates, under Dr. Hussey. It will be important to confirm Dr. Hussey's presence on that occasion. It is a matter of record that this particular effort with the general assembly 461 reporting through its chairmen the results of their deliberation, was most productive and effectiveo Perhaps Mro Stetler's report was the most comprehensive and involved the deepest grasp of the total problem, as might be expected, from industry. The magnitude of the task was apparent to all before the operation was undertaken, but it proceeded with regularity and expedition after an original period in which there was some tactical delay in the transmis­ sion of materials from the Food and Drug Administration. Under no cir­ cumstance did it occur that this was a roadblock, but rather that the "machinery had not been oiledo" To undertake the establishment of the efficacy of each of some 4,000 drugs, posed not only a task of magni­ tude but one of high judicial capacity on the part of the panels. Progress reports were made periodically and by February 1, 1968, it became apparent that by the end of June of that year, 80 percent of the total reports would have been transmitted. This time factor was important because the term of service of the United States Public Health executive secretaries would be completed at that date. However, it was the judgment of the staff that with the headway made by the panels, the rest of the task would be completed within the calendar year 1968. [End Side I, Reel 13] [Side II, Reel 13] February 12, 19690 Dr. M.: In retrospect, this enterprise on the part of the National Academy of Sciences was a bold innovation in American medicine. Its 462 accomplishment undoubtedly set a record in organization, comprehensive­ ness, and authoritative evaluation of drugso When one stops to consider the mere numbers involved, it would seem an impossible undertaking. Yet with the superb staff work of Dr. Cannan and Mr. Trexler, the machinery was set in motion, the support of the scientific and professional com­ munity was insured, the high measure of dedication of the young physi­ cians assigned as executive secretaries from the United States Public Health Service implemented the work of all panels, and, in turn, the panel members with conspicuous dedication completed a task that will leave its mark on American medicine for years to come. In the course of planning, it became apparent to many that there were by-products of this study that might definitely be turned to other objectives and certainly it (the study) will serve as a landmark from which future conduct of the study of drug efficacy may be gained on the highest plane. A grateful American public will undoubtedly reap dividends for genera­ tions to come. Dro O.: That's a very interesting point. In this study, one of the questions that arose, although I gather initially it was hoped it could be avoided, but the DES did find itself getting involved in discussion of generic drugs, and I know that Dr. Gilman, particularly, had some rather strong feelings about it and actually had a rather lengthy letter, I think, in the Medical Tribune which he spoke as an individual though unfortunately it came to be connected to his role in this body. At this point in time, is there still a discussion on how to best handle the problem of evaluation of generic drugs, or was this really ever solved in the deliberations? 463 Dr. M.: It was a subject of repeated discussion. Dr. Gilman rather embarrassed the staff and me by his breach of our tacit agreement that there would be only one spokesmano I still feel that this issue was not one that primarily affected the Drug Efficacy Study which was given the terms of reference for establishing only the drug efficacy and as such it would treat drugs, whether they were generically labeled or otherwiseo Therefore it is my maintained judgment that this question has to be resolved on an entirely different plane and not by the Drug Efficacy Study which was charged with the entire series of drugs and not whether they were generic or otherwise. Dro Oo: So you do feel that it is unfortunate that this was brought into the deliberations. Dr. Mo: I do not think it was a part of our mandate. I'm glad you brought the point up because I do believe the time will come when there will be a meeting of the minds and the simplification in the interest of the physicians who must now dispense and know among a dozen terms for the same basic chemical preparation--the generic as compared with the proprietaryo The atmosphere has been even more clouded as you know when the Parke Davis Company established that Chloromycetin--chloramphenicol--which was developed in their hands (I think they had the original patent on it), when prepared by other people under the generic name, was not as effective as their product. Certain physical differences in the crystals limited its solubility or absorptiono Now these are matters that did 464 not concern the Drug Efficacy Studyo Basically, we go back to the original tenets. When you introduce these variables, you're asking for argument. Dr. Oo: In reading through some of these documents, certainly Dr. Gilman stands out as the primary advocate of getting involved in this question in this program. I don't know really if he had a great deal of support in that feelingo Dro Mo: It was not the judgment of the Policy Advisory Committee as a whole that this should be a part of our function. It has to be answered some time, but you see, what I'm driving at is that----- Dr. O.: Yes, that you had another job to doo Dr. M.: until they simplify the entire case, they can't come to grips with the isolated differences among these several generic drugs qualitatively. I say qualitatively advisedly because I think that we all realize that the vehicle, the formulation of the compound--I'm speaking in physical terms now--solubility and so forth, will have a very definite effect on its efficacyo But you are charged here with specific terms of reference, or term of reference, and that did not in­ clude comparative valueso You recall that in one place in the discus­ sion we definitely raised this issue that a matter was brought up which involved the question as to whether the indication in question was inappropriate. The panel could defer to manufacturer as to whether they had further evidence or whether they wished to develop evidence. Under 465 these terms, the individual panel might invite the representative of the firm to come to present their particular approacho I think this was the latitude that the Policy Advisory Committee wished to maintain with an idea that this was not an infringement on the prerogative of the Food and Drug Administration; but they merely wished to extend their own information. You see what I'm driving at? Dr. o.: I believe so. Dr. Mo: They wished to have a full audience and not to rest entirely on the record either as it had come from the literature, as it had come from advice from the Food and Drug Administration, or last of all, from the inserts which were really transmitted from the pharmaceutical com­ pany. If there was a question, and this would be at Category C, a question of effectiveness, indication, impropriety of the indication, so forth that they could get a clearer judgment, but more particularly giving the atmosphere of openmindedness rather than closing the door. In the case of chloramphenicol, you recall that the Food and Drug Admin­ istration had to backtrack so far as withdrawing it--they said it would have to be withdrawn. Then they accepted the indisputable evidence of a material difference when the question of generic labeling against proprietary designation came up. Dr. Oo: I remember in the case of chloramphenicol, there was some give and take also on whether or not one had to hospitalize the patient prior to use and that it was decided that if it came to a judgment that it was up to the physician, depending on what the situation was in each instance. 466 There were two other questions pertaining to this that I thought I might ask. One is--I had mentioned this earlier--! believe there was some indication or some question raised by the American Academy of General Practice as to the composition of the panels. It seems to me I came across some notes that they felt these were the great academic physicians who are not treating patients daily in the numbers and so on that we GP's are; are they the ones to best judge the efficacy of these drugs. Dro M.: And of course, I think that that resolved itself very promptly into the accessibility of this group to the general medical profession, and the fact that on the Policy Advisory Committee, we named two men, Dro Daniel M. Rogers, of Winham, Massachusetts, and Dr. Stanley R. Truman, of Oakland, California, general practitioners, to the Policy Advisory Conunittee. Dr. O.: Who were practicing physicians---- Dr. M.: They were both general family counselors. Pediatrics was the other area that protested, feeling that pediatrics had a special situa­ tion; Dr. Harry C. Sherkey, of Birmingham--a pediatrician, was named. Now, this was not to say that every protesting body should have repre­ sentation; but when it came to the panels, we were quite amazed at how many of them had pediatricians on them. It is true that I think there were very few general practitioners, but they would be the first ones to complain about being assigned to a committee that had the judgment of the pharmacology of some very complex drug. Since they had free access, there's no question. 467 Dr. O.: The other point I wanted to raise for the record was this very interesting interchange between Dr. Walter Medell being quite critical of statements which emanated from the Food and Drug Adminis­ tration and, I believe, Dr. Herbert Lay which got a fair amount of publicity essentially stating that the directions of the package insert as approved by FDA should be looked upon as the gospel; they should be the directions and any physician who modifies his dosage schedule, etc., takes a legal--well, makes a step which could put him up for legal questiono Dr. M.: Well, that was brought under advisement, and I think it was the consensus that no text, no ipse dixit of a governmental body could fix the dosage of a given drug. My associate, Dr. Arthur L. Tatum, the Professor of Pharmacology at Wisconsin some years past, said the dosage of morphine is "enough"! And there's such a wide variance in human reaction that it's impossible. So that there has appeared through this picture and in the Drug Efficacy Study the suggestion that if the eventual compendium or if the package insert were to be the "law of the Medes and Persians that altereth not," medicine was being practiced by government. Indeed, a release from a certain official of the Food and Drug Administration had indicated that this was finalo If you departed from the recommended dosage and something happened, you might be legally responsible and malpractice suit be brought against you. This position would never hold water unless things change. Dr. O.: Well I gather, at this point in time, that it is sort of in 468 abeyance, in other words FDA has made these somewhat threatening sounds and subsequently they've had quite a response from the medical corrnnu­ nity including the DRB, and what will eventually happen we don't really know, but I would imagine it's probably quite likely it will 1:e a rather marked modification of this position. Dro M.: Oh, I'm quite certain there will be because, knowing Dr. Lay as I do, I don't believe that he would be party, ultimately, to posi­ tion that we would have a schedule of dosage as well as fees handed down from government. Because if you did not get effect from a drug within the range cited in the package insert or a proposed compendium published under auspices of government and the patient died, they could be had both for ill effects and after effects. It's an interesting period in time insofar as this angle is concerned. I think I should touch on it in the next relation. But all in all, this was a magnifi­ cent job for which the staff organization and the active participation of government, industry, and profession will go down to the credit of them allo [Pause] The transition from the University of Oklahoma visiting professorship to Madison posed a very serious question to the Middletonso At that time, there were several attractive offers. In the first place, my associates at the University of Oklahoma were kind enough to invite me to stay a second year; a most attractive offer, and one that tempted us sorely. There, too, came a most unusual invitation to spend a year in the Department of Medicine at Damascus. Foreign travel had interested 469 both Maude and myself, and I was sorely tempted to undertake this assignment, but the distance and the circumstances of further detach­ ment led to a rejection of this offer. Finally in the academic sphere, Dr. Harrington, Professor of Medicine at the University of Miami School of Medicine, asked that I come to that institution to pursue a similar program to the one at Oklahoma City. In the light of certain of the transition operations in the movement of the Veterans Administration Hospital from Coral Gables to Miami, there had evolved certain gaps that he felt I might fill. Indeed, he went so far as to extend an offer of a part time assignment that might take me from Madison to Miami periodi­ cally through the year. However, this arrangement did not conform to any set plans that we had for a renewal of our residence in Madison. Then the Association of American Medical Colleges was confronted with the necessity for evaluating medical libraries in foreign lands and a traveling assignment was offered to my by this body which I could not undertake. The National Board of Medical Examiners with which I had been intimately associated, largely through the kindness of Dr. John Hubbard, approached me to undertake an associate assignment with Dr. Hubbard. Attractive as was this with the promise that they would find an assignment for me at my Alma Mater or at the Philadelphia General Hospital, whichever might be my choice, I decided that a return to Madison was in order, both from the standpoint of time and design. The return to Madison was made more attractive by the overtures of Dr. John K. Curtis, Chief of the Medical Service at the Veterans Adminis­ tration Hospital. To clarify this situation, it should be understood 470 that I had refused to return to University Hospitals in any capacity since my emeritus status meant that I would displace a younger mano I could readily appreciate the junior attendings attitude toward a senior member who was on the retired list coming into the picture to make his promotion and advancement, professionally, more difficult. So that the designation of a Consultantship in Research and Education to the Veterans Administration Hospital in Madison gave me free access without any strictures as to time or assignment from the administrative standpoint and with every opportunity for professional maintenance if not advancement in the contact with students and staff. Since we had been away from Madison for nine years, this opportunity was a godsend and it proved to be even more than I anticipated in the intervening years. The professional relations were interesting in their modifica­ tion in the years of my absence from Madison. Naturally, the old friendships were renewed. Picking up loose threads of association, new obligations were naturally assumedo The change in the University atmos­ phere had carried over into the Medical Center. Reflection on my early associations was a natural one in my judgment. Since I had come to Madison in 1912 when it was a small university community, a college towno The University population under five thousand and the population of the city of Madison in the neighborhood of twenty-five thousando The physical appearance of the campus had been strangely changed by the appearance of high-rise University buildings for classrooms, offices, and dormitories, a prospect that I never conceived fifty years before-­ not even, for that matter, when I had left Madison nine years before. ii 471 The Medical School itself had gone through an extremely trying period of conflict with schism in the faculty. A situation that had made me heartsore because during the period of my residence and certainly in tenure as dean for twenty years, there had never been a semblance of division. When I had returned to Madison to attend the funeral of a close friend and associate some years before, my conversation with certain faculty members gave some insight into a division that was developing. My conunent at that time was "Gentlemen, do you not see what you are doing?" When they answered in the negative, I said, "You are already choosing sides. When sides are chosen, there is a division to be anticipated." So it has happened in the naming of a successor to the Chairmanship of Surgery, Erwin R. Schmidt. The situation then was well-expressed by a diener when, writing to me on other matters, spoke of the sharp division that had occurred within the faculty. He concluded his analysis of the situation with a very graphic statement: "This wound will not heal by first intention." To me, it was a most prophetic view of the situation. However, by the time of our return in 1963, things were beginning to settle to their normal status. Although there were certain areas of acerbity, it was my feeling that there had been progress made toward the healing of wounds. The University Hospitals which were completely familiar grounds and whose every brick I had seen laid, had undergone distinct changes. The movement in the direction of remodeling in areas of necessity was sound progress. The Service Memorial Institute for the basic sciences had been completed by the construction of the Bardeen wing which made - 472 possible the movement of the Department of Anatomy to the Medical Center complex. This construction had already been underway at the time of our departureo The greatest physical development had been the construc­ tion of the McArdle Memorial Laboratory whose background has been related in another directiono But this eleven-story building loomed threateningly over the rest of the Medical Center with its very bizarre external architecture or sheeting. I presume it is of a concrete or composition block; you remember ito It is nonetheless the most econom­ ical building on the University campus, insofar as return of effective laboratory space for a dollar is concerned. The attitude of the Medical School in general and the University Hos­ pitals in particular was rather a startling revelation. I do not refer primarily to the strangeness of the scene nor the unfamiliarity of the faces, but the bustle and pace that was entirely different from the one that I had left some nine years before. Yet upon reflection, it is true that the lack of familiar faces and the attitude of the staff and especially the general maintenance personnel was entirely apart from the situation with which I was familiar in the earlier day. Clearly, the University Hospitals had outgrown me or had grown up while I was away. I felt almost a stranger in a strange land except for the occa­ sional turn of a familiar area or face that brought me sharply into focus. Pride that had existed relative to service and maintenance, apparently no longer existedo The late Dr. Harold Mo Coon--"Fat" Coon to the most of us--had primary pride in housekeeping. With indifferent maintenance, it became apparent that there was not the attention paid 473 to such lowly functions in the modern state of affairs. The attitude of haste found expression, too, in the lack of rapport among members of staff or between the staff and supporting personnel. It's almost inconceivable to me that there should be so little interchange of the time of day among people who work together in a common cause. Accord­ ingly, it would impress me out of all proportion to the casual observer I imagine, but I believe that it makes for better teamwork and better careo I know there has been something lost in this directiono The occasion of visiting special units such as the renal dialysis unit, the intensive care unit, brought vividly to mind the fact that while the methodology was highly superior to that with which I had grown, there was an impersonality and a lack of true appreciation of patient need and reaction that was not to the advantage of the party of the first part. I feel that this is a matter that is not peculiar to Wisconsin nor to the University Hospitals, but permeates the entire system of medicine as we know it today. Dr. O.: I'm sure you're right. Dro M.: The feeling of seething unrest that marks the national and, indeed, the international scene today, has affected in no small measure the university scene throughout this country. The medical students have been fortunately aloof from this movement insofar as the local scene in Madison is concerned. It is my sincere hope that it remains soo We must consider the possible impact of such an infiltration on the ultimate product for which we are responsible, namely, the medical graduate, 474 which brings one at once to the consideration of the medical curriculum as it is now concerned. The curriculum of the recent past has largely been the stereotype pro­ duct of the Flexner Report of 1910. The difficiencies that existed at that time and the lack of a cohesive approach to the problem, gave Abraham Flexner a very fertile field to plow, harrow, seed, and culti­ vateo Familiar to all is the fact that in the 19th century, indeed until the work of N. S. Davis in Chicago, the medical courses through­ out the country represented repetitious didactic lectureso Indeed the subject matter in certain fields was so limited that the lectures of the second year repeated those of the firsto The Chicago Medical School was set up as a department of the Lind University--later the North­ western University--as a protest to Brainard's insistence at Rush that they follow the old pattern and not have a graduated course. Nathan S. Davis, who insisted that it should be a graded course, moved out from under Brainard's influence and set up this graded course at Northwestern in 1859. The thought that the philosophy that this movement represented was to bring the students, as in the general university courses, through more and more advanced stages to their completion of the course at the end of three yearso Harvard and Syracuse followed in twelve years in 1871, but the original pioneer was the Chicago Medical College in 1859. Medical schools had considered the preceptor plan as an important ele­ ment not only in preparation for, but as a part of their course, until the last quarter or third of the 19th century. Gradually only lip service was given to the preceptorship that steadily lost favor. They 475 might have a preceptorship under a certain person, but the mere signa­ ture of the physician eventually sufficed and there was no supervisor. The diploma mills had become notorious. When, under the Carnegie Foundation, the Abraham Flexner survey was made and his recommenda­ tions published, requirements for graduation were rather stereotyped in course and time. This was to be a formula to which the several State Boards of Licensure subscribed. In turn, the medical schools felt them­ selves bound by the strictures that were first met in the acceptance to the examinations of the licensure boards and then eventually to com­ ply with the spirit of the Flexner Report. In the years intervening from 1910, the statement that medical education had stood idly by and said that this was the formula so, is not true literally nor in actual fact. Among the various professional schools within the university domain, medicine has been the most progressive insofar as modification of curricula is concerned. I say this advisedly because the other pro­ fessional schools look upon medicine as the most liberal in this respect. The fact remains that the tremendous advancement of medicine through scientific application, or application of science as it was so rapidly moving, meant that we had an opportunity that was too often reluctantly accepted. The mandate for change was to come, not primarily from medi­ cal school, but from other forces--economic, sociologic, and otherwiseo Medical education lagged at a time when it should have taken the leader­ ship. To digress in just a small measure to indicate that in 1909 in the talk, ''Medicine in the Scheme of Conservation" before the Alumni Society of Rush Medical College, Henry Baird Favill, a Wisconsin man by the way, had had as a punch line in his speech, to which I referred iiiiiiia 476 previously, "the pathology of society is as much the responsibility of the medical man as the pathology of disease." Way ahead of his time, a most prophetic statement in the last analysis, and yet as I look at the situation today, I think that one of the circumstances that concerns me most is that our sociologic application is so far behind scientific advance. I have in another respect related to the fact that science is in the stratosphere while sociology is earthbound. It is a significant detail that as you carry this philosophy over to medicine perhaps from the sociologic adaptation of all of the professions, it is least geared to sociologic change. Now this circumstance makes itself felt not only in the practice of medicine, but singularly in the field of medical education where the roots should be so deep that the practice responds to the source. In my judgment, this is one of the extremely important lessons that we should take from the past. It is obvious that the sociologic changes are here to stay. Medicine has not accepted this premise, and organized medicine has particularly been resistant to change. I have indicated before that the practice of medicine has changed upon demand, to which we shall refer later. To go to the roots, the curricular changes that are now in active opera­ tion in every school in the land have a common pattern in many respects. Perhaps the most notable change came in Western Reserve, a situation that offered a great many promises with some local disruption; but many of the theses that were early proposed there under the leadership of Dr. Ham and others, have found deep root and are definitely being trans­ planted elsewhere. My concern, however, is an entirely different vein. 477 It is possible, even probable, that there were good things in the past; I cannot accept that all of earlier medical education was indifferent or poor, even as to methodology. I am the first to stand for change, but change for change sake alone is not enough. I am viewing the situa­ tion now from the sidelines, removed from the active scene, but I am concerned in certain basic principles. In the first place, I think that a physician should be an educated gentleman, and I do not see in many of the formulae that are being proposed any advancement of the culture of the physician. I see little more, probably even less, attention paid to the humanities and the sociologic aspects of life in the future of the product of our medical schools. To come down to the situation that is generally applied, we have in different external manifestations the same basic theme, that we will start our students off with a core pro­ gram. Now, who is going to decide the content of that core; just who has the wisdom to project this young man entering the first year of medicine into the practice of medicine ten years hence? If we admit that the product of the medical school under normal conditions is the intelligent, inquisitive physician, what proof have I that the founda­ tion that has been established by a committee of his peers on the faculty will have set up certain elements of certain subj¢ets--this is it and is this, in your judgment, any better than what Abraham Flexner set up in 1910? Then from there has been an increasing effort to channel this man into his area of greatest aptitude or design. What young man, at your time of undergraduate exposure, was ready at the end of his first year to say into what specialty he would fit? Where are his interests 478 going to lead? I think that we start with the erroneous premise that an individual should, at this stage of his development, specialize and set his sights for his ultimate objective. My contention is obvious that we have not yet built a firm enough foundation, so that we're cer­ tain that the superstructure is going to stand. Certainly, the fruits of such a program can never be read at the conclusion of a medical course. They are going to have to project it into his ultimate career. It is such a tremendous responsibility that I have frequently said that I wish there were some faculty that had the guts to say that "This is fine; we are thoroughly convinced that change is in order, but this should be phased in, bring it in gradually." Mais no, it has to go-­ all the way across the board. One complete turn and we are on a new channel. This revolutionary movement is now making itself felt in our Medical School. I am an innocent bystander and listen with both ears and with my receptors, certainly, wide open; there's no closed door. I shall be most anxious to see what the students do at the early phase-­ how they react--and my sympathy is all with the faculty that is trying to make the adjustment. How do you feel that the picture will alter, as it changes? I antici­ pate, even with the tremendous advancement in medical science, with the introduction of biometrics, of bioengineering, genetics, and a series of other subjects, into medicine that a medical curriculum is going to be simplified. I'm quite certain that we are going to have an increas­ ing movement toward the conception of the human being and his disorders as a biologic entity. I'm quite in harmony with the current thoughts 479 of bringing subjects as are closely related together, and the contin­ uity of thinking that comes with the course that incorporates neuro­ embryology, ne.uroanatomy, neurophysiology, neurochemistry, organic. neurology, from a clinical standpoint has all of my sympathy. I think that it's bound to come. In that thought I see a consolidation and truly a simplification of curriculum as an ultimate product of our present movement. At this point in time, my concern is that we have "rocked the boat" very seriously without perception as to where the rudder is going to take us. In the broad sense, this recent period has seen support of research from federal to private sources, of such magnitude----- [End of Side II, Reel 13] [Side I, Reel 14] Dr. M.: -----that it is almost inconceivable to relate one's thought to a period when small sums alone were availableo Yet in this period of tremendous scientific growth and support, there has developed a frame of mind among the oncoming generation as well as its seniors, that research is a way of life to which every young man aspireso Obviously, this dislocation has arisen because of the image of research in the lay as well as the academic mind. From extended experience before committees of congress, I concluded that education must be retailed while research is wholesaled. Dr. O.: That's very well put. 480 Dr. M.: The point in case being that even with these sophisticated men of affairs, the mere word research was a shibboletho I could defend our research program within the Veterans Administration to the magnitude of millions of dollars; whereas little attention was paid to the paltry sums that were requested for education. In the last analysis, education is the retailer of research. Until these matters are brought into appro­ priate relief, there will always be a disproportional attention paid to the needs of the research programs, both of federal and of foundation origin. Reflected in the educational program, therefore, has come a singular dislocation of the missions of our medical schools. Men of prominence in medical education are now realizing that the support of research, with or without diversion of sums irregularly to education, have seriously encroached upon their teaching programs. This has meant, in the first place, a prejudice to the quality of medical education, and a diversion of prospective teachers to research functions. Cer­ tainly, no one would deny that the men in the two fields may have the same quality of intellect and certainly gram for gram, the same constit­ uency of chemical elements in their respective brainso However, there has been created an image that is apt to distort the exact condition in the mind, and not only of the laity, but of the young man approach­ ing a life's career. Under these conditions, we have seen a reluctance on the part of well-qualified teachers to maintain teaching functions or to extend the same because they feel that it is prejudicial to their academic advancement. This is obviously a circumstance that makes it­ self felt in the recruitment of faculty for a primary teaching function, and, by the same token, ever deepening the rift between teaching and 481 research that should never have been permitted to develop. The curric­ ulum, then, must be devised with the primary objective of its product-­ the thoughtful physician in mind. If research is to be maintained at its present level, the dislocation can only be corrected by improving the lot of the teacher through appropriate recognition both in salary and rank. It is a matter of deep concern to medical educators that there is at present no early prospect of such a millennium. Until there is given incentive to the younger prospective faculty members in this direction in recognition proportional to their productivity in teaching, we may expect no great change in the early future. Perhaps one of the disturbing factors to the faculty member is the lack of close rapport with the student. Osler once wrote: ''The man who does not suffer the foibles of students gladly, misses the greatest zest in lifeo" I be­ lieve that were this message to be gotten across to the younger faculty members, there might be a better opportunity for high class recruitmento Since the rewards of teaching, although in the main intangible, are the greatest blessings in life. The medical student of the present day is an interesting individual. Having had some fifty-seven years of exposure, in my judgment he is a better product than his father or grandfather. In the first place, his basic training is better; in the second place, unless this structure be destroyed, his scientific training has better prepared him for the clinical instruction to which he will be exposed, and for the clinical practice that will be his lot having survived the undergraduate and the medical curricula. His attitude is a receptive, responsive oneo His 482 motivation is high; his vision, clear. If there are disillusionments ahead, at least it should be the lot of the instructor in the medical school to defer them and to maintain the light as long as is possible. In my judgment, the responsiveness of the medical student has not mate­ rially differed over the period of my exposure. Overwhelmingly, he is interested in human beings, and it behooves the medical teacher to keep this particular frame of reference closely in mind and never must he lose the human touch. I feel that to do so is to condemn the student to a cynical, ill-adapted futureo In my judgment, this is one of the important functions of the teacher in the medical school. It has been my practice to maintain, not only close rapport with the medical student and interest in his inunediate problem at the bedside, but to attempt to search behind the scene to see what makes him work. To avoid any semblance of idle curiosity in his personal affairs, but by the same token, to learn just how he is reacting to his own respon­ sibilities and how he is projecting his future to assume new obligations. It has been my observation over the years that the youth of the land respects disciplineo In this troubled period, it's rather an unorthodox position. While I tell them, without exception, that I do not respect a "yes-man", while I make it clear to them that I wish their frank opinion and nothing less, by the same token when I have taken a posi­ tion or when there is a definite rule or regulation imposed, I not only expect them to honor it, I expect them to accept this position with dignity and with the realization that this is a part of the manner of growing up. It is extremely interesting to me that with rarest 483 exception, if one avoids rancor, if one is not punitive, if there is no sadism in his approach to discipline, the student accepts it without question like a man. Dr. O.: I realize this rift between the teaching and the research in medical education and its effects on medical education undoubtedly started some while ago prior to World War II, but am I correct in feel­ ing that it is quite likely that the tremendous increase in funds available for medical research, available through OSRD, CMR, which all of a sudden there was more money than could be spent which was then con­ tinued following the war with essentially a transferral to the NIH fund­ ing and continuing to this point. It took what may have been a slight rift and really broke it wide openo Dro Mo: Oh you're absolutely on target. In an administrative post I am approached by one of the national agencies and they say "There is money available and you are not in on it. Don't you have something for which you can start this project? We would like to initiate this program with a $40,000 grant." And I reply, "Until we have an idea, I would ask you not to buy." And I think that is basico At the Univer­ sity of Minnesota, in the 75th Anniversary presentation that I made to them, I spoke of "soft money" and when the paper was published they had erased that "soft money!" (Laughter) Dr. O.: Well I am sure at the University of Minnesota something like the Department of Surgery would really be in severe straits without the federal support. 484 Dr. M.: This is another angle that we haven't touched upon which does not involve us directly here, but I have indicated in this article, "Some Tangible and Intangible Values of Modern Medicine," that this is the basic truth that I stated back in 1959----- Dr. Oo: '54wasn't it? Dr. M.: '54, 1954, I enunciated and I feel that this so obviously coming to roost today that one cannot escape ito Some deans, some schools had been placed in jeopardy because they did not observe what really the simplest rules of economy and planning. The medical student of the present day is confronted with a world of practice not of his own making and not of an order that he had envisioned when he came into the medical scheol. One could have predicted it, obviously, on the score of the increasing demand for medical care as the medical armamentarium improved and as the facilities were greatero The population increase indicated that there would be a need for a great increase in physicians. The ideas that had been promulgated to increase the number of physicians include several familiar to all of us. First, increase the number of students and by the same token, the product of output of existing schools which could be carried to a certain point of diminishing returns in the quality of medical careo To care for such students and to increase the number of medical schools, you will have to have increased faculty. At the present time, there are fifteen hundred vacancies in salaried positions in the system as it exists, so that if you multiply your schools or you extend the number of students 485 within existing schools, you're going to have to find a source of faculty which is in short supply at the present timeo The thought of the two-year school--the United States Public Health Service made a survey of this area some time ago and they proposed that we increase the number of schools and increase the two-year schoolso Now having lived in a two-year school for thirteen years before the University of Wisconsin Medical School became a full four-year school, I could answer immediately and I did make a protest. Unless you can insure a man who enters a two-year course that he will have an appropriate clinical outlet for his last two years, it is perfidious to accept him into medicine. We had the experience at Madison of taking a class of a hundred with the idea of retaining 50 at the end of two years--the other 50 going to other schools. As a two-year school, we had been sending men to all of the leading schools in the country, and the largest outlet was at Rusho In 1940, Rush gave notice that they could no longer accept our men to advanced standing since they were going out of operation in that area. So that I had to go to the Board of Regents and ask them that if we accepted 75 students on the four-year basis, whether we could cut back on the number of acceptances in the first year. I cite it because here was a circumstance under which with the advancing years, we found ever increasing difficulty in placing our two-year students in a good medical school. The only arrangement that had occurred to me as meeting the situation with full responsibility to the men who are accepted into the course, is like the Dartmouth arrangement with Harvard, and the early West Virginia arrangement with the Medical College of Virginia. If you 486 can have a working arrangement by which the graduates of two-year schools are regularly accepted with the assurance of continuity, then I have no fault to find with the establishment of two-year schools because there are a number of four-year schools who could take an in­ creasing number of students into their clinical years. Then it becomes an expedient that has real value. The practice of medicine as you and I see it today is an entirely dif­ ferent formula than presented when you graduated and when I graduated from medical schoolo As I have indicated in a moment past, the "hand­ writing was on the wall"; that there was going to be prehospital in­ surance and prepayment for medical care--this was on an insurance basis, but with the state or federal participation in the offing. I had, as I think I have said in another relation, lived through the period in Britain when the Beveridge Report came in the White Paper. The National Health Act was not passed until after the war, but it was passed at a time when a coalition government was in control under Winston Churchill-­ not a Labor government. I cite that because it is significant that the change (I don't know whether I have gone over this before or not) that had developed in Britain was that the support of a voluntary hospital system was by the landed gentry. Dro O.: Yes, you mentioned this yesterdayo Dro M.: Yes, and I think that this comes into very sharp relief because the collapse of our American hospital system is going to be on the finan­ cial basis and not a circumstance in which the physician, per se, is 487 responsible except as he uses those services. But unless there is a sharp curtailment, the graduating student of this day is going to live through the period when government increasingly takes responsibility for this function. I have called attention to Francis Fraser's attitude, insofar as the Cottage Hospital, the Regional Hospital and the University Hospital system is concerned. Certainly the Regional Medical Complexes that we are setting up, will have that ultimate impact. In speaking to the students, I have maintained to them that I do not anticipate a future in which the practice of medicine at its point of delivery will be any different from what it is at the present time. I think that third-party payment is the order of the day and that it will increase from the present 82 percent to even larger percents which means that they will perforce never see the day when they are paid directly by the patient. Now that seems like a far cry from what your father and I knew when we came into medicine; but he will tell you that he has seen the day when it was literally to rule yourself out of a medical society if you even thought of a Permanente connection. Dr. O.: Sure, in California that was a dirty word for a long time. Dr. M.: Oh, wasn't it. Horrible. So that when you now see the govern­ ment actively entering into the advocacy of group practice, you realize that there's a change in the air. In speaking to students, I have made it clear invariably that it is my firm conviction that while the manner of de~ivery of medical service will change, it will be better. While there may appear to be a shrinkage of the requirement and the production 488 perhaps before requirement of the family counselor, it is my belief that the future will see the family counselor in much greater demand than at the present time. He will practice either alone or as an essential member of a group. In a group, he will undoubtedly have more patients than any other member of the group and I think it may, if this pa~tern evolves, be the area in which he is used to the greatest advan­ tage. We have a straw in the wind in the action yesterday, or day before, of the American Medical Association through the Council on Medical Specialties recognizing the American Board of General Practice. Dr. O.: I hadn't noticed that. Dr. M.: Yes. It was just yesterday. I had word that it was going to come; but I was quite surprised that it came so promptly after the action of the Board of Trustees of the AMA. The specialization will be even more seriously extended and this is to be anticipated. Certainly the total effect will, in my judgment, be to strengthen the generalist. That is a strange paradox; but I think it will be by the manner in which he is utilizedo The mere assignment of a specialty designation to this generalist will not materially change his function. In the small com­ munity, he will still be the trusted image of medicine; but in the group I think he is going to have a very wide extension of his influence and activity. Actually about 85 percent of all ills could be taken care of by the generalist anyway. I have some misgivings as to a trend that is presently abroad in the delegation of responsibility. I have seen the time when a nurse could 489 not even start a hypodermoclysis--you haven't heard of that for a long while. Dr. Oo: No, but I know what it iso Dr. M.: Let alone an intravenous injection. And you have seen these functions pass through hands of nurses----- Dr. O.: IV teams, nurses. Dr. M.: Now down to the laboratory technicians and to some of the other personnelo With our tremendous mechanization, you have seen laboratory examinations extend beyond any concept. I used to have a philosophy that you justified your laboratory examinations and even your other procedures, therapeutic measures and so forth on the scores of essential, desirable, and excessive to the need. And now that position comes back at me because we have autoanalyzers and can do much less expensively on less material 14, 16 examinations. So that by serendipity you may dis­ cover things that you never anticipated when you use your brain presumably to disclose the need for laboratory or other supportive measures. So this is part of the progress in medicine. I still feel that the medical profession has too readily accepted the hospital as the total focus of activity. It's obvious that a considerable segment of patients could be taken care of in the office or at home. The attitude that this is econ- omy of time, that it is the better utilization of personnel, that more adequate facilities--if the complex were built in which the physician's office were a part of the hospital unit can be defended. It's simple 490 to see how this movement could be effected with greater convenience to both contracting parties. Stopping to look at this matter dispassion­ ately, I think that we would find little support for the heedless, needless hospitalization that is certainly a heavy contributor to the cost of medical care. The screening ought to be on a very much sounder basis than at the present time. Hospital utilization is being studied, I know at several layers; but it's an abused privilege under whatever type of insurance unless it is very carefully monitored. The distribution of physicians is one to which I have directed my atten­ tion over a number of years. Perforce by reason of my position as Dean of the Medical School, the requirements for medical care in a given conmunity would obviously have my inmediate attention. We know that in metropolitan centers there are physicians that are idle. Such overman­ ning medical personnel, both professional and co-professional, reflects itself in the siphoning off from the lesser populated rural areas. Unless there is some control at a higher level, which you and I would hesitate to reconmend, this is apt to persist. The medical man will consider his wife, his family, the physical, the social, economical, religious, educational setting into which he establishes his family. The fact of the matter is that it is very difficult for one to translate the needs of the conmunity to the individual unless you can satisfy certain basic requirements. Now this comes into a very subtle area where the family is concerned. I have had long experience of having wives come into my office to discuss the setting so far as her family and the rearing of her children is concerned. One cannot stand in judgment nor by the same 491 token didtate how that movement will be made. There have been certain devices by which this coverance has been attempted, as you knowo The only way it has worked is by command and that is not yet a situation with which we are confronted in this country. Dr. O.: Scholarship and support only if the person paid back the time owed and then they skidaddle off elsewhere. Dro M.: This, of course, was the fate of the Mississippi Plan, as you knowo Dr. Mo: Right. Well, that is a "pound of flesh" and not "a drop of blood" in principle. The fact remains that we do not have a solution for it. Whether it will come from federal sources or not, I do not know. We are extremely proud of the standards of medicine practiced in this country. I use the term "standard" advisedly because standard and quality of medical care are two different things. The standard you can measure quantitate by paper work, the records, the retrospective study of the record, the management of the patient, treatment, laboratory support to diagnosis and so forth, results, all can be worked out and a computer can give you the answer. These are standards. The quality of medical care is something that you cannot estimate. The patient also finds difficulty in this judgment; there is so much of the subjective in the personal equationo Hence this is a circumstance that seriously affects the young man when he looks into a possible location for the permanent career in practice. He realizes that he must have certain facilities; but given those facilities, can he deliver? And delivery 492 of services in quality can only be very inadequately approximated. I think it has to be largely the individual, and the patient, of course, in his response will too often be affected by circumstances that are not quality related. The last point that I wish to speak to has to do with the infiltration of other skills into the medical field. I've already indicated that the nursing area has been very active here, and now nursing aides and laboratory technicians are coming into the picture. The circumstance that directed my attention first to this was the suggestion of pediatri­ cians that nurses could and should be trained to a certain level of competence that would take away some of the routine of the pediatrician. And then I had studied the matter of the Feldsher Plan in Russia where about 80 percent of their practitioners have been given some basic courses in anatomy, physiology, pathology, then have been put on the preceptorial plan and in about two years, finished their course and are assigned to physicians. Within the cities proper, they do have super­ visiono The supervision in the country is really very superficial and the reviews are perfunctory. This is a pattern that Gene Stead has instituted at Duke under the term of Physician Assistanto It has all of the virtues of the Russian system in that the recruits at the present time are corpsmen from the Navyo To date, there's not enough production to say just where it will goo Now why should I, a man of my age and removed from the scene, be concerned? The first is in a very narrow viewpoint that from my observation the usual result of the introduction of a norunedical person into a field allied to medicine, is the 493 infiltration, an insinuation of their efforts into areas that were not originally envisioned. The experience that we have had in certain of these areas should come to roost. And I refer first, to the physio­ therapist. You turn physiotherapists out from a university clinic and he first has patients referred to him. Before you know it, he's prac­ ticing physiotherapy on his own without the prescription of a physician. Perhaps the most conspicuous area is the clinical psychologist. The clinical psychologist is now practicing not psychology but psychiatry, and there is no manner in which we can control it. We've seen the health educator pass out of the medical hands into a professorial rank at the University of Wisconsin. So that there are so many of these evidences of infiltrations that will eventually displace physicians. Now this may be a desirable end result. The physician assistant is to assume that unless he is immediately under the physician superintendent, he will be doing lesser things as the feldsher does, the communicable disease inoculation series, the physical examination, actually the delivery of babies and so forth. Eventually they are the physicians of the connnunity in the nonrnetropolitan areaso I do not think that this nation is ready for two-class medicine. You have the physician, univer­ sity based; you have the physician assistanto Very few people will agree that even though the individual be perfectly competent to do some minor things, they would be ready to trust themselves to the diagnosis and treatment of a second-class medical aid who does not have the background and training of a physician. If I understand the psychology of the American public, they're not ready for two classes of medical serviceo 494 Dr. O.: It's precisely the specific problem in clinical pathology now with lay laboratories opening with no medical supervision at all, with interpretation of laboratory results which is a medical problem, not a lay problem. Dr. M.: Well, that's my story and I stick to ito Is there anything else that you desire? Dr. Oo: No. Really, I think you've done more than I had expected or hoped for, frankly. This is an excellent note on which to bring the whole thing together. [End of Side I, Reel 14] 495 Maude Hazel Webster Middleton Born on the Fred Mcchesney farm, Vienna Township, Dane County, Wisconsin, on March 6, 1889, Maude Webster was the third child of George Warren and Christina Hyslop Webster. The Websters were of English origino One forebear had served with Cromwell. They moved to Wisconsin from New York State. One fraternal grandmother was a Burt, whose family came from Green County, Pennsylvania. On this side, there was a direct relationship with the Rush family of Eastern Pennsylvania. The Hyslops had emigrated directly from Dumfriesshire, Scotland. The grandmother was an Anderson, who had an abiding influence on the child, Maude. After attending public schools in Dane, Maude took her high school work at Lodi High School, from which she graduated in 1907. She enjoyed the dances and active social life of the small community of that day. Her splendid contralto voice led competent judges to urge her to train for a career in music. Qualifying for grade school teaching by summer school studies at Whitewater State Teachers College and Mt. Horeb, she taught in a single room country school for two years. The schoolhouse, near the Madigan farm, was two miles from her Grandmother Hyslop's home in Dane, where she had her room, since the Websters had moved to Madison. She walked to and from school. Maude found the role of the country schoolteacher most interesting in spite of the arduousness of teaching all grades and of physical 496 maintenance of the small unit. Her experiences afforded her family and friends much entertainment in subsequent years. The visit of a cousin, Martha Smart, to the Webster home was the occa­ sion of a change in Maude's plans. Miss Smart was a graduate of the St. Luke's Hospital School of Nursing (Chicago). Wearing her uniform, she gave such a glowing account of the opportunities for nurses that forthwith Maude made application for training in the Madison General Hospital School of Nursing. Accepted, the new world of medicine was opened to her. The period found the course for Registered Nurse of two (2) years. She, therefore, was capped in 1911. Maude credited the meticulous detail and success of her subsequent career to Miss Stoeber, a graduate of Jefferson Hospital, Philadelphia, and a strict discipli- narian. The services of trained nurses were in great demando Private duty on seriously ill patients was the rule both in the home and hospital. Maude Webster was fully engaged. One of my friends, Ned Griffith, Chief Forester of Wisconsin, and raconteur extraorddinaire, was a patient under her care when I first met Maude. Thereafter, I saw her as I called on student patients at Madison General Hospital. However, in 1914-15 my Chief, Dr. Joseph S. Evans, engaged Maude as the Chief Nurse at the Student Clinic. Obviously, we were destined to have continuous profes­ sional and personal interchange at the Clinic, 762 Langdon Street, from that time. 497 From the outset, Maude's fresh and wholesome presence impressed me; but my profession occupied my mind and body. My recreations were not con­ ducive to feminine participation--even if Maude had been interested in meo Our associations were not marred by my aloofness; but, obviously, friends read signs that were not apparent to me. We went to occasional shows; but two incidents that had a deeper meaning are recalled. One day, Maude came into my office, closed the door and asked, "Are you really engaged to a girl in Pennsylvania?" I answered, "Noo What makes you ask?" Then she told me that a coed who had vacationed in the East, had met a high school classmate of mine, who had spoken in such terms of our friendship as to leave no question in the informant's mind. War clouds were gathering and my commission in the Reserves had come (1917). I thought it only fair that I make my position clear. So we sat down on this latter occasion to talk things over. Mother Hazel, as I termed her then, listened thoughtfully to my outlined program of pro­ fessional preparation that had so fully occupied my time, my obligation (assumed) to my family, and now my military commitmento I told her that so uncertain was my future that I could (and would) promise nothing. She was a brick and said, "Obviously under the circumstances you are doing the fair and, from your viewpoint, the honorable thing." Called to duty May 24, 1917, there was a clear indication of my mental alliance. I asked for a favorite photograph of Maude from her sister Jean and carried it with me throughout my active service. Overseas duty denied me personal interchange; but we exchanged letters quite 498 regularly while I was with the British Expeditionary Forceso However, after I returned to the American Expeditionary Forces and after.her unit, Base Hospital 22, arrived in France, her letters ceased completelyo At the time, it was poor psychology, unless in her heart Mother Hazel really desired an end to this tenuous affair. I, nevertheless, persisted in the one-way correspondence. By some strange quirk of fate, my orders for return to the United States routed me to Bordeaux by way of Angers. Naturally, I called at Base Hospital 22, based at Beau Desert out of Bordeaux. Paying my respects to Miss Stella Matthews, Chief Nurse, I learned that Maude was on leave I I to the Riviera (with Miss Myserth). However, she gave me every assur­ I,, ance that she was due to return shortly. Fortuitously, I was assigned as escort for an officer under open arrest for thieveryo This circum­ stance gave me a grace period, during which Mother Hazel returned. Our reunion was a happy oneo We did Bordeaux--more absorbed in each other than in the city, dined, gossiped or covered the year of our detachment. On one walk through the forest, I gave her a keepsake, a gold medal of our patron saint, Jeanne d'Arc (that was never to leave her person dur­ ing her life)o Returning to civilian life (March 4, 1919), I resumed my duties in the Department of Student Health, and Maude joined us in a short time. Shortly, an industrial nursing position in the Edison Company at New London attracted her. Somewhat later she became a floor supervisor and instructor in the Madison General Hospital. Her close friendship with 499 Miss Grace Crafts, Superintendent, made this a happy arrangemento Mother Hazel lived at the Nurses Dormitory (Rest Harrow) and Mother Hodges was not too obtrusive a chaperon. Our courtship was uninter­ ruptedo In 1921, under a Public Health Service commission, I traveled widely to examine all veterans with chest wounds, who had been operated upon by Drso Yates and Verdi--a most rewarding experienceo Upon my return, with a further leg to the East before completing my assignment, I proposed to Maudeo Happily I was accepted; but my terms were precipitouso We would marry in six (6) weeks or postpone the wedding indefinitely. Revo Dro George Hunt married us on September 30, 1921 at the home of the Websters in East Gorham Street. On our honey­ moon, we visited the Narrs in Pittsburgh and my family in Jeffersonville (near Norristown), Pennsylvania. A short period was perforce spent with the Websters until our flat, 630 South Orchard Street, was ready for occupancy. The Schwab youngsters afforded Mother Hazel unusual joy. The while we were planning our own homeo With my brother Dick's technical knowledge, a Pennsylvania farm­ house design was adoptedo Unfortunately, not all of his superior speci­ fications were followed; but by Thanksgiving 1925, a family dinner was served in our new home. Significantly, it was designed to care for a family of four (4) children, all of whom were namedo The failure to conceive led to a surgical exploration by Dro Arthur Ho Curtis at Sto Luke's Hospital, Chicago. He determined nonpatency of the fallopian tubes, as the result of tuberculosis salpingitis. With her overwhelming 500 desire for children, this cross was to be a heavy burden for the rest of her days. Indeed, on repeated occasions, she urged our separation, so that I might have children. As I told her, this very magnanimity closed the door to me. Our life was a happy and congenial one. Our social outlets were never wide. We entertained simply and our only stated parties were large affairs (dinners or fancy buffets) for interns, residents, and faculty. Dory favored the teas or luncheons for small groups that she gathered. A routine release from the tedium of cooking came in our picnics. Practically every Saturday afternoon or Sunday we would cook outdoors. With typical feminine flattery, Dory would say, "Sonny, you are the best outdoor cook I knowo" And who was I to deny? Greatly afraid of snakes, our range of cooking over the open fire gradually shrunk until in recent years Brigham Park near Blue Mound was our accustomed site. The menu--steak, fried potatoes, Sanka, milk or iced tea, toast and fruit. We never tired of this fare. At our early day we regularly walked about Lake Wingra to the springso Here we toasted bread on which bacon fat was permitted to dripo Then the Wingra sandwich was completed by watercress fresh from the running water. Maude enjoyed basketball but irked at attendance on football after the roster of her friends among the players was exhausted. She amused me by attention to dress, fur coats and hats, rather than the play on the l 501 field. She frankly would have changed Camp Randall into a race track. She adored sulky racing. Through the years, my Little Mother never lost her interest in her pro­ fession. She was deeply concerned, lest the design for educational and academic advancement submerge the bedside function of the nurse. She had found such rewards in human service, she could not conceive of a substitute. Her ethical standards were ever high. Deep as was her interest, she never obtruded her judgment in affairs of the Medical School. Her code denied to her inquiries into my professional care of patients, friends or strangers. I know she served as a glowing example to the wives of young members of the staff by her quiet dignity, clothed in a warm personality that eschewed gossip and scandal. A fine mind, cultivated by careful reading, gave impetus to my collateral reading. Little Mother read to me each night. When she accused me of sleeping, I would repeat the last sentence or two she had read. I can­ not explain this faculty, but have reasoned that perhaps a change in pace or tone of her voice registered in my subconscious mind, as she prepared to call me to account. Little Mother loved to roll a wheel. Our first car was a Model A Ford bought in the Spring of 1929. We had shared a Model T Ford with father in Pennsylvania. Ten years after we had both left France (1929), we made our return. Visiting all points where we had served in World War I with the advantage of our new Ford, a most successful holiday was com­ pleted by visits to my old Second in Command of the King's Own Roy?l 502 Lancaster Regiment, John Kennington, in Grimsby and to Little Mother's ancestral home, Spango Farm, near Crawfordjohn, Scotland. Her delight in the visit with her kinfolk, Ina and Angus Anderson, knew no bounds. A ''wee" shearing of 400 sheep and tours over the farm occupied my attentiono Of course, Edinburgh, Sterling Castle and the North were much in my favor. I delighted in the Highlands; but Dory had less interest north of Inverness. Interestingly, I had made detailed notes of points of attention, costs, ways and means, and proposed to offer the same for publication, for at that time travel abroad in one's own car was quite uncommon. Dory was not favorable to this ideao In all, we made five (5) trips together to Europe. Our first was the best. However, on later voyages, the SS United States won Dory's complete patronage. Our last trip to Scotland (1960) found Spango in new hands. The Andersons had died and considerable remodeling of the old home had been accomplished. Fortunately, Dory felt that every change had been an improvement and none of its charm had been lost. Norway was her favored European country. Dory was a superb driver and as our finances permitted, better cars were purchased. She regularly took her parents and friends to neighboring towns for lunch or dinner. On several occasions she took her parents on more extended trips. Our own holidays took us far afield by car. During my parents' lives, we usually went East for a season. At times, Dory would take an independent vacation to visit kin or friends on the West Coast. Together our holiday tours took us to the Northwest quite frequently; we spelled each other in driving--i.eo one and one-half hours. F f 503 usually I took a somewhat longer turn. Crescent Lake on the Olympic Peninsula was a favored hideouto The water was so cold, Dory would have warm blankets to cover me after my dip. The cabins had stoves with a water-coil for bath and shaving water. It delighted Dory to push me out of bed to light the fire for heat and water. Empress Hotel at Victoria and Chateau Frontenac at Quebec were favored stopping places. We were concerned to observe the deterioration of the Empress and of Many Glacier Hotel in Glacier National Park. When I went to the Pentagon with G-1 in 1948, Dory took Grace Crafts south to New Orleans and Biloxi. As usual, she had many adventures. Invitations to far points were conunonplace; but Dory would not fly. For some time I did not press her and then I learned that the psychological barrier had arisen in World War I. Aviators in training naturally came ,I to the nearby Base Hospital 22 danceso When Dory would ask for Capto ----, the answer was, "He came down in flames last week." When this u experience was repeated a number of times, the mental barrier became 11 1:'1,11:! i![i insuperable. Actually it was broken only once. While we were in Okla­ ijl ! homa (1963-4), word came that led to a proposed meeting with a favorite aunt in Los Angeles. Dory found that connections from Oklahoma City by rail were most difficult. The aunt was coming by plane from Portland. Forthwith, Dory flew to Los Angeles. When she arrived, she called saying, "Bill, never travel any way except by jet!" Yet she reneged on two transatlantic and two transpacific trips, not to mention Puerto Rico and innumerable other attractive domestic jaunts, because air transportation was imperative. 1 504 Resuming the interrupted sequence, the late thirties found world affairs in a turmoil. America's involvement in European affairs that culminated in the Lend-lease agreement with Great Britain, became deeper and deeper, so that the Declaration of War with the Central Empires was inevitable. The Pearl Harbor attack (December 7, 1941) actually pre­ cipitated our action, since the United States declared war against Japan on December 8. Germany and Italy took like action against the United States (December 11, 1941) and in turn we took like action a few hours latero I was in the living room listening to the opera, when word of Pearl Harbor came over the air. I called Dory from the kitchen, where she was clearing the dinner dishes. We recalled the assurance of the American naval officer,who, as a guest, watched with us the first total blackout exercise in Honolulu (1939) from the lanai of a home on Pacific Heights. He had said, ''An effective surprise on the Harbor is impossible. We never have more than two warships there at a time!" Dory and I spent a solemn period of discussion and planning that afternoon. My return to active military duty was accepted by Little Mother as an opportunity rather than an obligation. In the interval between the two World Wars, I had assumed no military responsibilities. The affairs of the Medical School were in good conditiono Dory agreed that it would be unwise for me to serve with the 44th General Hospital that I had organized at Surgeon General James Magee's requesto Having volunteered for active duty, I was ordered to Lawson General Hospital, April 22, 19420 It was our obvious conclusion that Dory should not accompany me nor l 505 change her home base, until my permanent station was fixed. This proved a wise decision, for in a few months I was given orders for foreign dutyo A short respite was granted us when I was sent to Indiantown Gap, Penn­ sylvania to await transportation. Dory came to Harrisburg and we had a wonderful visit. Then my shipment to New York gave us two more mem­ orable days together. En route to Madison after a brave leave-taking, Dory stopped with my folks in Norristown (Jeffersonville). You may imagine her surprise when I turned up there on the grace of an added 36-hour delay. Dory's return to our home was a serious psychological shock, but it never tinctured her correspondence. Contrary to the World War I experience, her letters came to me very regularly and always with the love and courage that had sustained me in persono Favored with a faith­ ful maid, Lillian Schnieder, Dory was able to continue the Home Nursing Courses that she had so carefully and effectively organizedo The Sto Louis office of the American Red Cross commended her highly for her effort and she participated in conferences (national) in Washington and St. Louis. She was active in the recruitment of nurses for military service. Charged with the instruction of nurses in certain courses in the European Theater, I asked Dory whether she had a message for them. Characteristically she wrote, ''Wear your uniform proudly." I can think of no better charge to her professional sisters. Certainly her material contribution to the war effort was great. 506 Nor was my Little Mother's responsibility to stop hereo Her parents were failing in health. The sister and brother-in-law, with whom they were living, were employed. With Lillian, the housemaid, to carry the physical load, Dory undertook the care of her mother and father. Both of i::1 them were to die within a year. Then to compound her grief, a favorite niece developed carcinoma of the lung in the latter days of the war. When Dory met me at the La Salle Street Station on my return from over­ seas (August 2, 1945), I realized the toll of the years of my absence! Her earliest approach to a solution of the problem was a studied effort to dispose of our home and seek a smaller houseo From a wide experience, I realized that the house was beginning to possess its mistress. Com­ petent help could not be retained, if available, and this was a rare occurrenceo The fault was usually with the servant; but Dory was a perfectionist and was most exacting. Never would she accept her physi­ cian Ovid Meyer's advice that she ignore departures from her strict standards. The withdrawal of Lillian Schnieder to care for her step­ brother spelled the beginning of an insoluble servant problem that found very inadequate relief in day help. Meanwhile, my withdrawal from administrative duties at the University was scheduled for June 30, 19550 With her great pride, Dory could not conceive of my happiness or contentment in a subordinate position after having been Dean for 20 yearso However, I entertained no misgivings. When I accepted Harvey V. Higley's invitation to become Chief Medical Director of the Veterans Administration, she was openly relieved (March 1, 1955) o 507 The Washington interlude was a happy and rewarding one for both of us. We were comfortably housed in a new apartment house, 4200 Cathedral Avenueo A surprise movement awaited me on my return from Central Office early after our arrival. Dory sensed the noise and confusion of traffic on Arizona Avenue and we were exchanging our quarters for those over­ looking the Glover woods--a most satisfactory change. My Little Mother experienced some difficulty in navigating Washington streets and circles in taking me to and from work. She said indignantly, "Bil 1, I see no sense in these circles. Six streets go off from them and every one is wrong!" Dory showed her sturdy country upbringing. When she would lose her way, she would strike off at right angles until she met a road or street she knew. Then she would follow it to her destination. Aside from these petty trials, Dory came to delight in Washington and its environs. Of course, shopping was one of her delights. I accused her of buying shares in Garfinckel's and Woodward and Lothrop. The art galleries, concerts and theaters gave ample outlet to our tastes. Favored for eating out were the Army and Navy Club, Madame Kay's Toll Gate Inn and Olney Inn; but we went far afield in our explorations. Weekends toward the Skyline Drive, Charlottesville, Williamsburg, and other points lent diversion. Dory had a keen interest in the military operations of the Civil War and our forays needs must include every engagement in which Wisconsin troops, especially those of the Iron Bri­ gade, were involved. I admitted a shared interest. Certainly we gained an intimate picture of the campaigns in Virginia, Maryland and I Pennsylvania. One of Dory's amazing adventures was the drive to and r 508 from Madison to Washington (860 miles) alone. I used to say she did it whenever my back was turned. The least number of times was three in a year; the most, nine. She would make the trip in two days. Only once was I concerned, for she always stopped at the same motels and had complete confidence in the highway patrols on the throughwayso On the occasion to which I refer, because of threatening weather, she drove well over 500 miles in a day and was exhausted for several days thereafter. With a remarkable capacity for friendship, Dory not only renewed old friendships but made many more. However, we did not buy the Green Book or join the cocktail circuit. The Veterans Administration group was a splendid representation of civil servants in the loftiest senseo The warmth and depth of their friendship meant much to Dory and me. Cer­ tainly my Little Mother reciprocated with the fullness of her heart. Protocol had meant little to me, so I was mildly amused when Dory was impressed by the recognition of my position at formal gatherings. I would whisper to her, "Little Maude Webster from Vienna Township" and she would say, "And Little Bill Middleton from Norristown." The mili­ tary functions always impressed her. Among the women in high position, Mrs. Eisenhower and Mrso Nixon stood out in her estimation. For some reason, Mr. Charles Wilson had a strong supporter in her, although she met him only onceo Our friend, Frank Berry, entertained a group on the Sequoia as we cruised down the Potomaco However, his comment of the two barrels of Royal Crown Derby that he had in storage, excited Dory even more! 509 Automobile tours from Washington to the Gaspe Peninsula and to the Northwest and two of our cited trips to Europe marked our Veterans Administration holidays. Singularly, when I was urged to take a second 4-year term (1959), Dory was the determining factor in my decision. On the second European sojourn of this period (1960), two episodes occurred to my Little Mother that were ominously disquieting. We were driving through the quiet Swiss countryside, when Dory said, "Sonny, I cannot talko" I drew to the side of the road, took her pulse, looked her over casually and said, "You are tiredo Let I s stay quiet for awhile and res to" In a few minutes, she said that she was better. We drove to the next village, had a light lunch and there was no recurrence of the aphasia (?)o However, after we arrived in Paris and had settled ourselves, we dined at Poccardi's. A day or two later after what to me was an exhausting shopping tour, Dory said, "Let's go to Lanvin's for the rest of our perfumeo" Scarcely had we finished this purchase, when Dory stopped sud­ denly and said, "My, I have an excruciating pain in my right lego" She localized this pain to the right calf. When rest did not relieve it, I naturally concluded that there had been an arterial occlusion. Our activities were sharply curtailed thereafter and Ovid Meyer and Bill Young (surgeon) were consulted on Dory's first return to Madison. In Washington, Dr. George A. Kelser had already advised against surgery and Drs. Meyer and Young concurred. My second term concluded (1963). We had planned to return to Madison. Emeritus status had been granted by the Regents of the University (1960) 510 and I hoped to find some outlet in a hospital other than the University Hospitalso However, in early January 1963 came a warm invitation from Dr. Stewart Wolf, Chairman of the Department of Medicine at the Univer­ sity of Oklahoma, to serve as Visiting Professor of Medicine for the year 1963-4 during his sabbatical absenceo With Dory's enthusiastic concurrence, I accepted Stewart's proposal. Instead of the customary farewell parties in Washington, we entertained the senior staff of the Department at dinner in the Army and Navy Club--a joyous occasion with our warm friends and associateso Dory was not let off so simplyo She had been struck by the lack of cohesion among the wives of the Staff I in the Central Office. First by a series of small luncheons for these women, she evolved a plan that culminated in stated social gatherings of the wives of key members of the Department of Medicine and Surgery. By the quiet effectiveness of her leadership, these luncheons and other meetings wielded a splendid influence on the entire Central Officeo In appreciation of her contribution to social cohesion at the last meet­ ing before we left Washington, they gave Dory a. handsome Steuben bowl. Leaving Washington the evening of February 28, 1963, we encountered a snowstorm as we came to Breezewood; but without misadventure our journey was a happy oneo We were going home. The Washington interlude had been as rewarding as it had been exacting. Dory had followed her Wisconsin custom of taking friends into the countryside for leisurely visits and lunches. Of course, it meant nothing to her to drive to Catoctin Orchards (50 miles) for peaches and apples. On the way, she would stop at Brown's for eggs ostensibly, but actually to inquire about the family. The r 511 lately arrived son, Ronnie, was her particular joy. Much entertaining occupied spare hours in Madison, but the interval before our departure for Oklahoma permitted us to pick up loose ends and quietly to prepare for our return after the year at Oklahoma City. Again a conscious effort was made to obtain help. Increasingly, I was aware of Dory's deepseated attachment to our home (2114 Adams Street); but I persisted in the effort to seek a smaller house. Incidentally, Dory had out­ maneuvered me in the matter of leasing our home while we were in Wash­ ington. We had agreed that its occupancy during our absence was highly desirable. After refuting all obstacles Dory could raise, she finally had the support of Dean John Guy Fowlkes, who after two years in India returned to find their leased home in such shape that it cost more to rehabilitate it than they had collected. Dory won--2114 Adams vacant eight years. However, we set out for Oklahoma with the avowed plan to survey the situation carefully and to buy a new house or build on our return. En route to Oklahoma City we visited the Lairs (Mrs. Virginia Narr Lair and her family) at Kansas City. Settling in an economy apartment, we were both soon enthralled by our new lives. My professional outlet proved a godsend in the transition from an administrative life, while Dory found the life and people of the conmunity most interesting. The warm hospitality of the faculty and their families overflowed, so that Dory felt quite at home. Among her new friends, Francie (Mrs. William) Schottstaedt held a particularly intimate place in her hearto My duties were such that I was usually free from Saturday noon to Sunday night. 512 We took advantage of these breathing spells to explore the state. Oklahoma has been farsighted in its exploitation of its natural recrea­ tion areaso Where they did not exist, they made them. The artificial lakes, widely scattered over the state, are appropriately supplemented by a series of splendid lodges, to which we would regularly repair. Oklahoma City is so located as to make all of these parks readily acces­ sible for the weekends that we enjoyed so royally. Dory was a great admirer of the art of Charles Russell and Remington. The art museums in Tulsa and out of Bartlesville, naturally held her rapt attention. Will Rogers, of course, is one of Oklahoma's representatives in the Hall of Fame (Washington) and the Rogers Memorial Museum in Claremore was most absorbing to uso Dory reveled in its memorabilia. The arts are not neglected in Oklahoma and one of the delights of our stay there were the concerts and plays by amateur groups. One must hear "Oklahoma" on the native heath from such a group to really appreciate it! My Little Mother loved the soil and the Big Sky appealed to hero Two amusing incidents occur to me. Driving through the open country, Dory startled me when she exclaimed, "Stop, Bill, do you see that?" She pointed out a herd of Hereford steers grazing on a fine stand of winter wheat. I thought it unusual, but Dory was for action. ''We should tell the farmero" Fortunately, there was no farmhouse close at hand, for when she told her story to her young resident friends, Paul Houk and Victor Rohrer, they laughed and told her that this was the Oklahoma practice until late in Decembero l 513 Dory banked in a different bank and obviously soon established close rapport with the staff. On the advice of the cashier, we set out for Broken Bow one Saturday, for the hotel there had wonderful "family style" Sunday dinners. Stopping at Poteau overnight, we were delighted by this beautiful scenery through the Onachita National (Park) Forest. Our appetites whetted, we sat down to the long awaited meal. I see it still and the amused smile on Dory's face. For meat there was a sliver of baked ham, then mashed potatoes, corn on the cob (1/3) and pumpkin pie. The last named capped the climax. Each portion represented a 1/10 or less of the pie. And I never let Dory forget Broken Bow. With a Christmas holiday of a week, we planned a tour to the Southwest. Passing by way of Amarillo, we motored through Albuquerque and Santa Fe to Taos. The squalor of the pueblos was repugnant to Dory and I could not persuade her to investigate. She did comment on the cheap Sears Roebuck blankets rather than native ones. Dory was most interested in the Old State House at Santa Fe. Flagstaff was one of the most attrac­ tive cities on our trip, but here we were advised to omit the Grand Canyon from our itinerary. Snow had made travel hazardous. We treated Phoenix and Tucson casually when phone calls failed to raise friends. Turning eastwards, as we awakened in Abilene (Texas), we were greeted by several inches of snowQ Fortunately, it was soft and melted promptly. In Dallas, I had planned to buy Dory some clothes at her much admired store (Neiman-Marcus). In spite of a hostess-attendant, I could sell her nothing. We, then, came due north to Oklahoma City--an easy and enjoyable holiday. 514 So the year in Oklahoma speeded to its conclusion. Dory made the mem­ orable flight to Los Angeles, but she returned to Madison only once. She obviously did not feel as secure in the route or the patrol, as she had out of Washington. Six opportunities for our future presented them­ selves. Three involved visiting professorships. Two entailed foreign travel on an extended basis. And the last promised a return home! Dory and I decided that this was the best after our absence of nine (9) years. And the unusual status offered me by the Veterans Administration promised the outlets that were most attractive to me. My concern upon return to Madison was mainly in the resumption of the physical compromise imposed upon Dory by the direct supervision and actual work of our home. In Oklahoma, we assiduously studied plans, but Dory's heart was not in a change. I had real estate friends on notice, but none of their offerings met our requirements. Dory admitted that pride of possession was the ruling force. We then listed and made extensive im­ provements to our home, complete painting, electrification of kitchen and laundry by new equipment~ Still the servant situation was precarious. Our simple social and recreational activities remained limited. Our vacations usually consisted of journeys by car--and different routes-- to the Northwest to visit friends and Dory's favorite Aunt Annie Neill, who at ninety plus would wear her out shopping. Increasing fatigue was apparent. On December 29, 1964, my Little Mother was taken with severe crushing pain in the back. It had been anticipated by angina which had the suf­ focative onset. Ovid Meyer ordered nitroglycerin for the latter and 515 Dory tried to avoid disturbing himo However, in the early morning, he came in answer to my call and took her by ambulance to the University Infirmary. Here, there was established the diagnosis of infarction of the posterior wall of the left ventricle. Five and a half weeks in the hospital were marked by a steady convalescence without complications. Indeed, the recovery was quite satisfactory; but we realized the sword of Damocles hung over my dear Little Mothero However, she gradually resumed a measure of her activityo In fact, Dory was delighted to make the trip to Williamsburg in October 1965 where she met many close friends. In 1966, we attempted to recapture the charm and joy of our earlier trip to Alaska (1953). However, instead of our extended bus and train journey inland to Whitehorse, Fairbanks and Anchorage, we were satisfied with the glories of the Inside Passage to Skagway. Aside from the limitations of movement (and we had taken the SS Patricia, because it had an elevator), we had a happy holiday, and Dory found many new friends. Which reminds me. I had often wondered how Dory kept so many details of our vacations and tours in mind. In sorting her papers, I have un­ covered her secreto For example, there are notes of the table arrange­ ments, the menus, the guests, the hosts and hostesses, the names of children and at times some passing comments on the customs encountered in Hawaii (1933). As the Lurline passed Diamond Head, we threw our leis overboard after the customo Dory turned to me and said, "Sonny, we must never attempt this again." I said, ,,Just what do you mean, Dory?" She answered quite solemnly, "It has been such a perfect experience, we can 516 never duplicate it!" But we did in 1939--and Dory was the one to declare that Hawaii had lost none of its charm. She did not accompany me (by air) in 1953 and 1955. The sand was running low in my Little Mother's glasso The last extended trip we took, was by rail to Seattle and Portland (1967). Each stop was protected by wheelchairs and porters, both of which Dory resented vigor­ ously. Her myocardial reserve was potently limited; but angina, always with the tight feeling in the throat, boded ill. When she reneged on planned trips to Washington and Hot Springs, there could be no doubt of its significance. The friends whom she had planned to meet, could not balance the exhaustion she felto The evenings found her sleeping over her reading on the davenport, as I worked at my desk in the studyo Ovid Meyer recognized the deteriorating picture and remarked on the depres­ sion that attended the circulatory state. However, he advised the trip to Chicago to attend the meetings of the Central Society for Clinical Research as a trial (and change of scene, November 3 and 4, 1967). Dory was uncomfortable much of the time and perhaps enjoyed most her visit in the Hotel Drake with Jayne and Victoria de la Huergao Stopping for a drink on return home, the short step to the car in the wind was enough to cause anginao Nevertheless, on the 8th of November she drove to Berlin alone, when she could find no companion, to get her furs. She was quite tired when she picked me up at the Hospital. She rested the next day and was free from discomfort. However, a new cleaning maid came the following day 517 and Dory had to set the pace. When the window man came to replace the storm windows, I expressly asked Dory not to wash the sills. She exhausted herself at this task. The night of November 11, 1967, my Little Mother experienced the same type of interscapular pain she had suffered in 1964. We had the same reluctance to call Ovid Meyer; but failing of relief, he took her to University Hospitals in his car. Obviously, years and the advancing atherosclerosis had taken their toll. Shock was not a prominent feature. Anterior wall infarction had super­ vened; a pericardia! friction and atrial fibrillation appeared early. In spite of adequate support the inexorable decline prevailedo Dory showed her mettle by her fortitude that was rewarded by her return home January 12, 1968; but the psychological gain was very transient. After a long twilight, my Little Mother died 5:30 p.m. June 7, 1968. The peace for which she prayed had come to hero 518 "Heads and Tales" To facilitate the references to the following notes, the several sources are given as follows: lo Remembrancer [Dr. Middleton's personal diary of people and places] 2o Medical Department, United States Army, Internal Medicine in World War II, Vol. I; Activities of medical consultants, 19610 3. The Role of the Medical Consultan 4 Pharos, 24:145 (July, 1961). 4o John Augustine English Eyster, Transactions Association of American Physicians, 34:16 (1961). 5. William Davidson Stovall, "A Tribute to a personality," Wisconsin Medical Journal, 60:539 (0cto, 1961)0 60 Diffuse systemic sclerosiso The Alfred Stengel Memorial Lecture, Annals Internal Medicine, 57:183 (Augo, 1962)0 7. Walter Lo Bierring, M.D. and the American Board of Internal Medicine, Journal Lancet, 83:466 (Deco, 1963)0 8. Deans and Dieners, Wisconsin Medical Alumni Bulletin, 4:17 (Sept., 1964)0 9. William J. Bleckwenn; A tribute (unpublished notes). 10. William Alexander Werrell, Annals Internal Medicine, 62:174 (Jano, 1965)0 llo Continuing Education in Medical Rambling, Pharos, 28:46 I (Jan o , 1965) o 120 The Chair of Medicine at Cincinnati, Blankenhorn Memorial Lecture, Cincinnati Journal of Medicine, 47:155 (1966). l 519 13. Wisconsin Men in Chicago Medicine, Essays in the History of Medicine, David J. Davis Lecture, 4 (1947). 140 The Natural History of Disease, Frank Billings Memorial Lecture, Archives of Internal Medicine, 98:401 (1956). 15. Bleckley in the Changing World of Medicine, General Magazine and Historical Chronicle (July, 1940). 160 Memoir of Joseph Sprague Evans, Transactions and Studies, College of Physicians of Philadelphia, 4th Series, 17:119 (Dec., 1949). 17. Doctor William Snow Miller and His Seminar, Bulletin of the History of Medicine, 8:1067 (July 1940). 18. Middleton, Wo So, "Foreword" to ''High Blood Pressure and Longevity and Other Essays Selected from the Published Writings of David Riesman," John C. Winston Coo, Chicago, Philadelphia, This record relates primarily to the vignettes and the incidents of personal interchange with the individuals involvedo As indicated before, the references by numbers will refer to the above list of publications. Ackerknecht, Erwin. Erwin Ackerknecht, a Swiss, was enlisted in the Department of the History of Medicine at the University of Wisconsin largely through the good offices of Dro Henry Sigerist who placed him at the head of the available medical historians and through the subsidy of the Brittingham Fund, referred to in (l)o Erwin was a dynamic, craggy Swiss who had had his training largely under Dro Sigeristo He brought to Wisconsin not only a freshness of viewpoint, but a broad 520 general grasp of the subject of the history of medicine with its incidental interests. He held his student group and the faculty by his fine grasp of the subject and by his infectious enthusiasmo Rather dynamic, he quickly took to the idiom of the Middle West and prided himself in his use of the slang phrases and vernaculars of this sectiono His loss to Wisconsin and American medicine through the disaffection of subsequent administrators was a source of great personal disappointment to me. He returned to Zurich where as Director of the Institute of the History of Medicine at the University he has had a further increase in his stature. Adams, Sherman 9 (1) Adkins, Robinson E. A civil servant in the finest meaning of the wordo When I went to Central Office as Chief Medical Director of the Veterans Administration I found Bob as a most faithful and effective interpreter of the regulations, missions, and mores of the Veterans Administration. His long term of service had endeared him to thousands of its employeeso Where there were problems involving personnel, there was no clearer expression of the situation than could be gained from this loyal friend of the service. Portly, florid of face, and overweight, his growing disability from arte­ rial and articular involvement in the legs gave rise to certain therapy, I particularly recall the use of colchicine with resultant diarrhea, that led to his expression that the men's room was too far away from his office! He was a raconteur extraordinaire, and I not infrequently 521 was the butt of his stories. For example, after one introductory session he said that I had been a rather precocious youngster. When as a group we were given instructions in the first year of our schooling, the teacher concluded her comments by indicating that if we would raise fingers in given numbers we might go out for excretory purposes. He concluded his story by saying, "Billy Middleton being a rather unusual and perceptive young man said, 'How will that help my peeing?'" On another occasion, when I had reluctantly agreed to appear as the "pinch" speaker at a tri-state meeting of hospital administrators in Washington, Bob introduced me with the following comments: "Now Dr. Middleton has agreed to speak at our luncheon today and we are getting a rather cheap deal. We are merely buying his lunch for $4 which means that we will have $396 next year to get a good speaker!" In a word, Bob was never lost for the appropriate approach to the occasion. His was an unusual personal history, in that he had interrupted a pre­ medical course to enter the service in World War I. On his return he married and never completed his ambition. However, in his son, he found a sublimation of his ambition in that Paul became a prominent thoracic surgeon in Washington, D.C. The added cross of the daughter whose marital affairs were tangled, was to give a substrate of human trials that could not be overlooked. Angevine, D. Murrayo First came to my attention on the staff of the laboratory at Salisbury, England during the days of the European Theater of Operations when he was working with Ralph Muckenfuss. A very engaging personality, Murray, of Canadian origin and training, had had part of 522 his hospital experience in the Hospital of the University of Pennsyl­ vania in Philadelphiao He had come by regular growth to occupy a position in Wilmington in the hospital supported by the DuPonts. Of engaging personality and easy contact, Murray was a marked man and had my support for succession to Dr. Bunting who was retired from the Pro­ fessorship of Pathology and the Chairmanship of the Department at Wisconsino Arriving on the local scene he inmediately made his contacts effective and was a material addition to the faculty. However, in spite of his well-phrased and well-formulated programs of research, it was never my feeling that he contributed materially in a personal sense to this groupo However, through his stimulation and the enlistment of other members of the staff, he was a major contributor to the post-World War II program at Madisono Badger, Theodore L. A very engaging personality in all senses of the wordo Rather vocal in his interchanges, he was nonetheless an outstand­ ing student of diseases of the lungs. To his everlasting credit should be listed the formulation of a plan for the reception of returning prisoners of war, since when they came to us in masses, both from our own forces and from the Russian sources, a problem was created particu­ larly at such points as Besancon, France where without his foresight and organization there would have been chaos and confusion. In one detail, Ted embarrassed me no endo When he was returning to the United States as a. special agent, he asked me whether he might see the Surgeon General. I implied that there was no real reason why he should or should not go to Washington; but if he did, he should avoid any commit­ ment as to policy. Imagine my chagrin, before his return, to learn that r he had engaged General Kirk in a controversy relative to the priority 523 of the transportation of tuberculous patients. While he had reason on his side, he had not gauged his audience appropriately~ As a matter of fact, he had no right to cite policy before it had been determined by General Hawleyo So that he was caught between two fires, and General Hawley never forgave himo Bardeen, Charles R. See references (1) and (8) Bradley, Harold Co Dro Bradley was one of the stalwarts on my arrival in Madisono As the Head of Physiologic Chemistry, he was not yet granted the position of Chairmanship of the Department since it was still under physiologyo However, this was shortly amended and he became the leader in this area with particular interest in autolysiso Dro Bradley's mark on Wisconsin was left by his interest in outdoor sportso He eschewed competitive sports in the intercollegiate sense and encouraged personal involvement. It was not an unusual circumstance, in the winter months, to look out the window of our hospital and to see him and two or three of his youngsters in train on skiis coming to the rear door of the Service Memorial Instituteso An earlier incident that recalls itself at this time, was the occasion of Dro Bardeen's announcement of some further developments in the prospect of our completion of the four-year course at Madisono The several basic science departments having been housed in a basement and attics of the Science Hall and the Chemical Engineering Building, Dro Bradley broke the ice by asking Dean Bardeen whether it was not a close parallel to the 524 ''wisp of hay that was being held before the jackass' nose" to keep him going. In a more tragic vein I recall the serious illness of their one daughter, Cornelia, who suffered from pneumococcus meningitiso After the second spinal tap, Harold said, "Bill, do you think that you can gain anything from a curative standpoint by repeating such taps?" When I replied in the negative he said, ''Well, let's not do it anymoreo" So he had accepted the inevitableo The Bradley Memorial Hospital for r Children was built in her memory by the Bradleys and Cranes. Bierring, Walter L. See reference (7) Billings, Frank See reference (11), (13), (14) Birge, Edward A. See reference (1) Blankenhorn, Marion A. See reference (12) Bleckwenn, William J. See reference (9) Bliss, Surgeon General Raymondo During the Korean affair, it was my good fortune to serve as personal adviser to General Bliss, a gentle soul who, after General Kirk, was a strange paradox. Kirk, tough to the core, and Bliss, gentle, attempting to maintain a rough exterior. When he enlisted my personal assistance, he said, "Bill, it is your brains and not your nruscle to which I am looking for helpo 11 Kindly r and considerate always, he did everything in his power to make my office a useful one in the general scheme of affairso I was invited I 525 to all the briefings and from these gathered a rather clear concept of the problems confronting military medicine in the Korean area and also certain collateral interests that were to have a later bearing. One vivid recollection comes to mind. A returning observer from Korea who had gone down through Indochina--that is to say, Vietnam in particular-­ said, "Thank fortune, we are not fighting this war in Southeast Asia. If there is any possible natural obstacle to modern warfare and any neutralization of advantage to armor that can possibly exist in nature, you have it in that area of Asia. Let's stay out." It was my impression of General Bliss that he was too much impressed by the supremacy of the line and did not have confidence in his ability to resist its strictures. A benignant, not a forceful leader. Brittingham, Thomas J. See reference (1) Buerki, Robin C. One of the first men whom I encountered as an under- graduate student at Wisconsin was Bob Buerki who was in charge of the clerical work at the Clinic desk in off hours from his undergraduate medical school duties. A very dynamic, driving lad, he would run to work in the morning and run home in the evening. However, he had his moments when he would quite regularly be found at the Tri Delt House where he was courting his wife-to-be, Louise Matthews. When I would call up and ask for him and I was told he was not there, I would ask for them to look on the bench under the staircase where I knew that he was doing his courting! Louise was a faithful wife and they had one child. 526 Upon completing his first two years at Wisconsin, Bob went to the Uni­ versity of Pennsylvania School of Medicine to complete his medical course and made a name for himself as an intern and resident in the Hospital of the University of Pennsylvania. His influence was to continue in the person of Isidor Ravdin who was his nominee in succession to the chief residency. Thereafter, with a period of military service, Bob went to Boise, Idaho and then to Burns, Oregon where he practiced medicine until recalled to the University of Wisconsin to take charge of the emerging Wisconsin General Hospital. His driving force was to make itself felt not only locally but nationally until he went to the peak of accomplish­ ment as a hospital administrator in the University of Pennsylvania, the Graduate Hospital and then as the Vice-President for Medical Affairs at Pennsylvania, eventually to come to Henry Ford Hospital as the highest paid hospital administrator in the country. All of which is to say that Bob had what it took and spared no effort to accomplish the ends not only for himself but for the institutions to which he was devoted. I can still hear his explanations, "Just a second"; "I'll have it now"; "One minute please." He habitually promised the ceiling and then attempted to fill in the gaps; but all in all he was a very cooperative team worker and his career has been a source of deep satisfaction to meg Bunting, Charles Henryg A product of the Hopkins who prided himself in having been an intern under William Osler. His stories of Osler were extremely interesting and two, particularly, are recalled. In one instance he stated that he knew that the Chief felt that all relapse in typhoid depended upon extraneous sources of food to the ordered dietg 527 The Chief was unable to assign such a cause in a given patient and finally Dr. Bunting lightly said, "Perhaps it was the bed crumbs!" Whereupon Dr. Osler gave him a scathing glance and went to the next patient. Dr. Bunting always insisted that Harvey Cushing was entirely wrong in assigning the advice to young men to ''keep their emotions on ice." He insisted that Osler always said, "Young man, if you wish to be a success in medicine, keep your balls on ice." My relationship to the Bunting family was very close; but when a grand­ I child was born to sister Bunting, I commented on the joy that they would find in their newly attained grandchild. Dr. Bunting said, "Bill, a man who has been as close to our family as you have and would imply that anything could come between us and the children, I cannot possibly con­ ceive of your reaction." I said, "Dr. Bunting, I meant no offense but merely suggest that there could be some pleasure and we'll just overlook it!" About three months later he came to my office very apologetically and said, '~ill, I want to take back what I said to you because we have just had a visit from young John and I can say that we have never had such joy in our lives as with this youngster. We could take him and leave him as time and inclination dictated." Burns, Robert E. A most extraordinary character, probably largely a result of his associationso A blunt, brusque exterior covering a most kindly and sympathetic heart, and never does this come out so clearly as when he is left alone with a child deformed or sufferingo However, my personal contacts were very close and one intimate one relates to I 528 the trimalleolar fracture incurred in playing handball to which I have referred in (l)o The circumstances led him to advise that an open reduction should be done since there was left a miter of sufficient degree to give an unstable ankle unless there were better security than that afforded in the closed reduction. Having placed two screws in the ankle to effect adequate reduction of the mortise, he was quite satisfied with the result. I awakened rather hazily from the anesthetic to see two or three Bobs and two or three Dorys at the end of the bed. Dory asked Bob, ''How did the surgery go?" He said, "Perfectly o" She asked, ''What do you mean?" He said, "The result is so good that he can play handball again." She retorted, "You did not have to do that good a job!" Burr, Charles W. See reference (l)o In my personal contact with Dro Burr, I was impressed by his old school courtesy and his insistence upon the amenities of the medical profession. I was reminded of his attitude toward the students and particularly toward those who were apt to treat mental illnesses lightlyo On one occasion, he stopped sharply in the course of a discussion where students had shown some levity and said, "Young men, I would like all of you to realize that in one minute's time any one of you may be exactly in the condition of this poor unfor­ tunate patient who gives you such unusual mirth!" Cady, Lee. An unusual apology is due to Lee Cady, a friend of many years, who fell victim to the ill-concealed machinations of Representa­ tive Albert Thomas as given in reference (l)o Highly intelligent, I 529 domineering and self-assured, Lee had nonetheless run a very splendid hospital at Houston and did not deserve the fate that befell him. However, in spite of my efforts to protect him, as I have stated, he persisted in holding the fort and losing the fight. In his resignation the Veterans Administration lost one of its best administrators. How­ ever, the occasion of this note is to remark upon an entirely different incident when he was in charge of one of the large hospitals, coming from North Africa and settling in Franceo On one of my inspection trips there, I corrnnented on the depth of mud, and characteristically Lee said, ''Well, Bill, the next time you come you will not have to wade through the mud!" And sure enough he had it cleared up; I knew that he would do it even if it was by his own efforto Cannon, Walter B. See references (1), (11). In addition to the charac­ terization given to Dro Cannon, I would recall two other circumstances that are very vivid to me even to this day. We were walking along a street in Dijon, France when he said, "Bill, what is the most important problem that confronts you in your practice in Madison?" I told him that the differentiation of the so-called effort syndrome from thyrotox­ icosis was a very serious one. He said, ''When you return to Madison, I am certain that you will find that the work that has been done on basal metabolism will have solved this point," which not only dates the use of basal metabolic rates in the clinic, but also the state of our knowl­ edge at that time. On another occasion he rolled up a piece of foolscap paper and said, ''Will you look through this, Bill." And I did so and he said, ''What do you notice?" And I said that all of the objects seem I 530 smallero He said, "Yes, that's true and I'm just trying to get the reason." Of course, the physical reason was apparent; but he was, as usual, thinking. In the light of more recent studies on the shock state, Dr. Cannon's naivete in the experimental approach was extremely interestingo He observed most carefully the sludging of red blood cells in the capil­ laries of the mesentery of cats that were brought into a state of decreased effective circulatory volume by the introduction of normal saline intrapericardially to decrease the cardiac output. In these circumstances, the sludging could go on to a point of non-return. I recall vividly Dro Cannon's statement that the human subject who had a systolic pressure of less than 70 millimeters of mercury for two hours was physiologically dead although anatomically he might still live. This dictum has held through the years and certainly his physi­ ologic principles were soundo However, he had been a party to the development of gum acacia solution with Bayliss and this was our sub­ stitute as a plasma expander for blood when it was unavailable in our shock areas. The inherent kindliness of the man is always close in memory and I have only the kindest feelings toward himo His origin, having been born in Prairie du Chien, gave me a head start, as it were; but he recalled most vividly his attendance upon the German school as a youngster in Milwaukee. On one occasion he asked me whether I knew the manner of appointment of Dr. Bazett as Professor of Physiology at the University of Pennsylvania School of Medicineo When I told him that Dr. Meek had 531 been approached for this vacancy before Bazett he was all smiles. He said, '~hat's what I wanted to know, Bill. I thought if Meek had been overlooked for this particular post, Pennsylvania had done American physiology a disservice." Carlson, Anton Jo See references (1), (11) Carrel, Alexis. See reference (3) Casteel, Ralph T. A Georgian who first came to my notice as Executive Officer to Colonel Charles Spruit, Deputy Chief Surgeon, ETO. He had been with the 61st General Hospital at Taunton and I might have met him casually thereo My close association with Colonel, later General Spruit made the acquaint­ anceship with Ralph very much closer than it otherwise could have beeno When I came to Central Office and found him with the Research and Educa­ tion Division, he was a marked mano Bob Adkins aging, he naturally came into the Administrative Assistant post with the retirement of Bob. Perhaps this was the strongest appointment that I made in the staffing of Central Office during my eight years of tenure. Deeply versed in all of the modalities of organization and operation of the agency, he was first of all a loyal soul who would not sacrifice principles regardless of price. When the cards were down and the going heavy, one could always turn to Ralph Casteel with the knowledge that his support and intimate knowledge of the operations at hand would pre­ vail. His involvement in the military gave me further security in that II 532 we, out of hand, were able to establish the status of all of our medical personnel in relation to the national security. In a word, the first survey that we made, was to establish the commitments of our personnel to the Reserve effort, either Ready or Standby, and to enun­ ciate the principle that these commitments took precedence over any other design. Accordingly, we set up a formula that established the requirements of the individual station and how we might meet emergencies that arose from the withdrawal of essential personnelo This study estab­ lished a rapport and confidence with the military that was to persist throughout my tenure. Ralph's knowledge of the Research and Education programs gave added impetus to these efforts and certainly direction to my own thoughts. In the last analysis, Ralph Casteel again is an exem­ plar of the public or civic servant that is too often overlooked in our American way of lifeo His honesty and forthright loyalty led to his demotion after my retirement, a gesture that was scarcely in the interest of the American veteran, not to mention personal loyalty. In my book Ralph Casteel was the most valuable man on my Central Office team. Ralph earned a nickname by his interest in professional baseball. On many occasions we had discussed the virtues of the various players on the several teams and had a standing bet for the season relative to games won, championships and individual performance. In one interesting inter­ change, Ralph allowed that he would dismiss any player who struck at the first pitched ball, regardless of whether he made a home run or net:. From that time on, he was known as "Sleeper" to me. In another respect, , his judgment of players proved to be a boomerango He said that 533 Killebrew, of the Washington Senators, would never make the Big Time. And each year, I collected from him a pound or two of candy on the basis of the home runs hit by this particular player! Chen 2 K. K. See reference (1). In addition, it should be noted that Ko K. Chen was one of the most brilliant of our products of the two-year school. He obtained his first two academic degrees at Wisconsin, having come here as an exchange student under the Hay Act from his native lando Upon his completion of his academic work at Wisconsin, he took his doc­ toral degree at the Hopkins where he worked with Dr. Abel. Upon Ke K.'s departure for Baltimore, I requested that he make a serious effort to dissociate the taste and odor of paraldehyde from its active principle. In several months he wrote a characteristic letter: "Dear Chief, I have made the effort that you suggested and have found that like the skunk when one deprives paraldehyde of its odor it loses its potency!" It is a commentary upon Chen's integrity that in spite of his affiliation with a reliable pharmaceutical company--Eli Lilly--he was elected to rather restricted membership of national societies in his specialty and in research medicine. Indeed, I think that he was one of the early exceptions to the general rule. Keenly alert and intensive in his efforts, he had a power of concentration that quite surpassed any man of my experience. In a word, he could concentrate on some scien­ tific problem in his room with open door while other interns were playing hearts with all the vocal vigor attendant upon that game! Clark 2 Paul F. "Fishkettle" according to the students. As a matter of l 534 fact, Dr. Paul Clark was one of the outstanding teachers of the early faculty, soon after I came to Wisconsin. His insistence upon meticulous detail and his keen sense of scientific accuracy did not find favor in the casual student's mind. Had a vote been taken of his capabilities, he would doubtless have been ranked very low until the students had been in professional life for ten or more years. Tall, solidly built, intel­ lectually superior, and of affable disposition, he had the complete confidence of his associates on the faculty, and was quite active in r I I overall university affairso However, it remained for me to be respon­ sible for the establishment of the Department of Microbiology as an independent element from pathology. In a small point of pique, appar­ ently Dro Bunting demeaned the degree of Doctor of Philosophy and always referred to Dr o Clark as ''Mr. Clark." Broad in a scholarly and academic sense, Dr. Clark fitted well into the University community and was active not only in literary but in musical circles. In this regard, he was aided in no small measure by the supe­ rior intellect and talents of his wife, Alice. Cohen, Phillip P. Upon the retirement of Dr. Bradley from the Chairman- ship of the Department of Physiological Chemistry, a search was made for a responsible and competent successor. On one occasion, his assis- tant, Dr. Cohen, approached me and said that he did not see why he could not fill the bill. I indicated to him the ground that had been covered and men that were under consideration. He nonetheless felt that he had all of the qualificationso When this was brought to the attention 535 of Dr. Bradley, he said, "Bill, if you can manage him, you will do better than I can!" The other suggestion from less charitable asso­ ciates was that "you cannot make a silk purse out of a sow's ear!" I never felt that this was entirely fair in the light of Phil's ethnic origin and his capabilities. However, he had certain shortcomings that were to emerge in his subsequent careero I felt that it was a happy circumstance that gave him access to the front door of the President rather than his usual access. r Coon, Harold Mo Became the second Superintendent of the Wisconsin General Hospital on the resignation of Robin C. Buerkio Harold was a product of several colleges in the Middle West and eventually completed the first two years at Wisconsin and received his degree in medicine from Pennsylvaniao After a period of internship with us in the infirmary and Bradley, he joined his father in the operation of River Pines Sana­ torium. The most fortunate circumstance in his career was his marriage to Mary Morrissey who had been head nurse at the University Infirmary. Harold, "Fat" to his friends, was a very stout, florid individual--four by four, if you please!--a circumstance that lent itself to no end of familiarity on the part of his friends., An outgoing individual, he took well to the convivial cup and Mary kept him under control., This was an interesting circumstance since his parents were strict abstainers. As an intern, my attention was called to his meticulous care, not only in person, but in the organization and control of the patients under his t careo While human interests did not suffer, there was no detail that escaped his attentiono Warm-hearted, he did not permit discipline to 536 escaped his notice, although on one occasion he did, with Bob Gilman, raid Dr. Evans' private supply of Virginia Dare~ After the death of the Senior Dr. Coon, Harold sold his holdings in the River Pines Sanatorium and became Superintendent of the State Sanatorium at Wales, Wisconsin where there was a further opportunity to observe his capacity as an administrator. Hence, when the vacancy above cited occurred, he was a natural successor to Bob Buerki. In his capacity as the Superintendent of the University of Wisconsin Hospitals, he showed not only the meticulous care in operation and in the patient welfare that he had demonstrated in the other institutions, but a splendid grasp of the entire financial and physical operation of the planto With a rather short fuse, he not infrequently offended the superior authorities of the University who would perchance intrude upon his prerogative. He made daily rounds of every floor and every angle of the hospital. In addition he maintained rapport with the state profession and the judiciary to insure the regular flow of reference patients to our hospital. In­ tensely loyal, he was not given to compromises with integrity and friend­ ship. At times, his short temper reacted against the cause; but there was never a question as to his loyalties and his superior contribution to medicine in the State of Wisconsin. Crafoord, Professor. See reference (1) Crile, George. See reference (1) Curreri, Anthony R. Blood of my blood, a companion on the handball floor and in the clinic. A product of this school, greatly misjudged by 537 enemies, but one whose influence has always been for the advancement of his Alma Mater. A spontaneous, impetuous Latin whose loyalty to friends is boundless. For the record, it should be noted that he never initiated any of the publicity that led to dissension in the naming of the succes­ sor to Dr. Schmidt in Surgery. Cushing, Harvey. See reference (l)o In addition to the comments made in the above discussion of Dr. Cushing, there should be a note made of an unusual interchange. [End of Side I, Reel l] [Side II, Reel 1] I had referred to a certain combination of symptoms or signs as "syndrome." Dr. Cushing came quickly to me aside and said, '~ill, you and I are the only two educated American medical officers in Europe!" Davis, G. Gwilym. See reference (1) Dawson, Percy M. A most unusual charactero The origin of Dro Dawson is one of extreme interest in that he came of a wealthy family with very prominent siblings in Canadao His background from the Hopkins in Physi­ ology, then to the ministry in Michigan, and back to physiology in the University of Wisconsin Medical School. A tall, bearded patriarch, he was obviously a scholarly and intelligent individualo However, he af­ fected the bizarre in person, speech, and writingo A phonetic quality in the latter led to the publication of a rather unpopular text on phys­ iologyo Always interested in physical exercise, he made a spectacle of 538 each of his endeavors even to the point of eating his lunches on a stone tablet out of the window of Science Hall much to the elation of the passing students~ A fellow member of the William Snow Miller History Seminar, he not infrequently brought his knitting to the meet­ ings to engage in collateral conversation. His discussions were always learned and on a lofty plane. On one occasion the discussion turned to miscegenation and this detail with three very attractive daughters, his hearers were rather taken aback to have Dr. Dawson state that he would not mind if any or all of his daughters married Negroes. The dismay of the family can be imagined when two daughters who married Filipinos, were not accepted in Philippine society when they went to their husband's native land. Deaver, John B. See reference (1) Dibble, Eugene H., Jr. See reference (1) Dickie, Helen A. A woman of unusual capabilities. My first notice of her came through a rather unusual conunent from Dr. Bunting when he said, "She may be fat, but watch her eyes; she has the intelligence that is belied by her weight." Dr. Bunting's characterization proved true. With a decisive mind, very sharp tongue, and unquestioned excellent judgment, she has won her place in American medicine as one of the outstanding women physicians of her period. She asks quarter from none and gives none in discussions. Her short fuse has proved a handicap rather than an advantage, howevero 539 Di Wiart, Carton. See reference (1) Drane, Robert. My companion of the period immediately before World War I and through the World War I, a Tarheel from North Carolina, short, and most convivial, warm companion, close ally whose loyalty to his native state was only excelled by his kindlinesso However, tradition­ ally he held to the old line and said that his one regret in life was that he did not have the first Gatling gun known to man and occupying a hill upon which a Pennsylvania regiment was making the advance under one Bill Middleton, he might mow them down! Short, bald, red of face, sparkling blue eyes, and the charming manner that won friends everywhere. It was my loss personally and Wisconsin's generally to have him return to the South after the cessation of hostilities in France. But he said, "Bill, I want to get out and fish and hunt; go where people will not ask questions. Then too, I want to eat my bread with the knowledge that someone else is not always wishing for what I haveo" A true Southern philosophy! Drew, Charles. See reference (1) Duhring, Louis Ao See reference (1). To this isolated comment I would add only the interesting circumstance related to me by Allen J. Smith. It appears that upon Dro Duhring's retirement, Dr. Smith had made an unusual effort to find a room and a secretary for the retiree. Quite to the surprise of the University of Pennsylvania authorities where Dr. Duhring died, he left several millions of dollars to the Medical School. 11 Unexpected bread on the water," said Allen J. 540 Dykstra, Clarence. See reference (1) Edsal, David L. See reference (1) Einthoven, Wilhelm. See reference (1) Eisenhower, David Dwight. See reference (1) Elvehjem, Conrad Ao A native of McFarland, Wisconsin, Connie was one of the most brilliant products of this Universityo His training had been broadened by experiences in England and Europe and his contribu­ tions to the field of biochemistry were conspicuous. Among these pro­ bably the definition of the responsibility of niacin deficiency for black tongue in dogs, is most noteworthy; certainly in my judgment it deserved the Nobel Prizeo When overtures were made to Connie to assume the Deanship of the Graduate School, he came to me apparently on the advice of Dr. Fred. This circum­ stance led to a frank discussion of the ability of a Dean to divide his time and interests. In my own instance, I indicated to Connie that I had done so only on the condition that I might give one-half of my time-­ the mornings--to my ward work, teaching, and studying. These apparently were the circumstances that led to Connie's assumption of the responsi- bility of the Deanship. Tall, rather somber in external appearance, with a slight tic, calm blue eyes, and ready smile, Connie was a uni­ versal favorite in the University community. Unfortunately he did not have complete support of certain of the elements within the University faculty; but his loss by a premature death was a sorry blow to the Universityo 541 Evans, Edwardo Among the leaders in Wisconsin medicine when I came to this state was Edward Evans of La Crosse. A man of McGill training who wore the Osler Medal on his watch fob with great pride. Elder states­ man in medicine of that period, he was a Regent of the University as well as an active member of the councils in organized medical circles. Perhaps his most lasting contribution to Wisconsin medicine was in the area of the preceptorship where his library was the evening meeting place of the students under his guidance. One isolated experience suffices to demonstrate his sharpness of expres­ sion. It so happened that Dr. Ralph Waters, of Anesthesiology, and I were invited to a County medical meeting at Viroqua, Wisconsin, when Dr. Evans was in attendance. When we had completed our discussion, Dr. Evans very kindly referred to my contribution and then turning upon Dr. Waters said, ''And what is this I hear of you; are you folks in Madison next to Christ bringing the dead to life again?" With Dr. Loeven­ hart and Dr. Lorenz, Dro Waters had been administering carbon dioxide and other respiratory stimulants to individuals in catatonic states or in the withdrawn conditions of schizophrenia. When I was approached by Dr. Evans afterward with the question: "Did I hit him to hard, Bill?", I replied, "Not that, Dro Evans, but below the belt!" Evans, Joseph Spragg. See references (1), (16). To which should be added the difficulty encountered by the chronicler, Dr. Paul F. Clark, in attempting to capture the personality of Dro Evans. Dr. Evans was a suave man of the world, hon vivant, and preferred the devious to the 542 straight line in accomplishing his end. By this I mean that if there were several manners of resolving a problem, rather than approaching it frontally, the Chief would always take the devious route! Coming to Wisconsin on the recommendation of Mazyck Ravanel to head the newly created Department of Student Health, the Chief had left a background of training that would have anticipated a highly scientific future. However, he shortly became involved in medical-political affairs to such a depth that he was not able to shift his ground. Accordingly, his contribution to Wisconsin medicine was largely in the area of planning and developing the groundwork for the clinical departments of the Medical Schoolo His wonderful personality and his wide capacity for friendship won the various divisive forces of the state to the support of this particular and essential objectiveo He has been accused by the less well-informed and less kindly minded of having fixed a level of soldier's benefits after World War I to make possible the freeing of funds to complete the Wisconsin General Hospitalo Be that as it may, the Chief had won the complete confidence and friendship of Governor Phillips and through his widespread influence gained the objective of a university hospital--the Wisconsin General Hospital--which assured the institution of the clinical years. Furthermore, in the initiation of the preceptorial plan at Wisconsin, Dr. Bardeen's brilliant concept would have fallen on barren soil, had it not been for the careful manipulations of Dr. Evans. In a word, the selection of the preceptors, their enlistment in the new project, and their sustained support of the effort depended, in no small measure, 543 upon Dr. Evans' personal efforto Whatever may have been Dr. Evans' lack of sustained scientific contribution anticipated, his statesmanship in engineering the medical program through a very trying period at Wisconsin with a minimum of strife can be laid to his selfless efforts. Actually, the legacy of friendship and human understanding left by the Chief to hosts of Wisconsin students and friends is long remembered and cherished. Ewing, Oscaro See reference (1) l Eyster, John Augustine English. See reference (4)o In my judgment, Dr. Eyster was the most brilliant of the faculty that I met when I came to Madison. Keenly alert, extremely intelligent and perceptive in all of his research efforts, he unquestionably gave deeper depth to the Department of Physiology in particular and the Medical School in general than any other member of the staffo It is an interesting commentary that he regularly took the most advanced courses in mathematics in the University to keep abreast of developments in the physical area of his particular field of interest--electrocardiographyo Yet he did not receive national recognition that all of his associates felt his dueo For example, when Dro Meek was elected to the National Academy of Sciences and I congratulated him he said, "You know, Bill, English Eyster has more brains in his little finger than I have in my head. Yet when he goes to a medical meeting and gives a very profound paper--usually talking up his sleeve--he retires to a corner, sees two or three friends who are initiated into the area, and discusses the matter with them. j He does not receive the recognition that he deserves." I 544 Quite in keeping with this comment was the experience at the luncheon that I gave for Dr. Frank Wilson, of Ann Arbor, at the University Club in Madison. We had our soup and then the regular entree was served. The rest of us were through with our dessert while Dr. Eyster and Dro Wilson were still discussing some factors in the mathematical equa­ tions for the electrocardiogram! Neither had touched the main cause. Rather stooped in form, prematurely serious in his initial approaches, , Dr. Eyster could be warm to graduate students but was an enigma to undergraduates. The startling appearance of winter and Dro Eyster's j head retreating between his shoulders with his coat over his ears and head, was in strange contrast with his most relaxing reading of Arctic Il and Antarctic explorations. 1 Finland, Maxwello Unquestionably one of the leading lights in the study of infectious diseases and pa,rticularly the chemotherapy of infectious diseases in our time, has been Dr. Finland. Max, short, rather dwarfed in figure, keen brown eyes, full forehead, heavy shock of hair, and the keen response to every question and discussion, give the best judgment of the inner man. Perhaps his finest contribution, however, has been in the development of young men to "spread the Gospel. 11 From the Boston City Hospital there have emerged so many developments in this area that Max doubtless should take his place among our leaders of this period. Finney, J.M. T. See reference (1). As I have indicated elsewhere, Dr. Finney was, in my judgment, one of the great medical men of our time. His contributions to his surgical area are familiar to all. His 545 qualities of personality and character are less well-known; but they have been well-covered in my account of the same, including the diary of World War I. The circumstance to which I would call attention relates to his deep religious convictiono On one occasion I rather shocked Dr. John Lo Yates by referring to him as "the Episcopal pope!" This was a rather extravagant statement on my part; but, in any event, he was very highly considered in the church circles. Furthermore, he was twice invited to become President of Princeton University, his Alma Mater. Reluctantly, he declined this honor; but I am certain he would have done great justice to the dignity of tre post. In physique, Dr. Finney was obviously an athlete. He had played football in his undergraduate years, and had been very active physically through­ out his life. His fine head with a good shock of dark brown hair, brown eyes, engaging face w:ith a rather heavy mustache, are familiar to me to this day. Beyond and above these physical characteristics,is the heart and character of the man that meant so much to so many people. Fish, Carl Russell. See reference (1) Fitz, Reginald. Reg Fitz was one of the original American Board of Internal Medicine and a true friend. A rugged individualist, husky, tall, vigorous, out-of-door man, his friendship and personal contacts were of tremendous value to me. I shall cherish them always. One of his characteristic approaches was to invite a detailed discussion, and then after serious deliberation--either interrupted by his cackling r laugh or by complete silence--"Sorry, Bill, I don't agree with you." I 546 One such occurred when I outlined, at his request, the pattern under which we planned the advancement of the staff at the University of Wisconsin Medical School. I told him that we always had a runner-up for a Chairmanship of the Department. This individual was not the natural heir to the Department; but he was a runner-up against a field, should there occur a vacancy above him. Reg characteristically held his peace until I was through and said, '~11 very interesting, Bill, I don't agree with you!" What is one to do with a man like that? Fox, Leon. See reference (1). A short, extroverted and vociferous type of gentleman who wore his medals with great display, was a very unusual raconteur. His story relative to the conquest of typhus fever bear repetition. In the first place, he told of coming from North Africa to Italy on the same plane with General Eisenhower. "Just by chance," he said, "I happened in the same seat with the General!" The chance was made by General Fox, I am certain. In any event, he engaged the General in conversation and General Eisenhower said, "I am relieved to know that one problem is under control. I have learned that the greatest authority on typhus fever has been assigned to Italy and I do not have to worry about that!" General Fox claims that he responded by saying, "I wouldn't be too sure of that s.o.bo!" Relating the experience in Italy, General Fox told a group of us on one occasion, "I had a ringside seat in the greatest drama in medical history. Here we had typhus fever abroad and the escape of certain individuals--some five, I believe it was--from Naples down into the heel of Italy led to our isolation of them there. r Of course, with a five-day period of grace before the lice could become 547 infective, we had DDI''d them and we had therefore for the first time in history prevented a second outcropping of the disease." Regardless of what may be our judgment of his bombastic vociferations, the control of typhus fever in Italy and Europe in general was a major conquest of World War II for preventive medicine. Francis, Kayo See reference (1) Frank, Glenn. See reference (1) I Frazier, Charles H. See reference (1) Fred, Edwin B. See reference (1) Gale, Joseph W. Joe was the successor to Dr. Alton Ochsner when Dr. Erwin Schmidt was in the Chairmanship of the Department of Surgery. A product of Washington University and Evarts Graham, Joe proved a very intense and effective teacher of surgery. Undoubtedly much of the immediate training of our residents fell in his hands and his operative technique was superb. His temperament was rather fiery. His blue eyes would flash as he resented and resisted intrusions on his particular area, and he was a splendid fighter. His weakness for alcohol grew in the sense that everlessening quantity put him into a compromised posi­ tion rather early in the evening, but in no sense interfered with his technical skillo His background as the son of a country physician in , Missouri, gave him a very splendid perspective. His strength was doubled by his marriage to a stalwart girl of Scotch descent. And Margaret played a very strong part that became increasingly evident on her death. 548 Joe did a great deal of work in the early period of collapse and resection surgery for pulmonary tuberculosis and earned the unhappy nickname of ''The Boy Butcher of the Wisconsin General Hospital!" I was merely his associate and did not suffer quite the same odium. However, his works were recognized by the Mississippi Valley Tubercu­ losis Association in their award of the year, the first surgeon to receive such recognition! In retrospect, it is interesting to observe the ebb and flow of various therapeutic procedures. None has suffered a greater retrenchment than the radical surgery of pulmonary tubercu­ losis after the advent of the antituberculosis drugs; but this was merely a mark of the times. Gasser, Herberto Herbert Gasser was a graduate student or student assistant when I arrived in Madison and he never was one of my students. However, a number of my research problems crossed lines with him and we held him in highest respect. His work on the nerve conduction that, with Dro Erlanger, won the Nobel Prize, undoubtedly had its inception in the Laboratories of Physiology at Wisconsino Herbert Gasser was a pituitary deficient individual; tall, lean, almost cadaveric in frame and appearance, with a bulging forehead, clear, intelligent eyes, and a piping squeeking voiceo On one occasion at a national meeting, he asked a question from the back of the room and was embarrassed to have the speaker respond by saying, "in answer to the question of the lady in the back of the room, I have this to say!" r This had, however, no influence upon his superior intelligence and 549 contributions. He is a splendid example of the product of the early Medical School at Wisconsino Gilman, Alfredo My service with the Drug Research Board in recent years, brought me into intimate relations with Al Gilman. A Ph.D. whose text­ book with Goodman is a classic, proved one of the best committeemen, with whom I have ever servedo Fine, analytic mind, clear perception and insight into the problems presented in connnittee, he was an invalu­ able associate. There was never a question as to his superior rating with all of us associated in this group. When my retirement became forced by reason of Dory's illness, he took over the Chairmanship of the Advisory Committee to the Drug Efficacy Study. The occasion of including Al in this particular discussion has to do with the unusual situation with which he was confronted by the Food and Drug Administration. He had been requested to serve on one of their commit­ tees and had been required in the formula to establish the nonexistence of a conflict of interest to fill out the sources of incomeo When he indicated that he had some minor holdings in a drug or chemical firm, they asked him how much his holdings were and then on return connnunica­ tion just what percentage of his total income this represented. He said to me, "Bill, if they feel that my judgment or my position can be bought for a few hundred dollars, I am not worth anything to them and therefore refused to serve on the committee." The National Research Council and our Drug Research Board were favored by the ability to waive such trivia j and certainly we benefited tremendously by the judgment of men who were 550 denied to the Food and Drug Administration by reason of such punctilios. Gonce, John E. One of the most conspicuous members of the staff that was being assembled for the Clinical Division in 1919, after World War I, was John Gonce. "Slim," as most of us knew him, was a tall, very angular individual who moved with a rather ungraceful gait and possessed an engaging personality and smile that won friends everywhere. His background was Delaware born, Pennsylvania trained, with a term of ser­ vice in the Anned Forces on the Mexican bordero A period of residence in Paris gave him an urbanity, of which few of our associates could boast. His interest in pediatrics emerging, he left for a period of residency training at the Hopkins and then returned to head the program in this area at Wisconsin. One of my favorite tennis rivals, we had many engage­ ments on the courto He was ever thoughtful, ever kindly, and the soul of grace and fidelity. When I was named to the Deanship, "Slim" came to me and said, "Do you know that Louise had planned this for you all the while? She claimed that you were the logical man to become the Dean of the Medical School .. " Gordon, Edgar S. Eddie Gordon's background of music with the father in the School of Music and music in the home always, found expression in the associations of the Medical School and the University Hospitals where a cappella choruses were the rule or instrumental music indulged in by individuals drawn by a common interesto The circumstance of relating his peculiarities of public speech arose from an experience at one of the Lake Shore Medical Societies when, after the meeting, a member of the audience came forward and said, "Dro Gordon, I have been interested in 551 public speech for a long while. There are certain idiosyncrasies of yours that have attracted my attention. For example, if you lean for­ ward on the podium, of course there is always a sense on the part of the audience that they are boring to you. Or if you make passes across the face, you distract them in some measure. But the one gesture that particularly took my eyes that I think that you ought never to follow is that of the fig leaf when you put both hands over your pubis!" And Eddie told this tale on himself! I Gorman, Mike. See reference (1) Graham, Evarts A. See reference (1) Gray, Carlo See reference (1) Griffith, J.P. Crozer. See reference (1) Harris, John W. John Came to us from North Carolina by way of Yale. Actually, he was one of "Bull" Williams' products from Johns Hopkins and he never let one forget ito As a young man--as a matter of fact, as a boy--he was known as "Jelly" Harris in his home place; again, a circumstance we were not apt to let him forgeto His physical charac­ teristics did not carry under his calvarium, since in spite of his extreme obesity, John Harris was a keenly alert, live obstetrician. However, John never evinced the interest in scientific research that had been the basis of his call to Wisconsino He was a skilled obstetri­ cian. As evidence of his ability, at one time, professorships in three major medical schools of this country were occupied by his residents, I 552 so the gospel went abroad whether or not research advanced in his tenure. John was a master of the superlative. There was never a hundred percent, but a hundred and twenty percent. The abdomen was not difficult at palpation; but it was "as hard to palpate this woman's belly as it is to findanickel in the bottom of Lake Mendota!" Perhaps it was a dogmatism carried over from Williams that gave strength to his teaching; but certainly there was never a doubt in the student's mind as to the , gospel as preached by John Harris. On his death bed, when he was under the care of Dr. Chester M. Kurtz for coronary thrombosis with myocardial infarction, I called to be con­ fronted by John with a rather ample portion of ham which he raised in his index finger and thumb to show me. He said, "Bill, why in the hell would they give a man from North Carolina a piece of this anemic ham? What I want is a real Smithfield!" Incidentally, when John came to necropsy, his myocardium was so flabby that the finger could readily be pushed through any portion of the infarcted area. Hartzell, Milton B. See reference (1) Heard, James. See reference (1) Hedblom, Carl A. Hedblom was the first choice for the Chair of Surgery in the clinical development of the University of Wisconsin Medical School. Coming to us directly from the Mayo Clinic, Dr. Hedblom had very distinct ideas relative to the place of the surgeon in the Medical School complex. Unfortunately, these ideas did not tally with those of other departmentso 553 For example, it became impossible for pathology to maintain a senior member of the staff waiting for three to four hours while Dr. Hedblom removed a lung or section of the lungo Hence, the breach was serious and resulted in the replacement of Dr. Medlar by Dro Stovall in this relation. Dr. Hedblom's ideas of fees were somewhat at variance with our own and a notable example is an follows: I had followed one of his patients through the preoperative and the postoperative phases assiduously by daily attendance. When he asked me what my fee was to be I told him that it was the custom of the faculty privileged to charge professional fees to do so only as a single person. For example, if a medical man were in charge he would render the bill to the patient and, if a surgeon, he would be responsible. We did not make separate bills, nor did we have any exchange between participating members, so that only one fee of a professional order was to be rendered. He said, ''Well, that's strange, I'm charging this woman of a very wealthy family, $10,000 for my services!" My yearly salary was very little above that level at that time! Heidelberger, Michael. See reference (1) Herrick, James Bo See reference (1) Higley, Harvey V. See reference (1) Hill, Lister. See reference (1) Hirst, Barton Cooke. See reference (1) Hobby, Oveta Culp. See reference (1) 554 Hodges, Fred J. See reference (1) Holland. See reference (1) Holmes, Sir Gordon. See reference (1) Horlick, Alexandero See reference (1) Hyland, Mirt W. See reference (1) Irons, Ernest Eo See reference (10). Ernest was a very erect individ- ual; tall, spare, with iron gray hair, blue eyes, and chiseled features. Externally, rather cool and austere, but responsive to many external stimuli. His interest in the finances of the several organizations with which I was thrown into contact with him, was characteristic. Always he would say, "Bill, we must spare our finances against a rainy day!" Such was the circumstance that led me to differences with him on the American Board of Internal Medicine, for example, where, as Secretary­ Treasurer, I assured him that we were inviting the Internal Revenue authorities' inspection of the surpluses or reserves that were far in excess of any perceivable need of the early future. I indicated to him that we might better reduce the fees or increase the emolument of examiners or, by some device, deplete the ever increasing reserve. I lost the day, but in the long run won the war, I think. Ernest was the Dean at Rush at the time of the loss of its identity in an amalgamation with the University of Illinois. Regardless of his responsibility for this movement, the die-hards and old faithful alumni 555 of Rush never forgave him for what they felt was a selling-out of the cause. It will be recalled that at an earlier period, Dr. Billings had endeavored to have a graduate school established under the aegis of the University of Chicago. This too failed at the time through lack of support from John Do Rockefeller. Whatever was the background and whatever the factors involved, Ernest Irons was held to be a traitor to the cause in making Rush an orphan medical school after its illustrious paste 1 Ironside, Lord. See reference (1) Isaacs, Raphael. See reference (1) Karsner, Howardo Dro Karsner was in the Department of Pathology when I took my course at Pennsylvania under the Chairmanship of Allen J. Smith. A young instructor, he was impressive by reason of his erudition, his precise expression, and his insistence on clarity in definition. His personality was attractive as was his persono Always meticulous in dress, he impressed one by his insistence on excellence in all qualities. As a matter of fact, for years after the completion of a course in pathology, I maintained his marked record of my final examination. Sub­ sequent events were to bring us together on numerous occasions in a rather removed order, but always in warmest amity. Perhaps the occasion of Dro Karsner's continued interest in me arose from the circumstance of my relief of Dr. J. Earle Ash during the summer of his tour in Europe with Dr. Karsnero 556 Kay, Harry M. The first of my close friends in Madison and one to be maintained as a cherished associate over the years was Harry Kay. A Jew of lowly origin, he had come to a place of respect and responsi­ bility in the Madison community by his devotion to his patients and by his inherent qualities of humanity and compassionate attention to the needs of individuals of whatever social level. His very significant adherence to the oppressed or the presumed oppressed was a character­ istic that followed to the end. His hates were never deep although his expressions might be violent, but his allegiance to his country and j 1 friends was never questioned. One of his interesting friendships was with William J. Evjue, Editor of the Capitol Times. This unusual alliance rose between a congenital battler and one whose ordinary tones were conciliatory, but they were nonetheless bosom companions. Kennedy, John F. See reference (1) Kennedy, Robert. See reference (1) Kimbrough, James C. See reference (1) Klippen, Arthur. See reference (1) Kneeland, Yale, Jr. This good friend was unquestionably the most highly organized and developed of my close associates in the European Theater of Operations. If I were to select from among the host of medical office~s whom I knew in that war, Yale would take the first place. Not J only was he highly intelligent, keenly perceptive, and most cooperative and helpful, but he had the human touch that made all forces in his 557 reach cooperative. In a word, not only did his unit work smoothly under his leadership, but wherever his touch was felt in the Theater, there was harmony. Personally gracious and graceful, Yale had the fine feeling for human dignity that gave proper proportions to every situation with which he was confronted. Brilliant in speech and thought, the disabling handicap of arthritis that has befallen him, has deprived medicine of one of its leading lights in this country. Kretzschmar, Herman. See reference (1). Were I to select a single individual whose contribution was the greatest to the resolution of local, small, and large problems, in the Department of Medicine and Surgery, this man, "The Judge," would take first place. [End Side II, Reel 1] [ Side I, Reel 2] By his qualities of integrity and character, he was able to maintain an even keel in the very trying ethnic situation that confronted the Veterans Administration. Rather unprepossessing in person, keenly alert mentally, and eminently fair in all of his dealings, he was able to win the confidence of the dissident and to afford the administration a clear bill of health insofar as its dealings with the various racial problems within our extensive system was concernedo Never did he fail me in a matter of judgment or advice. 558 La Follette, Philip F. See reference (1). On one occasion, Phil told me of an interesting interchange in the high sunmit meeting of President Roosevelt with his advisers and the high command of the Pacific in Honolulu. After luncheon, the President said, "Bring out my maps." Whereupon a large map of the entire Pacific area was thrown on the wall. Turning to General MacArthur, Roosevelt then said, "Let us have your plan, Generalo" Without further ado and with complete dispatch and precision, General MacArthur proceeded to outline the dis­ tribution of all troops, ships, and aircraft in the Pacific area with such accuracy as to astound his audience. Thereupon, he launched upon a discussion of his "leapfrog" technique that was to astonish the military worldo After he had completed without prompting from any quarter and without interruption over a period of an hour and a half or more, the General concluded his discussion with the comment that "in his judgment this plan would conquer the Japanese commando Turning to his Naval staff members, President Roosevelt had a short word of counsel, then, as he wheeled to the assembled group said, "That is it!" And so the program for the continuance of the war in the Pacific was outlined. Lasker, Mrs. Mary. See reference (1) Lawlah, John. See reference (1) Leake, Chauncey Do "Sarge" to his friends and a most outgoing, extro­ verted soul he iso From the early days of our association in the University of Wisconsin where he was on the staff of the Department of l 559 Wisconsin where he was on the staff of the Department of Pharmacology under Dr. Loevenhart, a close friendship was enjoyed. Perhaps it was even more appreciated by the fact that his light of love was Elizabeth Wilson, one of our technicians in the clinical laboratory. A beautiful girl, she has become a most gracious wife and helpmeet. Ever an evangelist, "Sarge" was not infrequently involved in situations beyond his depth. On one occasion he came to me seeking my involvement in a rather sordid matter. He said, "Bill, I have just learned that a J certain doctor on the East Side of Madison is an abortionist, and I want you to take the complaint to the Grievance Corrnnittee of the Dane County Medical Society." I responded by saying, "Sarge, this is a rather delicate matter and I shall require several details before I can undertake such a charge. In the first place, it must be established that the accusation is sound which means that the woman would have to make an affidavit or appear in person before the Grievance Connnittee before I could take any part in such a situation." Whereupon Sarge said, "Of all things, here I was taking it for granted that I could turn to you as a friend and a man of high moral standards and expect action. Now you are unwilling to take the first step." I said, "Sarge, have you stopped to consider what might be the reaction of my asso­ ciates in the Dane County Medical Society if I were to make such a charge without supporting evidence?" He apparently was not persuaded and the matter dropped. j , As a member of the William Snow Miller Medical History Seminar, Sarge was one of the most active and productive participants. Scholar at I 560 heart, and deeply versed in the classical languages, he was to make significant contributions to the history of medicine not only on the Madison scene but after he left us. As I have indicated, Sarge was not infrequently carrying the torch and the unfortunate situation in Galveston undoubtedly led to his resigna­ tion from the Deanship of the University of Texas Medical School in that community. It appears that there had been a notorious red-light district to accommodate the sea-going fare. Imbued with high sense of ] social responsibility, Sarge had attempted to close this particular activity only to find rising objection from unexpected sources. This situation, according to my advices, became so embarrassing as to lead to his withdrawal from that sceneo Lee, John C.H. See reference (l)o This regular officer commanding the Communication Zone in the European Theater of Operations was known for his ability to arrange every facility including billets and trans­ portation to the highest level the traffic would bear. Accordingly, attached to his Headquarters we anticipated the best to be had in any location. After a short stay in the field at Volognes, Normandy, we were not surprised to be transferred to Paris. Howev~r, we scarcely anticipated the luxury of the quarters that were ours at the Hotel Georges V. By a singular coincidence, since we~were both early risers, it was a running race between General Lee and me as to who would be the first to reach the breakfast table. Hence the informality of our interchanges 561 grew with the passing months. His insistence on the usage of rations was a logical one, but carried to illogical extremes insofar as control was·concerned. I have cited these in another relationo He was a dynamic, hard-driving, balding, well-knit soldier who asked no more of his staff than he exacted of himselfo In one instance he forced Paul Hawley's hand in requiring an osteopath for his personal attentiono Of General Lee's personal interest in me, I had ample evidence at a later date. In the first place, I learned that he had insisted on for­ l I warding the recommendation for my advancement to General grade. While I never got my star, I was always grateful to him for his support of my worthiness. Even after the war he apparently maintained contact, for when I was given the Honorary Degree of Doctor of Science by Cambridge University, his was one of the first letters of contratulationso Leonard, William Ellery. See reference (1) Link, Karl Paulo In my conunents relative to the tremendous advantages of the geographic association among the several departments of the University, I have placed some stress on our functional as well as phys­ ical relationship with the College of Agriculture. In the instance of Paul Link, there was a very characteristic interchangeo At an earlier date in his work on the spoiled sweet clover, he had enlisted the financial support of the Medical School since his funds were running shorto I indicated to him that we could not possibly extend our limited resources unless there were an established relationship to human medicine. Incidentally, Karl Paul kept a careful chronologic record of the I 562 interchanges between our respective schools. When at last he had come to a point of final definition of the relationship of the spoiled sweet clover to the hemorrhagic manifestations in stock, he called and asked, "Are you busy, Dean?" When I answered that the Dean was never busy, we arranged an early conference. It was a matter of minutes to pass from my office on North Randall Street to his laboratory. When I arrived, he showed me a pail and asked, ''What is this?" When I said, "Blood," he responded characteristically, "Any damn fool would know that; but what is wrong with it?" I answered, "Obviously I do not know, but J it is fluid." He said, "That is the trouble; this calf ate spoiled sweet clover and from the clover I have isolated this substance (demonstrating a vial with powder in the bottom) and I call it dicumarol. 11 Thereupon he asked whether we had anyone in the Medical School interested in the matter of coagulation. I indicated to him that Dr. Fred Pohle had just returned from Boston where he had last worked with Laskey Taylor on problems in the coagulative system. Returning to my office I called Fred and within a matter of minutes he was back with Link and the work on the clinical application of dicumarol had started. I give further emphasis to the importance of the physical relationship of two depart­ ments that functionally were to initiate a world-stirring movement in the study of the use of anticoagulants in the treatment of thrombem­ bolic diseaseso The work of Fred Pohle was interrupted by World War II when he was called to duty and experienced subarachnoid hemorrhage from a berry aneurysm that eventually was to lead to his demise after a respite of 563 a short period of relative freedom from symptoms and signs. Loevenhart, Arthur So One of the most engaging of all personalities. An extrovertive Jew with a keen mind, he was full of tales and one of the best raconteurs of my acquaintance. In his classroom, he was rather diffusive and read his lecture from notes that were placed on cards. When the cards were mixed, he invariably ended with a discussion of the pharmacology of alcohol. However, in the laboratory he was intensely stimulating and the graduate students under his care and tutelage went to high places in American medicine. One of Arthur Loevenhart's favorite stories related to his old mentor, Dr. Castle of Kentucky, who sought a position of some importance in government, but came down with an attack of scarlet fever while in the east. Dr. Loevenhart was instrumental in having Professor Osler see him and the day was cleared by Osler's light touch when he reported Professor Castle to be in the "pink of condition." Another characteristic yarn has to do with Dr. Loevenhart's appearance as an expert for the American Medical Association in the famous Wine of Cardui suit--one million dollars against the Association by the manufac­ turers. After an array of experts had appeared for the defense, the crowning interchange came from a practitioner from Arkansas who was placed on the stand for the plaintiff. He claimed that he, a practi­ tioner, had experienced a great benefit the proprietary wine. When questioned by the defense, he said that he not only had given it to his l own patients, but he had taken it himself and had found great profit in it. 564 When the question next came, "And you suffer from women's disease?" He said, ''We 11, I have been married for 44 years!" Always Dr. Loevenhart set the scene by breaking out into his characteristic infectious laugh as he concluded his yarn. As a much sought for expert witness, Dr. Loevenhart was very hard to corner. He allowed that the best preparation for cross-examination was to define one's limitations as well as his area of expertise. In his own instance he inevitably indicated his familiarity with the laboratory r experience and his lack of clinical contact. One of his disarming retorts, after an array of expert sources had been cited, was to indicate that he was his own authority, and, for that matter, the authority on a given field--particularly impressive to a jury, I can assure you! On one occasion he related the story of the Negro, much respected in the corrnnunity, who was brought before the judge for indecent exposure. It appears that this particular Negro had applied for work with a new family. When the mistress asked him to show his hands, he did so and she inspected the palms and nails and then the mouth, the teeth and his general tidi­ ness of the man, she asked, "Now, let's see your testimonialso" The Negro explained to the judge, "And thar, Judge, is just where I made my mistake!" Of course Dr. Loevenhart had convulsed himself before his audience at the conclusion of this tale! Lorenz, William F. "Boss" to me. Bill Lorenz was a dynamic, heavily .I set, athletic individual who was as full of ideas as he was of physical energy. The Wisconsin Psychiatric Institute was set up at Mendota State I 565 Hospital and had as one of its early functions the serologic studies for syphilis in the mentally ill. This movement spread to the state at large and Bill was induced to bring his show to the Medical School campus. Extrovertive, gregarious, and a born leader, he was a very wel­ come addition to the Medical School Faculty. His leadership was to afford direction and impetus to the movement for the study of the men­ tally ill in the state at large. In the immediate post-World War I period, Bill and I were constituted a l team to study the psychiatric and physical status of veterans held in penal institutions in the stateo This movement led to a state-wide survey of all institutionalized patients or persons with the same ob­ jective of establishing the relationship of mental and physical condi­ tions to crime incidence to which corrective measures might be applied. Having commanded the 135th Medical Regiment of the 32nd Division in World War I, and having maintained an interest in military affairs in the intervening period, Bill was tremendously disappointed when age and other circumstances made it impossible for him to become active in World War II. An interesting sidelight, however, has been related in reference (1), and the circumstances of the vacancy in the Presidency of the University on the resignation of President Clarence Dykstra. Bill, together with certain of my other friends, waged an unequal campaign to have me named to this position. Obviously I was neither temperamentally nor adminis­ tratively in tune with the movement and I was dismayed on my return to I 566 Madison to find that they had taken such active steps in my interest. A lusty soul, Bill Lorenz had a fund of tales with which he regaled us from time to time. One of his most amusing ones related to a patient with a mental disorder who had been subject to his detailed interview and study and the~ on its conclusion, he had requested the patient to give him a specimen of urine. The patient, rather dull of comprehension, said, ''What, what doc?" He said, "Just piss in the bottle over there (the bottle was on a sink some eight or ten feet removed)." The patient 1 said, ''What, Doc, from here?" Again, in telling of a patient with general paresis who had several delusions, the patient allowed that his membership in the several fra­ ternal organizations, and fraternities in general, was so wide that he could not even scratch his ass without giving away one of the secrets of the orders! Or again, the patient with general paresis who claimed to know all of the national figures of high rank, told of his marching by in the review after World War II. When he came to the White House, "Black Jack" Pershing recognized him, hurdled the rail and came dOW\l to the ranks to shake hands with him! Luce, Clare Booth. See reference (1). Ludwigsen, Alfred. See reference (1). Lyon, George. See reference (1). Lyons, Champ. See reference (1). 567 McCarthy, Daniel J. See reference (1) McNerney, Colonel. See reference (1) Magee, General James A. See reference (1) Magnuson, Senator, See reference (1) Magnuson, Paul V. See reference (1) Marks, William Leroy. Bunny Marks was a very close friend of our under- I graduate period at Pennsylvania. An outstanding athlete, center and end in football, guard in basketball, he obviously required a certain support from the academic standpoint. It fell my lot to tutor him throughout the medical school days, and to this exposure I attribute in no small measure my interest in teachingo Of course, the work was largely informal by way of quizzing and prompting in the areas of Bunny's weakness, either by absence or lack of application; but, in any event, this discipline has lasted throughout the intervening years. Marks was a very stout, swarthy individual, better than six foot three, rather sloping shoulders and athletic stride. His face was not animated but swarthy, brown-eyed, he had a splendid capacity for friendship. Our period of close association was unusually interrupted by lack of corre­ spondence on his part in the period immediately following graduation. He went into nose and throat work, and died prematurely from influenza, to the best of my knowledge. r I Marlatt, Aviel. See reference (1) 568 Marshall, John. See reference (1) Martin, Edward. See reference (1) I t Mastin, Mabel G. Meakins, Jonathon C. See reference (1) John Meakins was a distinguished Canadian of tall, aristocratic mein whose habit of folding the lapels of his coat as he addressed an audience was conspicuous. His presentations were orderly and well-organized. On one occasion when we were mutual participants in a graduate course at Oklahoma City, we were housed in the University J Club. He came to my room one evening and said, "Bill, these folks in Oklahoma are hogs for punishment. Have you had the request for another presentation?" I had, and we served together. The closest association with John Meakins was in the American Board of Internal Medicine, of which we were original members. I most vividly recall his careful participation in the original design of our brochure of purposes. His was the broad and comprehensive approach to preparation for the specialty and he held his ground logically and forcefully. One of his expressions constantly recurs to mind. He would state that a candidate had an "untidy mind". Perhaps this expression better than any other discloses his underlying background of physiology. Medlar, Edgar M. "Hippocrates" to me. Dr. Medlar came to us from Iowa. A rather controversial figure, his work in tuberculosis was conspicuous. The tremendous energy of the man in sectioning lung and kidney. In the l latter instance to make apparent the bilaterality of hematogenous 569 tuberculosis of the kidneys, he had sections to the limit of some ten thousand of either kidney. These serial sections disclosed that this situation inevitably occurred. His was the breaking point with the original surgical team that led to the separation of pathology from the I clinical division--surgery. He could not tolerate Dr. Hedblom's dal­ liance and patronage. In a word, he refused to sit by for three to four hours awaiting the removal of a lung for section as had been Dro Hed­ blom's order. I l Blue-eyed, baldheaded, heavily built through the shoulders, he was most energetic in spite of a rather low physical presenceo His speech was husky and his thinking clear. A deforming arthritis eventually led to his physical incapacity and his latter days were spent in a wheelchair long after his withdrawal from Wisconsin to New York. Meek, Walter J. Short, compact figure, alert brain and movements, clear incisive thinking, amazing capacity for organization and one of the best teachers of my long experience. President Conrad Elvehjem said that he was the best teacher to whom he had been exposed, and of course that covered two countries and a long life in academic medicine. C~arged with the responsibility of interviewing and advising the premedical stu­ dents, Dr. Meek cultivated their close acquaintance. His keen human insight and interest afforded invaluable information as to the capabil­ ities of applicants. Among the members of the faculty in basic sciences, he was the one who insisted upon the personal conduct of a general course { in the College of Letters and Science. I refer to General Physiology which he taught throughout his active period. A teamworker of the first 570 order, there was no task beneath his notice or dignity. And when called to duty in World War II, I had no hesitancy in recommending his assignment to my responsibilities in the Dean's Office. These were discharged with fidelity. Unquestionably more than any one individual, the stability of the Medical Faculty and the adequacy of the medical instruction during this period are to his credit. Warm and direct in all of his interchanges, there was only one occasion upon which he came in error. His secretary, Miss Josephine Maher, had 1 been typewriting my papers as a source of independent income. One day when I was giving her some instruction, Dr. Meek said, "Bill, I do not see why you cannot have your own secretaries do this work rather than interfering with Jo." I made no comment; but shortly Dr. Meek came to my office and apologized. He said, "I did not realize that you two had a working arrangement in her own interesto" In relating Dro Eyster's place in our affairs I cited Dr. Meek's election to the National Academy of Sciences, and in the same matter, his frank estimate of his associate, Dr. Eyster. A member of the William Snow Miller Medical History Seminar, Dr. Meek's contributions were always most scholarly and appreciated. His "Gentle Art of Poisoning" is a sample of the same. Meyer, Ovid O. Among my associates, perhaps none can more regularly be assigned as a "Middleton man," since it was by my own personal effort ( that Ovid Meyer came into the Department and ultimately the Chairmanship I 571 of the Department of Medicine in the Medical School. However, it should be noted that only my withdrawal through the period of World War II made this opportunity logical. Since I had been assured of the Chairmanship of the Department by Dr. Joseph Spragg Evans when I took the Deanship. Indeed this was a final condition under which I undertook the Deanship. However, Ovid had grown in stature, had shown his admin­ istrative capacity, and had attracted to the Department a strong support­ ing cast so that it was only justice that he should have the Chairman­ ship which he discharged with complete fidelity and consummate skill. I Primarily a clinician, OVid Meyer made certain fundamental contributions to our knowledge of blood diseases. Perhaps his most significant con­ tribution was in the matter of the relation of the hypophysis to erythro­ poiesis. Still his strength was at the bedside and it remained so throughout his academic career. Rather dogmatic and forceful, he none­ theless commanded the respect and affection of his associates and stu­ dents by his complete fidelity and dependability. Having completed the undergraduate course in Columbia University after the first two years at Wisconsin, he returned to have his internship in the Wisconsin General Hospital. A residency in medicine followed and then a period of polishing in Boston under Joe Aub and George Minot. Upon Ray Blankenship's death he was recalled to the University of Wis­ consin Medical School and began a most fruitful career in academic medicine. However, shortly after his return, he had a most unusual experience. An inveterate cigarette smoker, he experienced what appeared to be a classical anterior wall left ventricle myocardial infarction, 572 established not only by the painful episode, but by electrocardiographic changes. [At that period there were no enzymatic studies to guide the clinician and the only leads were the limb leads.] The prompt return of the electrocardiogram to normal within 36 hours led, after a period of several days, to my request that he try another cigarette. When he did so, he had a return of the angina and of the electrocardiogr.aphic changes. Whereupon he discontinued cigarette smo~ing and had no recur­ rence of the manifestations above cited. I At an early period in Ovid's tenure, there was a visitation to me by a self-elected committee of the Junior Class who maintained that he, Ovid Meyer, should never have contact with students. He was overbearing, arrogant, and impossible of student rapport. Naturally, I was taken aback and it was with some persuasion that the committee held fire! The exuberance of youth and the lack of early adaptation undoubtedly led to these overt manifestations, for Ovid Meyer was later to become one of the truly popular and most effective teachers in the Medical School. An inveterate gambler in small matters, our issues relative to baseball activities at the high level were a source of unending badinage. A great Yankee fan, he was fortunate to back the winner for a majority of years of our verbal contest; but I always maintained that he was a splendid doctor but knew nothing of baseball. However, he usually got free hair­ cuts, during the World Series affair, from Steve Maloney, the barber, on the basis of their differences in this relation! Ovid Meyer was slight in build, a rather tense and taut in personality 573 with a keen sense of humor and a ready interchange with his associates and students. The inherent quality of human kindness, his compassionate approach to patients and his devotion to his friends were equally impor­ tant in his consummate skill at the bedside. He handled his materials well in discussion and had splendid organization with a capacity to pin­ point his approach and to tailor it to the audience. His was the responsibility for developing a strong Department of Medicine in the Medical School. A Democrat and a devout churchman, left two hiatuses which we never discussed. I Miller, Joseph L. See reference (1) Miller, William Snow. See reference (1), (17). Short, rotund of figure, white-haired with sharp blue eyes that could become kindly or very cold if so ordered by the higher centers, extremely deaf--convenient at times. Dr. and Mrs. Miller received me into their home as a son. Many was the hour that I spent in the library and in corrnnunion with the old masters largely through the kind hospitality and friendliness of the Millers. As a measure of Dro Miller's influence, one need only cite the splendid library that he had gathered about him with the particular stress in anatomy, and the number of men of prominence in American medicine who developed an interest in the history of medicine through his informal seminaro These circumstances are of extreme importance in the total story of the man who was denied clinical contact largely by reason of his deafness. In sublimating his talents in the field of histology, his work on the lung was to become the classic in this areao Always, 574 Dr. Miller was piqued by the fact that the Department of Physiology had so limited its area to cardiovascular and gastrointestinal physiology as to find no place in its researchs in the field of the respiratory system. In this respect, Dr. Miller was certainly before his time since recent years have given to the physiology of respiration an unusually prominent place. Certain of the dividends on Dr. Miller's influence were to be deferred and in many respects remain unknown to history, but to record one: When Captain Manchester approached me relative to the disposition of his estate which amounted eventually to over a million I and a half dollars, he told me that it was largely through the personal interest and guidance given him by Dr. Miller that his loyalty to the University of Wisconsin Medical School had remained intact. The gifts of Dr. Richardson and others to the medical library could likewise be so traced. So Dr. Miller's spirit continues to live in a material sense in the University of Wisconsino Mills, Charles Ko See reference (1) Minot, George Parr. See references (1), (11). A tall, spare, almost cadaveric diabetic, Dr. Minot had an unusually alert mind. In a respect­ ful vein, I have referred to him as a "mental grasshopper," in that he was always one or two jumps ahead of me. On one occasion, making rounds with him, he closed the door of the patient's room rather hastily and as we stepped out into the corridor he asked the group what we thought of him. After several suggestions, I said, "Hanson's disease." Dr. Minot ( said, "By George, that's what I thought!" The patient proved to have mycosis fungoides. 575 My earliest contact with Dr. Minot was shortly after the report of the efficacy of liver in the treatment of pernicious anemia. When I indi­ cated to him that we had used the same, the interchange was as related elsewhere. Then I had the effrontery to say, "Dr. Minot, it is my personal judgment that as important as is your contribution of liver to the treatment of pernicious anemia, you will have opened up an entirely new approach to the subject of hematology in general. In other words it is my opinion that it will be this movement rather than the isolated I observation of the efficacy of liver that will influence the thought for the rest of the way." After a few moments of reflection, Dr. Minot said, ''Middleton, I believe you are right!" Morgan, Hugh J. See references (1), (2). A fine figure of a man, quite large in frame, heavy in muscular development without excess fat, Hugh was the soul of kindliness with beaming eyes and smile who could, on occasion and with vehemence, take the position of the crusader. He and the diminutive Bobby were a remarkable coupleo Their vivacity, recourse to the banjo and song, and a fine sense of hospitality and conviviality made for a host of friendship and happiness wherever they went. One of Hugh's off moments recalls itself to me. We were visiting in Atlantic City at the time of the Association meeting, and he was pecul­ iarly glum. I said to him, "How come that a man of your ordinary cheer should have such a glum, gloomy face today? 11 He said, "Bill, haven't you heard the results of the Derby?" I said, "Yes, but what does that ' mean?" He said, "A horse has won the race"" I asked, ''We 11, how can that affect you so?" ''Well," he said, "Bill, have you no feeling that 576 a tradition can be carried through only by a mare or a stallion? Here a mere horse has demeaned the entire prospect of progeny!" So went the tradition of a Southerner! Hugh was a man of strong principles. He had furthered the cause of improvement of the lot of the Negro as a family tradition. He was a trustee at Meharry as had been his father before him. When the cards were down in opening the membership of the American College of Physicians to Negro physicians, it was singularly two Southerners, Hugh Morgan and I Jim Paullin, who forced the issue to their everlasting credit. Mortensen, Otto. A natural successor to Bardeen and Sullivan, whose qualities of human interest and compassion made him a marked man in our Faculty. Indeed, on one occasion when he introduced me to one of the returning students of a generation after my departure, the young man said, "Dr. Middleton, I cannot tell you how much the interest and guid­ ance of Dr. Mortensen has meant to me." I embarrassed Otto when I said, "Well, he deserves no credit, he got all that he has from Dro Walter Sullivan!" A mildly amusing incident occurred when Otto, who was made my Associate Dean, told Maude that he was a Democrat! Otto was convulsed when Maude said, "Not really!" Musser, John H. See reference (1) Musser, John H., Jr. A well-setup, rather florid individual, brown hair, ( brown eyes, more urbane and outgoing than his father, graduated in the 577 distinguished Class of 1908 from the University of Pennsylvania School of Medicine. As undergraduates, we had looked on this group--Musser, Perry Pepper, Forrest Willard, Bob Van Valzah, and others--as house officers with some awe and envy. I came to know John Musser intimately in the original American Board of Internal Medicine. His studious habit of listening, making notes, and deferring mature judgment was most impressive. The worthy son of a distinguished father. I [End of Side I, Reel 2] [Side II, Reel 2] Nardin, Fo Louise. See reference (1) Narr, Frederick Conrad. Friend of my youth and closest confidant through the years. Of German origin, Philadelphia born and bred, he was to become my intimate of undergraduate years and closest friend and asso­ ( ciate through the Bleckley and subsequent years. Fair complexion, average build, studious of habit, clear of thought, a practical idealist, he was the soul of loyalty and kindness. I was best man when he married Elsie Lawson, and I gloried in their family of three splendid children-­ two daughters, Kathryn and Virginia, and one boy, Lawson. Fred was my best man when I married Maude Hazel Webster, 1921. After an unsuccessful flight in general practice in South Philadelphia, I Fred directed his attention to pathology, joining the staff of Allen J. Smith at the University of Pennsylvania and having assignments at 578 St. Joseph's Hospital and Methodist Hospital. The opportunity for a full time job at Passavant Hospital, Pittsburgh, attracted him. After a very successful tour there, he had an attractive offer at the Research Hospital, Kansas City where his last years were effectively spent. We regularly recommended this hospital to our seniors at Wisconsin for the internship, and the influence of Fred Narr was to extend widely through the Middle West through the medium of these men who came under his immediate supervision. He remained a teacher to the end, which resulted from adenocarcinoma of the colon subsequent to the polypoid changes of I ulcerative colitis, which had first made itself manifest in the Blockley days. Fred did not approve of my decision to go into service in World War II, although he admitted the wisdom of the move in the light of the national emergency. As in World War I, his heart was deeply involved in the struggle with the Central Empire; there was never question of his unwaivering loyalty. He took unusual pride in Lawson's record in the ( Naval Air Force, but one of my last letters from Fred indicated his deep concern even though Lawson had already brought down three Migs. He said, "I am oh so fearful"; and fate proved him to be prophetic, for Lawson was brought down in flames when he turned to protect a flight-mate who ! I had been engaged by two Migs. Fred made a study of southwestern and American folklore and history. Wellman dedicated one of his historical novels to Fred. Unfortunately, I Fred's second wife, Jim, dissipated his wonderful collection of Americana for the advantage of independent sale, on his death. 579 Osipov, Colonel. See reference (1) Owen, Edward T. See refere.nce (1) Parran, Thomas. See reference (1) Patton, George. See reference (1) Paul, General. See reference (1) Pepper, Oliver Perry Hazardo One of my brilliant young associates from I the Class of 1908, Pennsylvania, who was to carry the tradition of the family to even greater heights. Admired from afar as a house officer or resident, he was to become an assistant visiting man on Ward 14, Men's Medicine, Philadelphia General Hospital, where we came into very constant contact. As a measure of our intimacy, when he and I agreed more than once on rounds, we would stop solemnly and shake hands. He was of such a fine caliber. Provocative and stimulating, unquestionably his influence was the most profound of the men of his generation at Pennsylvania. We were thrown into close association in the original American Board of Internal Medicine where his fine mind and outgoing personality did much to keep the group as a cohesive whole. When I remained silent upon the question, ''What should constitute the standards of qualifications of internists?", he turned to me and said, "Bill, you are unusually quiet, just what is on your mind?" Whereupon I responded, "Perry, the real f question is in the matter of the level as has been discussed. In my own 580 judgment, there are only three internists in the country, namely, Henry Christian, James Herrick, and David Riesman." You may imagine the reception that this generalization brought to the group as a whole! Piersol, George A. See reference (1) Pillsbury, Donald M. See reference (1). In reference (2), I have well outlined the organizational pattern of the Medical Consultation Service in the European Theater of Operations. It was our good fortune to have I assigned to us Don Pillsbury as Senior Consultant in Dermatology and Syphilology. His fine insight into the total program was a boon to the soldiers entrusted to our care. His gregarious personality and easy rapport made him a most useful associate. At times, I questioned his judgment insofar as policy was concerned; but there was never a question of his loyal support. It was a high mark in my experience of World War II to work with Don. A Nebraskan by origin, Don had had his training in dermatology and syphi­ ( lology at the hands of John Stokes at Pennsylvania and had come to full professorial rank and chairmanship before coming to military duty. In a word, his professional status did not require any explanation. Further­ more, as a dermatologist he was unusually well-versed in the general field of medicine--an attribute that was to prove invaluable to the Theater as a whole and to me in particular. Energetic, poised, and yet purposeful in all of his movements, he wasted little time and was instru­ mental in effecting a clear working relationship, not only in his own ' area, but in the direction of preventive measures against venereal 581 diseases. See full account in reference (1). A thorough teamworker, he lent life to every gathering whether profes­ sional or social, and his friendship in the intervening years has been a source of great gratification and strength to me. Pohle, Ernst A. Was the first of the roentgenologists to have full academic status in our midst at Wisconsin. A well-trained roentgenolo­ gist, he had a further stout b,ackground in physics and gave unusual prestige in the area of therapy. Singularly, he was not primarily I interested in diagnosis and this particular aspect of the subject fell to other hands. A tall, well-formed Prussian, his exterior was that of his origin and he took great delight in the naval uniform that he had gained as a Reservist in the United States Navy. A great stickler for form and protocol, it was always interesting to see him in a medical meeting or in conference. Rising in strict military form, he would discuss a sub­ ( ject in precise, almost staccato notes and dogmatically take a fixed position. Singularly, he was intensely loyal to me and I could make any demands on his time or duty that were required by the exigencies of a given situation. Dinner with the Pohles was always a stag affair. Ernst dealt out the rare wines with the utmost formality and finesse. When it came to service, he made a particular point of seeing that I, as the Dean, received unusual attention. Again, there was a certain stiltedness ' about the procedure that took away the usual informality of our 582 gatherings. Always in defference to my abstinence candy was served me • in place of after dinner beverages. Pohle, Frederick J. A native of Bagley, therefore Bags, came to us by way of Michigan and had his internship and residency in medicine with us. An unusually capable, brilliant prospect, keen face, keen eyes, brown and always sparkling with the movements of an athlete, he rose by regular stages in the academic scale until called into service with the Reserves at the time of the build-up for World War II. [ In another relation, I have indicated that Fred suffered from subarach­ noid hemorrhage due to a Berry aneurysm. His military service inter­ rupted, he returned to Madison and had begun to get on his feet through easy stages when he had a second and fatal hemorrhage. A great loss to Wisconsin and to American medicine. Puestow, Karver L. A Wisconsin product whose last two years of medicine were taken at Minnesota, returned to Wisconsin in the Student Health Department in 1919 to become a rather unusual figure in the development. Rosy cheeked, blonde, blue-eyed, of Teutonic origin, he was a product of a mixed marriage--his father being a Protestant, his mother Catholic. It was interesting that Karver, when influence was to be exerted, always took the side affected, indicating, although a devout Catholic, that his father had been a 32nd Degree Mason. Rather stilted in his ordinary approach, it is interesting that Karver [ not infrequently used his position to further the ends of the University 583 and the Medical School. Eventually his contacts with the members of legislature, either professionally or socially, came of such importance in his life that politics took over where medicine left off. Be that as it may, to the influence of Karver Puestow more than any other individual may be attributed the material gain of additions to the Uni­ versity Hospital and to the Service Memorial Institute. Ravdin, Isidor S. One of the most unusual figures in American medicine of my time. Rav was a hard driving, dynamic, aggressive, and highly intelligent individual whose background was that of the son of a physi­ J cian in Evansville, Indiana. He came to Pennsylvania without fanfare. As a protegee of Bob Buerki, he succeeded him in the Chief Residency at the Hospital of the University of Pennsylvania. From this time, his ascendancy in American medicine was a phenomenal one. Before the onset of World War II until his untimely detachment by reason of cerebral vascular injury, Rav was the spearhead of so many movements in American medicine as to defy enumeration. [ Persuasive in his personal approach, aggressive without offense and yet with many enemies because of his ever present power, he was the consul­ tant to Leonard Heaton when the latter operated upon President Eisenhower. Paul Hawley always said very lightly, "You know who handled the knife!", but it was Leonard Heaton who did the surgery. Notwithstanding this circumstance when John Kennedy came to the Presidency, Rav was at his right hand. I could not quite follow the deal. 1 One of my interesting interchanges with Rav had to do with his appointment 584 to the Council of Surgical Consultants to the Veterans Administration. With the design on my part to consolidate to the Special Medical Advi­ sory Group and the Consultants, I turned to Rav and asked him whether the fact that he had not yet been placed, nor had served, on the Council would make any difference if in the reshuffle and combination I were to drop him. Realizing that he was already overburdened, I was still quite surprised to have his complete acquiescence. Ravenel, Mazyck Po A most unusual character. Quite voluble and articu­ f late, the story is told that he once had made the statement that he could isolate a single tubercle bacillus. Koch took exception to his state­ ment, but Ravenel proved his point by demonstrating to the master the technique of isolation of a single organism! My occasion for relating an acquaintance with Dr. Ravenel is in a personal.interchange that occurred at a tea given by the Bardeens shortly after my arrival in Madison. Announced as "Dr. Middleton," Dr. Ravenel rushed to my side and said, "Of course you are of 'the Charleston Middletons' ." Quite overwhelmed by his approach, I said flatly, "No, my folks were on the other side!" From that time, there was never an interchange between the two of us. Dr. Stovall tells an interesting story of an exchange on Lake Mendota. Dr. Stovall was rowing and Dr. Ravenel was sitting in the back of the boat when suddenly out of the blue Dr. Ravenel asked, "Stovall, do you believe in the hereafter?" Dr. Stovall said, "Well, I was brought up that way and I.suppose I do. r What about you, Dr. Ravenel?" am damn afraid there might be!" Dro Ravenel said, "I do not know, but I 585 Rayburn, Sam. See reference (1) Raye, Martha. See reference (1) Reichert, Edward T. See reference (1) Rice, William G. See reference (1) Richards, G. Gil. Unquestionably one of the most substantial of the group to form the original American Board of Internal Medicine was Gil Richards. A sound internist, a devout Mormon, one of whose forefathers r had been an original scout selecting the site of Salt Lake City, ''Here is the place". I recall two incidents of unusual significance to me personally. In the first place, it was Gil Richards who always insisted on a complete and accurate history and physical diagnosis. Lacking these essentials, no candidate for the American Board ever passed his examination. The second detail relates to a visit to the Richards' home. A warm and ( convivial surrounding, there was the quiet Christian atmosphere of the Mormon household. Gil spoke to me about fishing indicating that my psychology was one that certainly should take to this sport. When I allowed that most of my friends did fish and that a considerable number spent their winter nights in tying flies and wrapping the poles, he said, '~hat does it, Bill, it is a rod after all!" Which leads up to the point of my story. Gil told me at great length of his joy in fishing in the streams of Colorado and Idaho, and said, ''We shall have a fish for l breakfast and I shall cook it for you." Sure enough he did and it must 586 have been a two-pound trout that he had caught in the Snake. As he had prepared it for me I needs must eat till full and I can assure you it was a delicious, if an overabundant, meal. Unfortunately, Gil died at the time of the Boston meeting of the College. Riddoch, George. See reference (1) Riesman, David. See references (1), (3), (15), and (18) Riess, Hans H. A very good friend of later yea.rs who had come to the f Wisconsin Psychiatric Institute with Bill Lorenz and his group after World War I. One incident should be a matter of record. Since my feel- ing against the Germans was so strong, I could not bring myself to give a fair examination in the State Boards. Accordingly, when Hans came before me I explained the situation to him and he understood so that our friendship grew from that point. A rather dogmatic, Prussian type of individual, with a stilted measure of learning which usually was ordered to the occasion, Hans was nonetheless a superior organic neurologist. By dint of continuous study and effort, he became one of the leaders in the field in Wisconsin and in the Middle West. Although our friend­ ship was a close one, I do not believe that Hans was ever completely at ease in the knowledge that he had been under the blanket on the occa­ sion of his first arrival in Wisconsin. Incidentally, of athletic back­ ground he played on the German soccer team in the Olympic Games. During World War I, he had commanded a destroyer in the German Navy. Neverthe­ ( less, in World War II, he had been given such clearance that he was 587 entrusted with a counterintelligence mission in the United States Army in the European Theater of Operations! Roosevelt, Mrs. Theodore, Jr. See reference (1) Rosenow, Edward. See reference (1) Runge, Carlyle P. See reference (1) Scott, R. Wesley. See reference (1) r Seevers, Maurice H. One of the most brilliant and productive of the younger men coming out of the Department of Pharmacology who was to attain national and international prominence by reason of his work on morphine and other habituating drugs. Mose was powerfully built, solid bunch of humanity, full of the zest of life, and possessed of Nebraskan quality of candor. Ovid Meyer always said that he could not tell him apart from the monks when he was in the cage with his experimental animals! ( Mose was a very warm friend and he made me his confidant. Accordingly, when recurrent offers for an improvement of status came to him, I advised frankly in all details until we came to the Michigan offer, then I said, "Mose, we will meet any offer that Michigan may make except that we cannot give you the Chairmanship of the Department (which he coveted)o Remember that you may have any quality in rank, salary, or other emolu­ ments at Wisconsin; but it would be my advice that you take this oppor­ l tunity to head the Department in a highly respected medical school." He did so. 588 Our contacts were more than professional since we were commonly rivals on the handball court. Playing doubles, our game was not entirely conventional and I was accused of making rules for each of the contests. This was not the case. Under our standing rule, a man might leave his position, in returning the ball, until the ball hit the front wall, whereupon the obstacle to the opponent might be set up with a properly placed shot. Having done this repeatedly, Mose would charge in and say, "The next time you get in my way (with certain nonendearing terms), I'll lam the hell out of you!" And of course, he was fairly capable of doing the same! A real friend! Sellery, George c. See reference (1) Sensenbrenner, Frank J. See reference (1) Shumacher, Leopold. See reference (1). "Shuey" was a warm, highly intelligent, gifted Jew, who was intensely proud of his origin; rather of the aristocracy, if you will. It appears that at the University Club, one of the bright, young instructors in sociology had made the comment in Shuey's presence that "the situation with the Jews was much as that of the Negro in the South", to which Shuey took gross exception. Shuey once told me that when he applied for the residency at the Hospital of the University of Pennsylvania, he approached Dr. Alfred Stengel with the statement, "I know that Jews have never been accepted into this residency; but I seriously covet the same and can assure you that I will give you all that I have." Whereupon Dr. Stengel said, "Shumacher, you need make no apology to me because I am one-quarter Jew!" 589 Sigerist, Henry. See reference (1) Smith, Allen J. See reference (1) Smith, Bedell. See references (1), (3) Smith, Howard Lo See reference (1) Snyder, Howard McC. See reference (1) Stanley, Aramel H. See reference (1) I Stengel, Alfredo See references (1), (6) Stovall, William D. See reference (5) Sturgis, Cyrus C. See reference (1) Sullivan, Walter. Successor to Charles R. Bardeen as Chairman of the Department of Anatomy, Dr. Sullivan unquestionably had a greater personal influence than practically any other member of the Medical Faculty of ( his time. His interests were in the students, a~ I can still hear him taking one or other of the staff--not excepting myself--to task for their rigorous adherence to standards. He was essentially a man's man and one respected by associates and students in general. Tall and well-formed, well-muscled, he preferred walking to any means of transportation. His complete candor, honesty, and forthright deal­ ing with his fellow man won the deep affection of all with whom he was ( associated. Certainly the University of Wisconsin Medical School was a stronger institution for his presence and influence. 590 Teague, Olin. Congressman from Texas, Chairman of the Connnittee on Veterans' Affairs in the House of Representatives, "Tiger" Teague undoubtedly had a wider influence among the veterans than any other member of the Congress. It was my privilege to work closely with this Representative, and I came to hold him in the highest respect. A World War II veteran, he had spent over two years in Veterans Admin­ istration Hospitals recuperating from disabling wounds of the legs, and he walked with difficulty with the support of the orthopedic appliances. I In my interchanges with Mr. Teague, I found him honest and trustworthy in all details. There was always the vigorous championship of the veterans' rights, and he would brook no interference that he deemed unfair to the same. We differed on one fundamental score. Having seen the Veterans Administration pass from the Bureau to its dignity of the Department of Medicine and Surgery under the reconstruction of 1946, I was loathe to see any movement that would downgrade the quality of medical care. On occasions within and without Committee meetings, I l tried to make it clear to Mr. Teague that we were manned to a point that any dilution by reason of addition of nonmedical problems would entail a serious threat to the maintenance of the quality care that we had achieved. He was possessed of the idea, largely through his Adminis­ trative Assistant, Mr. Meadows, that we might better utilize beds that might become available for the purpose of nursing care. I indicated to him that were this to become the rule and were it to encroach upon the bed space either by the physical displacement of patients who might I receive definitive care towards restoration of health, or by ruling of 591 the Bureau of the Budget encroach upon our existing levels of beds-- 125,OOO--such a movement would constitute a serious deterrent to recruitment and a definite threat to quality care, as I have indicated. During my tenure, I was able to prevail in this respect and I am certain that Mr. Edwin Patterson and Mr. Teague agreed that my position was sound. However, pressures apparently arose of such order as to involve a new policy for the care of nursing home-type patients in numbers steadily mounting after my retirement. I Incidentally, Mr. William Driver who succeeded Mr. Gleason as Adminis­ trator of Veterans' Affairs was Teague's own man and continued to receive his undivided support. Thayer, William S. See reference (1) Thomas, Albert. See reference (1) Thompson, Lloyd D. Was assigned as Senior Consultant in Neuropsychiatry to the European Theater of Operations and proved a very worthy asso­ I ciate. Rather florid and overweight, Tommy had a splendid sense of humor and a fine ear for music. Incidentally, on one occasion, after landing at Valognes, France, he gave a cornet solo in the moonlight when we were in tented posts at that time. Permissive rather than dominant, he proved an effective leader with the support of a loyal group of psychiatrists, both in the Surgeon General's Office and in the European Theater of Operations. It is my personal I judgment that Tommy did a superior job largely in the area of preventive 592 or prophylactic psychiatry, in that he carefully indoctrinated not only officers of the Medical Corps but of the line, in the recognition and control of combat fatigue. He was a loyal and effective teanunate. Thurmond, Strom. See reference (1) Tyson, James. See reference (1) Uhl, Arthur. See reference (1) Ungley, Co C. See reference (1) I Van Fleet, Generalo See reference (1) Van Heiss, Charles R. See reference (1) Van Valzah, Robert. Beyond a question of a doubt, Bob Van Valzah was the most superb bedside clinician of my acquaintance. As I have indicated in other relations, the group of brilliant young Pennsylvanians of the Class of 1908 had attracted our envious attention as undergraduates, but I it came my lot to serve intimately with Van for almost 25 years. tall, rather slender, with a poor, slouching carriage, swarthy of com­ He was plexion, brown eyes, and well-oiled, heavy shock of black hairo He had been a semi-pro ball player during his college years at Princeton, and had lived most of his early adult life with kinfolk in Indiana. However, he was the fourth in direct line of physicians and was to the manner born in all respects. Kindly and considerate, he had the quality that made the patient feel that for the time being there was no one else in the I world to Dr. Van Valzah beside himself. Accordingly, there developed a , rapport between patient and physician that lasted for a generation 593 after Van left Madison. His clinical approach was an interesting one in that more than any other able physician of my acquaintance, he practiced medicine in no small measure by intuition. After he had made a brilliant diagnosis or had disclosed some of my shortcomings, I would say, "Van, just how did you come upon such an answer?" And he would say, "Bill, I cannot possibly tell you. Perhaps it was a patient that I saw, or something about the I patient that impressed me as parallelling a situation I had met pre­ viously, or there was something in the smell or the feel of the patient that was distinctive. In any event, I cannot tell you why or how I came to my conclusion!" This shortcoming was to make itself manifest in his teaching. At that period, he gave the lectures in bandaging and minor surgery. They were read lectures from the notes that he carried over from year to yearo His touch of the bedside was lost at the podium and his lectures were anything but stimulating. Nevertheless, he won the complete devotion and affection of every class that he met through his patent sincerety and empathy. Much has been written about the "bedside manner," and in too many instances it is a "counterfeit coin." However, in the case of Bob Van Valzah, there was never a question as to the depth of his feeling and of his true devotion to the task at hand. Bob married Aglae Keen, a woman of means, whose original origin was in I Milwaukee but whose education had been a rather broad one with foreign , 594 1 exposures. Her many interests, her scintillating brilliance, and her distaste for the exactions of medical practice did not make for the happiest of home lives. And it was my sincere judgment that ''Mother Van," as I termed her, had persuaded their young son, Bob, not to enter the practice of medicine. In any event, Van developed bronchiectasis with advancing pulmonary insufficiency, and in 1936 retired to the large farm that they had bought out of Fredricksburg on the Potomac Rivero The change in scene may have slowed Bob's decline; but when I returned from World War II in 1945, I visited them only to find that Van's ' reserve was very limited and he would perforce go to bed to read from the early evening until sleep cameo Finally, he died in 1946 of chronic cor pulmonale. With him passed one of the finest traditions of the bed­ side practitioner, and his like is not soon to appear on the human scene in the future. Waters, Ralph M. An engaging, extrovertive type whose development of anesthesiology at Wisconsin marked a milestone in this specialty. Actually, Ralph Waters was the catalyst in a team composed of Walter J. Meek in Physiology, ''Mose" Seevers in Pharmacology, and himself. Noel Gillespie gave some substance to the statistical analysis, but the triad that I have first cited was the one that attracted men from all quarters of the globe to constitute a virtual international club or college, if you please, in anesthesiology--much to the credit of Wisconsin. Welch, William H. See reference (1) t 595 Weston, Frank L. "Hoody" Weston, or "Red" Weston as he was known in j the undergraduate years as captain of;the football team, brought into the clinic of the University of Wisconsin Medical School and the Wiscon­ sin General Hospital a fine spirit of human service and clinical interest. Even after his red thatch had turned gray and his years should have weighed upon him, he maintained a fine enthusiasm that attracted students and patients to him as a successor to Bob Van Valzah. Whitby, Sir Lionel. See reference (1) f White, J. William. See reference (1) Whittier, Sumner. See reference (1) Wineburg, M. See reference (1) Wolbach, So Burt. See reference (1) Wolford, Roy A. When I came to Central Office, Washington, I found as my Deputy, Roy Wolford, than whom there could have been no more able ( nor loyal associate. A West Virginian, he was, in every quality of character and personality, true to his origin in the mountains. His high ideals, his fine grasp of the clinical problems, opportunities, and responsibilities of our mission left nothing to be desired. In other words, we moved closely in team without a word or an action of difference in the years that were given to me to have his association. In one of Mr. Whittier's flippant I moods, he implied that Dr. Wolford had let him down and this was enough 596 to tip the scales. Already having served as long as there was any material gain, Roy was not willing to take the odium of such implied charges from Mro Whittier. Accordingly, he resigned. Thereupon, Mr. Whittier came to me and asked whether there was not some honor, some recognition that could be given to Roy to compensate for his obvious sense of personal injuryo I told the Administrator that he reckoned without his host, that to begin with, the West Vir­ ginians in general were an independent breed of men, and to be specific, f Roy Wolford could not be bought by favors, cajolary, or promises. I charged him with the necessity of letting matters rest. Yates, John L. The association with Dr. Yates is well-covered in the diary of World War I. But to the man--a brilliant individual with unusual physiologic outlook for a surgeon of his period, he was none less a rather indifferent technician. Furthermore, when it came to the matter of organization of our team in the laboratory and field, I found that I was virtually the executive and to me, Jack deferred all deci­ ( sions as to movement, timing, and activities while he was let free to pursue such diversions as might interest him on the moment. One small detail I recall in this latter relation had to do with sched­ uling of the experimental surgical procedures that we were applying to our dogs. When I called for Jack, I found that he had overlooked the matter and was for the moment much more interested in the shock work of Dr. Cannon. ( 597 Maude was very fond of him, but on one occasion he held her off at a distance to admire her legs and remarked, "Fireplugs!" From that time on, he was rather discounted because there was no similarity between the two structures. Jack was not given to rational or even courteous treatment of his asso­ ciates. I recall on one occasion the visit of Major Lillienthal, a thoracic surgeon from New York, when he asked whether Jack was operating upon all of his patients with thoracic wounds, and Jack said, "Yes, all f of them." I cautioned Jack by stating, "I am certain that Major Lillienthal is referring to thoracotomies." He answered, "Hell, Bill, I'll just tell him what I wish and that's enough! I do operate on all of them." "But," I said, "you might at least show the Major the cour­ tesy of telling what you really do." Which, incidentally, was to carry the wounds of entrance and exit down to the thoraxo If there were no fractured ribs and no evidences of respiratory embarrassment, he debrided and closed the same. However, the more radical surgery weighted those with the lacerated wounds and extensive trauma within and without. t One of our mutual friends always said that Jack Yates would not die happy if he were not teaching and I know that this was a source of great disappointment to Jack when he failed to place in academic position after World War I. Young, Senatoro See reference (1) Zinsser, Hanso See reference (1) [End of Side II, Reel 2] 598 INDEX Abbott, Alexander Co, 24 Armed Forces Medical Advisory Committee (Cooper Committee), Ackerknecht, Erwin, 519-520 399, 400, 403, 408 Adams, Scott, 426 Asper, Sam, 212 Addison, William H. Fo, 20 Association of American Medical Colleges, 109, 428 Adkins, Robinson Eo, 327, 396- 397, 520-521 Association of American Physi­ cians, 105, 108 r Albright, Edwin, 116 Association of Physicians of Allen, Kenneth D. A., 198, 230 Great Britain and Ireland, 235 Allied Consultants Club, 208 Auerbach, Oscar, 336 American Academy of General Practice, 466 American Association of the Babinski, Joseph F. F., 179 History of Medicine, 107 Badger, Theodore L., 198, 230, American Board of Internal 522-523 Medicine, 187-188, 216-217, 298-312 Bambach, Earl, 436 ( American College of Chest Physi­ cians, 296-297 Bardeen, Charles R., 54-55, 59, 65-69, 84, 172 American College of Physicians, Bauer, Walter, 258 107, 286-298, 324 Baumgartner, Leona, 395 American Medical Association, 425-426, 430, 432-433, 436, Beattie, John, 238-239 437-438, 452 Bechtold, Ida, 101, 184 American Society for Clinical Investigation, 108 Beers, Robert M., 401, 405-406 American Society of Internal Berliner, Robert W., 418 Medicine, 297-298 ' Berry, Frank, 414 Angevine, D. Murray, 521-522 599 Betts, Norman, 127 Cannan, Keith R., 415-418, 419, 420, 430, 443-444, 450-451, Beyer, Karl H., Jr., 418, 435 452, 455, 460 Biggam, Alexander H., 190, Cannon, Walter B., 158-162, 199-200 529-531 Bird, Robert M., 277, 280 Carpenter, Richard Eo, 279, 282 Blankenhorn, Marion, 170 Carrel, Alexis, 247-248 Bliss, Raymond W., 266, 275, 410, Casteel, Ralph T., 384, 397, 524-525 531-533 Boone, Joel T., 323-325 Castle, William B., 418, 435, 443, 452 Bowen, Albert, 186 f Boyd, David, 367 Central Society for Clinical Research, 105-106 Bradley, Harold C., 58-59, 61, 523- Chemosurgery: work of Frederic 524 E. Mohs, 92-93 Bradley, Omar N., 259, 385 Chen, K. Ko, 418, 452, 533 Brash, James, 144 Chiari, Hans, 269 Bricker, Eugene, 229 Christian, Henry, 106 Brown, James Barrett, 198, 229 Civilian Component Policy Board, 403, 406-408 Brown, John, 212 Civilian Health and Medical ( Buerki, Robin C., 122, 129-130, 525-526 Advisory Council (Dept. of Defense, 1953-1955), 413 Bunting, Charles H., 57, 526-527 Clark, John Go, 36 Burns, John Jo, 120, 418 Clark, Paul F., 533-534 Burns, Robert E., 527-528 Cluff, Leighton E., 432, 452 Burr, Charles w., 528 Coggeshall, Lowell, 419 Cohen, Phillip P., 534-535 Cady, Lee, 528-529 Collins, J. Lawton, 401-402 ' Canfield, Norton, 198, 229 Conferences of the Chiefs of the Medical Services, 208 • 600 Conn, Jerome w., 418 Drew, Charles, 266, 271-272 Conrad, Loyal L., 281 Drug Efficacy Study, 452-468 Coon, Harold M., 472, 535-536 Drug Research Board (National Research Council), 416-452 Cooper, Garrett A., 118 Drug supply, in World War II, Cornell, Walters., 20 218-220 Craig, Winchell M., 399 Duhring, Louis A., 539 Crosby, Warren M., Jr., 279 Durant, Thomas, 434-435 Curreri, Anthony R., 114, 536-537 Eastland, Doyle, 49 ' Curtis, Arthur, 174-175 Ebert, Richard, 212 Curtis, John K., 469 Eclat Club, 179-180 Cushing, Harvey, 147, 148-149, 537 Edsall, David Lo, 27, 29 Cutler, Elliott, 197, 199, 222, 228, 229, 231, 248, 250, 254, Edwards, Jeffrey, 200 384-386 Elvehjem, Conrad Ao, 540 Eppinger, Hans, 268 Davis, Frederick A., 120 Erickson, Theodore c., 120 Davis, Gwilym, 23, 34-35 Evans, Edward, 541 I Davis, Loyal, 198, 229 Dawson, Percy Mo, 537-538 Evans, Joseph Spragg, 54, 100- 101, 128, 172, 541-543 Deaver, John Bo, 28, 33-34 Everett, Mark Ao, 281-282 Denit, Guy B., 264-265 Eyster, John Ao E., 58, 172-173, 543-544 Dickie, Helen A., 119, 538 Diveley, Rex, 198 Favill, Henry Baird, 475 Douglas, John, 233 Fetterof, George, 21 Drane, Robert, 137, 157, 160, 163, 165, 539 Fife, Charles, 43-44, 51 l 601 Finland, Maxwell, 418, 424, Gonce, John E., 119, 550 I 452, 544 Finney, John Mo T., 161, 178, Goodenough Connnittee, and National Health Plan, 248-249 180-182, 397-398, 544-545 Gordon, Edgar s., 116, 119, Fish, Carl Russel, 131 550-551 Fitz, Reginald, 545, 546 Gordon, John, 206-207 Fleming, Alexander, 139 Grady, Daniel, 97 Fleming, William, 242, 243 Gray, Carl R., 319-321 Florey, Howard, 219 Grear, James N., Jr., 229 Food and Drug Administration, Grove, Earl, 452 423-461, passim; see also, Larrick, George P. Gwathmey, James, 158, 165 Forster, Otto, 118 Fox, Leon, 243-244, 546-547 Haase, Gunter, 278, 282, 283 Friou, George Jo, 282 Hain, Gordon, 198 Hamman, Louis, 311-312 Gale, Joseph W., 101, 118, 184, Hand, Alfred, 43 547-548 Hardgrove, Maurice, 297-298 Gas defense, in World War II, 241-243 Hardin, Robert, 230 Gasser, Herbert, 548-549 Harper, Carl, 120 Gibson, John Currie, 130 Harris, John W., 120, 551-552 Gillespie, Noel, 121 Hauser, Julius, 452 Gilman, Alfred, 418, 423, 460, Hawley, Paul R., 193-195, 201, 462-463, 549-550 219, 232, 234, 237, 241-242, 250, 261, 263, 275, 317, 321, Gilmore, John, 48-49 343, 381, 383-385, 405 Gleason, John, 332-335 Hays, Silas, 276 Gluckman, Earl, 347 Heaton, Leonard, 256, 411 Goddard, James L., 438-439, 444, Hedblom, Carl A., 118, 120, 450, 455-456, 460 552-553 • 602 Heidelberger, Charles, 113-114 John, Henry, 186 I Heidelberger, Michael, 113-114 Johnson, Lyndon B., 356 Heller, Ben, 278, 280 Johnson, Mark, 279 Hematology, basis for studies in, Jones, Boisfeuillet, 419 95-96 Hepatitis, in army, 238-239 Karsner, Howard, 555 Hill, Robert, 412 Kay, Harry M., 556 Hirst, Barton Cooke, 36 Keefer, Chester S., 418, 435 Hirst, John, 36 Keeler, Max, 210 r Hodges, Courtney Ho, 256 Keller, William L., 180-181 Holmes, Gordon, 236 Kelsey, Ellis, 426 Hood, Alexander, 200 Kennedy, John Fo, 337-338, Howard, Leslie, 246 370-371 Hubbard, John, 469 Kennedy, Tom, 131-132 Humphrey, Hubert, 416 Kenner, A. W., 261-262 \ Hussey, Hugh H., Jro, 418, 460 Kennington, John, 152 Kimbrough, James Co, 190, 195- 197, 242-243, 249-250 I Interallied Conference on War Medicine, 200-201 Kirby, William Mo M., 418 Interservices Consultants Con­ Kirk, Norman T., 185, 223-224, ference, 200 232, 265, 275 Irons, Ernest Eo, 554-555 Kneeland, Yale, Jro, 198, 217, 556-557 Kohlstaedt, Kenneth, 435 Jaeschke, Walter, 122 Kretzschmar, Herman D., 325-327, Jamison, Wilson, 263 577 Jaques, William, 280 Kurtz, Chester, 119 l Jennings, John J., 452 • 603 La Follette, Philip F., 558 Magnuson, Paul B., 314, 316, I Larrick, George P., 419, 421, 424 318-323, 383-384 Magnuson, Warren G., 330-331 Larson, Paul S., 418 Marks, William Leroy, 567 Lasker, Mary, 331 Marshall, Richard A., 278 Lay, Herbert, 467, 468 Martin, Charles F., 287 Leake, Chauncey D., 121, 558-560 Mason, James B., 399-400 Learmont, James, 249 Meakins, Jonathon c., 568 Lee, John Co H., 191-192, 225, Medical Division of RAMC, 226-227 560-561 ' Medical education: WSM on, Levitan, Sol, 98 473-486 Levitt, Donald, 436 Medical student, Attitude of modern, 390-393 Lewis, Dean, 173 Medicine, Practice of: WSM on, Link, Karl Paul, 115-116, 561-563 486-494 Loevenhart, Arthurs., 57-58, Medlar, Edgar M., 122, 568-569 563-564, and assistants, 117 Meek, Walter J., 102, 121, 122- Long, Perrin, 241-242 124, 569-570 Lorenz, William F., 564-566 Meiling, Richard L., 398-399, 400, 406-407 I Lovelace, William R. II, 399 Lyon, George, 241 Meningococcal infection, in World War II, 245 Lynch, Kenneth M., 49 Merrill, James A., 279 Meyer, Ovid Otto, 115, 570-573 Mccann, William J., 216 Middleton, Maude Hazel Webster, 133-134, 174-175, 184, 188, McDonough, Kenneth, 119 227, 265, 283-286, 495-517 McIntosh, Roscoe, 118 MIDDLETON, William S.: genealogy, 1-8; parents (mother), 3-4, 8, Mackay, Alexander M., 121 (father), 6, 9-11; early home life, 8-10, 13; sisters (Rena), l Magee, James, 183, 232-233 11-13, (Catherine), 12-13; 604 MIDDLETON: high school, 14-15; University of Oklahoma, Med­ I early interest in medicine, 15-17; sports, 18-19; medical school (University of Penn­ ical School (Visiting Profes­ sor of Medicine), 276-286; American College of Physicians, sylvania), 20-26, 28-36, 38; 288-298; American Board of internship (Philadelphia Gen­ Internal Medicine, 307-312; eral Hospital), 38-43; Babies' Veterans Administration, 313-397; Hospital, 43; University of Reserve components of Military, Wisconsin (decision to enter), 397-414; study of drug industry 44, 50-51, (first impressions), (Drug Research Board), 416-452, 52-53, (quarters), 60; opposi­ (Drug Efficacy Study), 452-468; tion to Preceptor plan, 65; professional opportunities, idea for integrated medicine 468-469; changes and develop­ and surgery program, 68-69; ments at University of Wisconsin: thesis and doctoral examina­ 469-473; views on medical educa­ tion for students, 73-75; views tion, 473-486; observations on on education, 76-80, 86; contemporary practice of medi­ r appointed to Deanship, 84-86; cine, 486-494 nonscience elective in curricu­ lum, 90-91; interest in history Miller, J. Roscoe, 316 of medicine, 93-94; Deanship and University Administration, Miller, William Snow, 55-56, 573- 96-99; military duty, World War 574 II, 101; medical societies, 105-109; consultant to Dept. of Mills, Charles K., 41 the Army (1946-1950), 109; chairman of Task Force in Med­ Minchew, Harvey, 452 ical Reserves Corps (1949), 109-111; Civilian Health and Minot, George Parr, 574-575 Medical Advisory Council (1952- 1955), 112; Third Medical Plan­ Mitchell, John, 177-178 ning Conference of NATO (1954), 113; Special Medical Advisory Mock, David c., 276 I Group of Veterans Administra­ tion (1946-1950), 113; daily schedule as Dean, 124-126; uni­ Modell, Walter, 467 versity life at Wisconsin in Mohs, Frederic E., 92-93 1912, 126-132; holidays spent in Pennsylvania, 132-133; ac­ Montgomery, Lorne c., 190 complishments at University of Wisconsin, 134-135; World War I, Moore, Carl v., 418, 424 135-172; resumption of work at Wisconsin, 172-173; orders to Moore, John Walker, 163 return to U.S., 173-175; rela­ tionship of Regular Army Medical Moran, (Lord, of Manton), 236 Corps to Consultants, 180-183; World War II, 183-265; survey Morgan, Hugh J., 254-257, 263, European hospitals, 266-272; 265, 575-576 I Pentagon duty, 272-275; survey Army hospitals in u.s., 272-273; Mortensen, Otto, 576 605 Musser, John H., Jro, 29-30, Paul, Willard So, 272-274 576-577 Paullin, James, 186 Myers, Jack, 212 Pennsylvania, Universityo School of Medicine, 20-36 Narr, Frederick C., 40, 45-46, Pepper, Oliver P.H., 133, 172, 577-578 579-580 National Academy of Sciences, Peptic ulcer disease, in army, 451, 452, 461-462 239-240 National Institutes of General Pharmaceutical Manufacturers Medical Science, 428 Association, 415, 421, 425, 430, 431, 433-434, 436, 438, 452 I National Institutes of Health, 415-416 Philadelphia General Hospital, 38-43 National Library of Medicine, 426, 430 Piersol, George A., 21 Nelson, Gaylord, 437 Pillsbury, Donald Mo, 198, 257, 580-581 Newberry, Huck, 130-131 Pohle, Ernst Ao, 581-582 Nunnemaker, John, 383 Pohle, Frederick J., 116 Psychological reactions, of Oatway, William, 119 aviators, 251; to dishonorable discharge, 251-253 Ochsner, Alton, 118, 336 Puestow, Karver L., 582-583 Odom, Charles, 255 Oklahoma, University. Medical School, 276-286 Raines, George, 367-368 Orth, Sidney, 121 Rankin, Fred, 165-166 Rankin, Winton, 436 Pancoast, Henry, 30 Ravdin, Isidor S., 400, 583-584 Parsons, Ernest, 185 Ravenel, Mazyck P., 51, 584 Patton, Georges., Jr., 238, Rayburn, Sam, 352-356 255, 260 Reich, Rudolph, 266 Paul, John, 178 606 Renal injuries, in World War II, Schmidt, Carl F., 418 I 240-241 Richards, Alfred No, 27, 220 Schmidt, Erwin R., 471 Schneiders, Edward, 120 Richards, G. Gil, 585-586 Seevers, Maurice H., 121, 587-588 Ricketts, Howard, 26 Seitz, Frederick, 460 Riesman, David, 32, 35, 38, 42-43 Sensenbrenner, Frank, 97 Riess, Hans H., 586-587 Sevringhaus, Elmer, 119 Riker, Walter, 453 Shannon, James A., 415-416, 419 I Riley, Harris D., Jr., 279 Rinker, Fred, 130 Sheldon, John, 239 Sherkey, Harry C•, 466 Robertson, Oswald, 175-176 Sherman, Forrest p., 402 Robinson, John, 221, 229 Shreiner, George E., 418, 452 Rogers, Daniel M., 466 Shumacher, Leopold, 31, 128, 588 Rogers, John, 275 Sims, Leroy, 117 Roher, Vic, 281 Smith, Allen J., 25-27, 37, 51, 133 Royal College of Physicians, 236 Smith, Austin, 419, 436 Ruskin, Arthur, 452 Smith, Bedell, 247 Russia, and disease in World Smith, Robert G., 452 War II, 234-235 Smith, William O., 278 Spiller, William, 41 Sadusk, Joseph, 436 Spruit, Charles, 227-228 Scarff, John Eo, 229 Spurling, R. Glen, 229 Schilling, John, 278 Stanley, o. H., 189, 202, 273 Schilling, Robert, 116 Steiner, Joseph M., 179 Schillinger, Rudy, 219 Stengel, Alfred, 31-32, 287 607 Stern, Heinrich, 286 Typhoid fever, in World War II, I Stetler, Joseph, 436, 442-443, 460-461 244 Typhus, in World War II, 243-244 Stevans, Arthur A., 30 Stiehm, Reuben, 119 Vail, Derrick T., 198, 204, 229 Storck, Ambrose H., 229 Van Valzah, Robert, 99-100, 172- 173, 592-594 Stovall, William D., 84, 122 Vandenberg, Hoyt So, 402 Sullivan, Walter, 589 Venereal disease, in World War II, Swift, Homer, 170 236-238 I Verdi, William Fo, 170 Tatum, Arthur Lo, 467 Veterans Administration, 313-397: alcoholism, problem of, 388- Teague, Olin E., 342, 349-352, 389; appropriations, budget, 590-591 organization, 329-336; Booz, Allen and Hamilton Report, 332, Tenney, H. Kent, 119 334; educational program, 337- 339; hospital, utilization of, Terrell, Truman Co, 49-50 342-349; hospital admission and discharge, rules for, 387- Thomas, Albert, 329-330, 331- 388; hospital dedication, in 335, 353 Philippines, 362-364; hospitals and medical system, during Thomas, Hal, 272, 409 emergency, 356-362; medical centers and regions, associa­ Thompson, Lloyd D., 198, 591-592 tion with, 375-384, 386; medi­ cal students (foreign), 394; Tidwell, Charles, 452 nursing home care, 350-352; patient, financial status of, Tidy, Sir Henry, 235 339-342; research program, 364-371; segregation, policy Tovell, Ralph M., 198, 266 toward, 324-327; Special Medi­ cal Advisory Group, 316-319, Traub, Sidney B., 279, 280-281 323; Tobacco Merchants Asso­ ciation, 336-337; U.S. Congress, Trexler, Duke c., 418, 419, 452, 349-350, 373-374 (See also, 455 appropriations, budget, organ­ ization); WSM, Chief Medical Truman, Harry s., 353 Director, 327-389, 394-397; WSM on period of service in Truman, Stanley Ro, 466 VA, 371-374 608 Waisman, Harry, 119 Wolf, Stewart, 276-278 I Walton, James, 127 Wolford, Roy A., 316, 355, 396, 595-596 Warkany, Josef, 418, 425 Woods, Sandy, 278 Waters, Ralph M., 121, 594 Woolsey, Clinton, 115 Weil's disease, in World War II, 245-246 Wright, Almoth, 139 Weinstein, Howard, 452 Weisenburg, Theodore, 42 Yates, John L., 137, 157, 160- 162, 164-165, 168, 173, 179, Wells, Charles Ro, 400 596-597 I Werrell, William A., 188, 307-311 Zinsser, Hans, 158-160 West, Kelly, 278 Zollinger, Robert M., 229 Weston, Eugene, 436 Weston, Frank L., 101, 184, 595 White, Sam, 270 Wilson, George, 46-48 Wirka, Herman W., 120 Wisconsin Society of Internal Medicine, 297-298 Wisconsin, University. Medical School, 44, 50-124, 469-473: admission standards, 102; advisor system, 71-73; build­ ings, 59-62, 97-98, and funds, 80-82, (hospital), 104, (lib­ rary), 103; curriculum, 65-71; faculty, 54-58, 63; honor sys­ tem, 71; influence extended, 105; medical profession, rela­ tionship with, 87-90; patients, 64; research developments (and staff), 113-124; students, se­ lection of, 64-65; thesis and doctoral examination, 73-74; WSM on changes and new devel­ opments, 469-473 • COPY 609 DRUG EFFICACY STUDY NATIONAL ACADEMY OF SCIENCES NATIONAL RESEARCH COUNCIL Panel Chairmen Blank, Dro Harvey, Professor and Chairman, Department of Dermatology, University of Miami, Miami, Florida Brown, Dr. Harold, Professor of Parasitology, Columbia University School of Public Health, New York, New York Crosby, Dr. William H., Chief of Hematology, New England Center Hospital, Boston, Massachusetts Eichenwald, Dr. Heinz, Professor and Chairman, Department of Pediatrics, Southwestern Medical School, University of Texas, Dallas, Texas Freedman, Dro Daniel X., Professor and Chairman of Psychiatry, University of Chicago, Chicago, Illinois Frei, Dro Emil, III, Associate Director, Anderson Hospital and Tumor Institute, Houston, Texas Freis, Dr. Edward, Senior Medical Investigator, Veterans Administra­ tion Hospital, Washington, D.C. Hewitt, Dro William Lo, Professor of Internal Medicine, University of California at Los Angeles, Los Angeles, California Katz, Dr. Sol, Chief, Medical Service, Veterans Administration Hospital, Washington, D.C. Kirby, Dr. William M. M., Professor of Medicine, University of Washington, Seattle, Washington Kunin, Dr. Calvin Mo, Associate Professor of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia Lasagna, Dr. Louis C., Associate Professor, Division of Clinical Pharmacology, The Johns Hopkins University Hospital, Baltimore, Maryland Leopold, Dr. Irving H., Professor and Chairman, Department of Oph­ thalmology, Mount Sinai Hospital, New York, New York Mudge, Dro Gilbert Mo, Professor of Medicine, Dartmouth School of Medicine, Hanover, New Hampshire Nelson, Dr. Don Ho, Associate Professor of Medicine, University of Southern California, Los Angeles, California Papper, Dr. Emmanuel, Professor of Anesthesiology, Columbia University, New York, New York Ragan, Dr. Charles, First (Columbia) Medical Division, Bellevue Hospital, New York, New York Rose, Dr. Bram, Director, Division of Irrnnunochemistry and Allergy, McGill University, Montreal, Quebec, Canada Rostenberg, Dr. Adolph, Jr., Professor of Dermatology, School of Medicine, University of Illinois, Chicago, Illinois Segaloff, Dro Albert, Head, Section of Endocrinology, Alton Ochsner Medical Foundation, New Orleans, Louisiana COPY 610 Panel Chairmen (Cont.) Sessions, Dro John T., Professor of Medicine, University of North Carolina, Chapel Hill, North Carolina Strauss, Dr. Maurice B., Chief of Medical Service, Veterans Admin­ istration Hospital, Boston, Massachusetts Thorn, Dr. George, Physician-in-Chief, Peter Bent Brigham Hospital, Boston, Massachusetts Tucker, Dro William B., Director, Medical Service (III), Veterans Administration Central Office, Washington, D.C. Tumen, Dr. Henry J., Professor and Chairman, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Yahr, Dr. Melvin, Attending Neurologist, Neurological Institute­ Presbyterian Hospital, New York, New York Zegarelli, Dr. Edward V., 630 West 168th Street, New York, New York Liaison Representatives Food and Drug Administration Smith, Dr. Ralph G., Director, Division of New Drugs Public Health Service Kelsey, Dr. F. Ellis, Special Assistant to the Surgeon General for Science Information National Academy of Sciences-National Research Council Division of Medical Sciences Cannan, Dr. R. Keith, Chairman Barie, Dr. Jacob J. Eggers, Dr. Robert Fink, Dro Dave Gilson, Dr. James Grove, Mr. Earl Lukin, Dr. Robert Manspeizer, Dr. Sheldon Middleman, Dr. Edward Nelson, Dr. G. E. Steinman, Dr. Ira Trexler, Mr. Duke C. Winemiller, Dr. J. H. • COPY 611 POLICY ADVISORY COMMITTEE DRUG EFFICACY STUDY NATIONAL ACADEMY OF SCIENCES NATIONAL RESEARCH COUNCIL Policy Advisory Connnittee Middleton, Dr. William S., Dean Emeritus, The University of Wisconsin, Madison, Chairman Astwood, Dr. E. B., Professor of Medicine, Tufts University, Medford, Massachusetts Barber, Dr. Bernard, Professor of Sociology, Barnard College of Columbia University, New York Berliner, Dr. Robert W., Director of Intramural Research, National Heart Institute, National Institutes of Health Beyer, Dr. Karl H., Jr., Vice President for Life Sciences, Merck Sharp & Dohme Research Laboratories, West Point, Pennsylvania Braunwald, Dr. Eugene, Chief, Cardiology Branch, National Heart Institute, National Institutes of Health Burns, Dr. John J., Vice President for Research, Hoffmann-La Roche, Inc., Nutley, New Jersey Castle, Dro William B., Thorndike Memorial Laboratory, Boston City Hospital Chen, Dr. K. K., Professor of Pharmacology, Indiana University School of Medicine, Indianapolis Cluff, Dr. Leighton E., Professor of Medicine, The University of Florida, Gainesville Finland, Dr. Maxwell, George Richards Minot Professor of Medicine, Thorndike Memorial Laboratory, Boston City Hospital Gilman, Dr. Alfred, Chairman, Department of Pharmacology, Albert Einstein College of Medicine, New York Hussey, Dr. Hugh H., Director, Division of Scientific Activities, American Medical Association, Chicago Keefer, Dro Chester So, Wade Professor of Medicine, Emeritus, Boston University School of Medicine, Boston Kirsner, Dr. Joseph Bo, Professor of Medicine, The University of Chicago Larson, Dr. Paul So, Haag Professor of Pharmacology, Medical College of Virginia, Richmond Lehmann, Dr. Heinz, Associate Professor of Psychiatry, McGill University, Montreal, Canada Moore, Dr. Carl Vo, Professor of Medicine, Washington University School of Medicine, St. Louis Pillsbury, Dr. Donald M., Duhring Laboratories, University Hospital, Philadelphia Rogers, Dr. Daniel M., Wenham, Massachusetts Schmidt, Dr. Carl F., Research Director, UoS. Naval Air Development Center, Johnsville, Pennsylvania - COPY 612 Policy Advisory Committee (Conto) Schreiner, Dr. George E., Professor of Medicine, Georgetown University Hospital Shirkey, Dr. Harry C., Director, Children's Hospital, Birmingham, Alabama Truman, Dro Stanley R., Oakland, California Warkany, Dr. Josef, Professor of Research Pediatrics, Children's Hospital Research Foundation, The University of Cincinnati Wartman, Dr. William, Professor of Pathology, Northwestern University, Chicago Zubrod, Dr. C. Gordon, Director, Intramural Research, National Cancer Institute, National Institutes of Health Liaison Representatives Food and Drug Administration Goddard, Dro James L., Commissioner Smith, Dr. Ralph G., Director, Division of New Drugs National Academy of Sciences - National Research Council Division of Medical Sciences Cannan, Dr. R. Keith, Chairman Barie, Dr. Jacob J. Eggers, Dr. Robert Fink, Dr. David Gilson, Dr. James Grove, Mr. Earl Lukin, Dr. Robert Manspeizer, Dr. Sheldon Middleman, Dr. Edward Nelson, Dr. George E. Rapalski, Dr. Adam J. Seeley, Dr. Sam F. St. John, Mrs. Dorothy Steinman, Dr. Ira Trexler, Mr. Duke C. Winemiller, Dr. Jay H. COPY 613 NATIONAL ACADEMY OF SCIENCES NATIONAL RESEARCH COUNCIL 2101 Constitution Avenue, N.Wo, Washington, D.Co 20418 DIVISION OF MEDICAL SCIENCES 10 November 1966 Dr. James L. Goddard Commissioner Food and Drug Administration Washington, D.C. Dear Dr. Goddard: Your presence at the meeting of the Drug Research Board on November 7 and your participation in the discussion there of problems of patient consent were greatly appreciatedo The Board also appreciated your presenting for discussion the Proposed Revision, dated November 3, of the Regulations that were published in the Federal Register on August 30, 1966. I would remind you that a draft of a modification of the Regulations had also been prepared for the Board's consideration without knowledge that you would introduce your own Proposed Revision at this meeting. The views and recommendations of the Board are therefore drafted in terms of your Proposed Revision. I believe you were sensitive to the quality of the discontents that were voiced by the Board in the general session on November 7. This letter is intended to present the essence of the recommendations as approved by the Board in the executive session that followed the morning discus­ sion. Recommendations of the Drug Research Board with Respect to the Proposed Revision of November 3, 1966 - Regulation 130037: Consent for Use of Investigational New Drugs on Humans Paragraph (a). The Board offered no suggestion for amendment of para­ graph (a). Paragraph (b). The Board considers that the intent of the Law and of the Declaration of Helsinki is to fix responsibility on the physician for judgments affecting the welfare of his patient. The Board therefore reconmended that the addition of the phrase: "where feasible except when, in the judgment of the physician, it is not deemed in the best interests of the patient" would more specifically recognize this responsibility. COPY 614 Dro James L. Goddard 10 November 1966 Page 2 Paragraphs (c), (d), (e), and (g)o The definitions that are attempted in these paragraphs add nothing to an understanding of the language used in paragraphs (a) and (b), are didactic in tone, and may serve to confuse rather than contribute to the guidance of the investigator to whom the Regulations are directed. The Drug Research Board therefore reconunends that paragraphs (c), (d), (e), and (g) be omitted in their entirety from the Proposed Revision. If, nevertheless, it is thought necessary to include the paragraphs in question, the Drug Research Board would not object, provided the phrase ''which exceptions are to be strictly applied" were omitted in paragraph (d)o Paragraph (f). The Board offered no suggestion for amendment of para­ graph (f). Paragraph (h). The Board offered suggested amendments in a number of instances: i. The requirement that the investigator present "all material infor­ mation" (line 3) poses a categorical and impossible requirement. Since care must be taken in framing the Regulations that compliance is, in fact, possible, the Board reconunends that the language be amended by substituting "pertinent" for "all material." 2o The entire second sentence of paragraph (h) attempts to dictate the substance of the physician's communication with his patient. The Board believes this is impracticable and an intrusion on the responsibility of the investigator. Moreover, its effect would be to encourage the physician to consider his own welfare before that of his patient. Section III (3c) of the Declaration of Helsinki provides that "o•• the respon­ sibility for clinical research always remains with the research worker; it never falls on the subject even after consent is obtained." The judgment of what is pertinent in the physician's communication with the patient must therefore rest with the physician. If, nevertheless, further definition of the word "pertinent" is thought desirable, the following sentence could be considered in place of the second sentence, paragraph (h), in the Proposed Revision: "Pertinent information may include the nature, expected duration, purpose, and mode of administration of the investigational drug, together with a discussion of potential benefits and hazards relative to current therapeutic practice." COPY 615 Dr. James L. Goddard 10 November 1966 Page 3 3. The Board believes that written consent of the patient should be obtained except where the interests of the patia:it himself run counter to this principle. The Board therefore reconunended that paragraph (h) conclude with the following sentence: "Said patient's consent shall be obtained in writing by the investigator, whenever in the judgment of the responsible physician, the patient's interest would not suffer thereby." 4o In the Proposed Revision, a final paragraph (not lettered) follows paragraph (h). If the Board's reconunendation as offered inunediately above (paragraph 3) is accepted, then your final paragraph becomes superfluous. Moreover, the distinctions between phases I, II, and III are conceptual, not operational, the investigator himself would experi­ ence difficulty in determining the applicable investigational phase, and the language would further imply that the physical and mental state of the patient need be considered only in the phase III cases. You will appreciate that this sumrmry of the Board's recommendations is offered inunediately following the meeting of November 7 and that only the essential reasoning is presented as a preface to the reconunendations. The Board would, however, be glad to aid in any further clarification that might be useful to your review. Sincerely, R. Keith Cannan Chairman ~ Proposed Revision November 18, 1966 616 (Published in the Federal Register of August 30, 1966) TITLE 21--FOOD AND DRUGS CHAPI'ER 1--FOOD AND DRUG ALMINISTRATION, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SUBCHAPTER C--DRUGS PART 130--NEW DRUGS CONSENT FOR USE OF INVESTIGATIONAL NEW DRUGS ON HUMANS: STATEMENT OF POLICY Pursuant to the provisions of the Federal Food, Drug, and Cosmetic Act (secs. 505(i), 701(a), 52 Stato 1053, as amended, 1055; 21 u.s.c. 355(i), 371(a), and under the authority delegated to the Commissioner of Food and Drugs by the Secretary of Health, Education, and Welfare (21 CFR 20120; 31 FoRo 3008), and in consonance with the Declaration of Helsinki QR ~:ymae 91cp0~im9etation, adopted by the World Medical Association, Part ;J- 130 is amended by adding thereto a new statement of policy, as follows: 130037 Consent for use of investigational new drugs on humans; statement of policy. (a) Section 505(i) of the Act provides that regulations on use of investigational new drugs on human beings shall impose the condition that investigators "obtain the consent of such human beings or their representa­ tives, except where they deem it not feasible or, in their professional judgment, contrary to the best interests of such human beings." (b) This means that the consent of such human beings (or the consent of their representatives) to whom investigational drugs are administered primarily for the accumulation of scientific knowledge, for such purposes as studying drug behavior, body processes, or the course of a disease, must be obtained in all cases and, in all but exceptional cases, the con­ sent of patients under treatment with investigational drugs, or the consent of their representatives, must be obtained. (c) "Under treatment" applies when the administration of the investiga­ tional drug for either diagnostic or therapeutic purposes involves respon­ sible medical judgment, ta.king into account the individual circumstances pertaining to the person to whom the investigational drug is to be administeredo (d) "Exceptional cases," as used in paragraph (b) of this section, which exceptions are to be strictly applied, are cases where it is not feasible to obtain the patient's consent or the consent of his representa­ tive, or where, as a matter of professional judgment exercised in the best interest of a particular patient under the investigator's care, it would be contrary to that patient's welfare to obtain his consent. (e) "Patient" means a person under treatment. l!ll!l!!IJIII COPY 617 -2- (f) "Not feasible" is limited to cases where the investigator is not capable of obtaining consent because of inability to conununicate with the patient or his representative; for example, where the patient is in a coma or is otherwise incapable of giving informed consent, his representative cannot be reached, and it is imperative to administer the drug without delay. (g) "Contrary to the best interest of such human beings" applies when the conununication of information to obtain consent would seriously affect the patient's well being and the physician has exercised a professional judgment that under the particular circumstances of this patient's case, the patient's best interests would suffer if consent were sought. (h) "Consent" means that the person involved has legal capacity to give consent, is so situated as to be able to exercise free power of choice, and is provided with a fair explanation of all pertinent information con­ cerning the investigational drug, or his possible use as a control, as to enable him to make a decision as to his willingness to receive said investi­ gational drug. This latter element requires that before the acceptance of an affirmative decision by such person the investigator should care­ fully consider (taking into consideration such person's well-being and his ability to understand), and make known to him the nature, expected duration, and purpose of the administration of said investigational drug; the method and means by which it is to be administered; the comparative hazards in­ volved, including the fact, where applicable, that the person to receive the drug ma~ be used as a control; the existence of alternative forms of therapy, if any; and the beneficial effects upon his health or person that may possibly come from the administration of the investigational drug. When consent is necessary under the above rules, the consent of persons receiving an investigational new drug in Phase I and Phase II investigations (or their representatives) shall be in writing. When con­ sent is necessary under the above rules in Phase III investigations, it is the responsibility of investigators, taking into consideration the physical and mental state of the patient, to decide when it is necessary or preferable to obtain consent in other than written form. When such written consent is not obtained, the investigator must obtain oral consent and record that fact in the medical record of the person receiving the drug. COPY 618 UNITED STATES GOVERNMENT MEMORANDUM TO Dr. Keith Cannan DATE: March 31, 1966 Division of Medical Science, NAS-NRC FROM : James L. Goddard, M.D. Commissioner of Food and Drugs SUBJECT: Efficacy Review of Pre-1962 Drugs The Food and Drug Administration is confronted with the extremely important task of reviewing for efficacy those drugs that came into use after the basic drug act of 1938 and prior to the drug amendments of 19620 Although this is a one time task requiring evaluation of material somewhat different from that now obtained in current drug approval procedures, its long range significance exceeds that of all other drug activity currently pursued by the Food and Drug Administrationo Reconunendations from the most ex­ pert sources are essential if this Administration is to suppress flagrant claims, eliminate worthless products and at the same time protect the physician's therapeutic resources. Congress has been assured this task will receive priority attention. Multiple Panel Method for Approaching the Problem The Food and Drug Administration records show some 3000 products for which applications were filed during the time period in ques­ tion and probably more than 1000 additional products are marketed without applications. Only a fraction of this number of chemical moieties are involved, however; a preliminary estimate is between 300 and 400. Our data processing system groups these active com­ pounds into about sixty categories of therapeutic effect. These categories could be combined into ten or twelve groups, each group being appropriate for consideration by a different panel of expert advisors. A given panel could consider each selected therapeutic moiety in relation to justified indications, routes of administration, dosage schedules, suitability in compound formulations and other appropriate attributes. Recommendations to the Food and Drug Ad­ ministration could then be utilized by FDA personnel to resolve problems encountered in the general marketing of the moiety in question even though several manufacturers and several forms of the drug moiety are involved. Such a review, directed primarily toward efficacy rather than relative efficacy or safety, rould lead to identification of perhaps four categories of indication­ efficacy status. COPY 619 Dr. Keith Cannan 2. Indication-Efficacy Status Determinations Category I -- Clearly Effective. For the presented list of therapeutic indications this drug is considered effective beyond a reasonable doubt, appropriate documentation exists in the medical literature and FDA should accept such evidence of efficacy. Perhaps as many as 75% of the major indication-efficacy considerations will lead to this determination. Category II -- Probably Effective. For the therapeutic indications. presented here the efficacy of this drug is questioned and more evidence is required to provide an answer. The recommendation to FDA could be that within a year additional and adequate supporting evidence be produced or else the therapeutic indication in question will become unacceptable. Perhaps there are 25% of the chemical moieties where one or more important indications encounter this degree of uncertainty. Category III -- Probably Ineffective. In relation to the indication in question there seems little likelihood that efficacy exists. The recommendation to FDA could be that unless it has evidence that studies are being initiated promptly with an experimental design appropriate to the development of substantial new evidence within a year, the thera­ peutic indication in question should be considered inappropriate. Perhaps there are 25% of the chemical moieties where ancillary thera­ peutic indications encounter this much uncertainty and a smaller percentage where the primary indication is involvedo Category IV -- Clearly Ineffective. In relation to the indication in question there not only is no significant evidence to support a claim of drug efficacy but also there is substantial evidence that efficacy is nonexistent, perhaps even to the point that placebo effect alone is without redeeming value. The recommendation to FDA could be that !!2. useful purpose is served by continuing to make this product available to the medical profession for the indication in question and immediate administrative action seems justified. The number of completely worth­ less drugs is probably not large and probably concentrated primarily among certain drug groups. Consequently, the major use of this category would probably be in relation to ancillary indications claimed for a larger number of basically useful drugs. Documentation for the Food and Drug Administration Records In each case where a panel arrives at a conclusion concerning a given therapeutic moiety in relation to a specific therapeutic indication, FDA would need the key references (probably never more than a dozen and usually fewer) which provide substantial evidence to support the conclusion. Where FDA data could significantly assist in clarifying problem areas, appropriate procedures would be devised to make such available. However, where primary file data were of interest, panel sessions would need to be held in the immediate Washington area. COPY 620 Dr. Keith Cannan 3. Proposed Time Scale In order to initiate this critical project promptly and yet to give adequate consideration to its magnitude, the following time scale seems reasonable: Submission of a proposal to FDA by mid-April if possible but no later than May 1. Execution of contract by June 1, 1966 with work to begin as soon as possible thereafter but no later than June 30, 1966. Before the end of this calendar year multiple expert panels, well-balanced between clinical and pharmacological disciplines, would have begun drug review sessions. By the end of the next calendar year (December 31, 1967) the preliminary review would be completed, all the straight-forward reconunendations concerning efficacy would have been submitted and reconunendations suggesting the need for further studies would have been developed. (This does not imply that the panels would be expected to devise specific experimental plans for any given drugs although of course any suggestion or recommendations would be most welcome.) During the subsequent year and one-half the panels would consider new data developed in response to their earlier recommendations, or otherwise, in an effort to arrive at a final position on as many therapeutic moieties as possible. On June 30, 1969 this project would end unless by mutual agreement there is a decision to extend the time period to permit resolution of problems then currento - Thus the current concept is for a three-year special project to run from June 30, 1966 through June 30, 19690 Administrative Support The Food and Drug Administration would plan to do everything within its capabilities to assist the NAS-NRC and make its task easiero Funds to permit NAS-NRC subcontracting to obtain adequate adminis­ trative support would be providedo At least one FDA physician would be given a priority task on a full-time basis of maintaining liason with the NAS-NRC, providing professional administrative support, assisting the various panels in devising review guidelines that would meet FDA's needs and otherwise lightening the load where ever possibleo Required administrative and data handling resources of the Bureau of Medicine would be available to the FDA physician serving the liason function. COPY 621 Dr. Keith Cannan Conflict of Interest No problems are anticipated here. The Food and Drug Administration is prepared to accept the principle of professional integrity whereby panelists with personal interest in a therapeutic entity will not personally participate in deliberations where their personal interest is involved. Likewise FDA is confident that professional personnel of the caliber utilized on NAS-NRC panels would not put information obtained from panel discussions to improper use in other activities conflicting with the interests of FDA. NAS-NRC Versus FDA Advisory Boards The Food and Drug Administration sees no conflict in this area. The FDA advisory groups are not equipped to undertake a task of this magnitude and cannot be expected to alter their other activities to the extent that would be required. The FDA Medical Advisory Board will be integrally involved in assisting the FDA in the implementation of appropriate measures in response to NAS-NRC recommendationso Isl James Lo Goddard James L. Goddard, M. D. Commissioner of Food and Drugs 622 Tape-transcript Correlation Reel Side Pages 1 I 1 - 19 1 II 19 - 39 2 I 39 - 56 2 II 56 - 76 3 I 76 - 100 3 II 100 - 119 4 I 119 - 135 4 II 135 - 151 5 I 151 - 172 5 II 172 - 193 6 I 193 - 215 6 II 215 - 231 7 I 231 - 253 7 II 253 - 273 8 I 273 - 286 8 II 286 - 304 9 I 304 - 313 9 II 313 - 328 10 I 328 - 349 10 II 349 - 369 11 I 369 - 394 11 II 394 - 413 12 I 413 - 429 12 II 429 - 445 13 I 446 - 461 13 II 461 - 479 14 I 479 - 494