Philadelphia Reflections

Academia, Medical Version

The first hospital in America generated the first medical school, the first medical society, and many of the unique features of American medicine. In modern times, the gusher of federal research funds not only distorted academic medicine, but academia as a whole.

The First and Oldest Hospital in America

South East Prospect of Pennsylvania Hospital

There is a painting of the region around 8th and Spruce Streets in the 1750s, depicting a pasture, with cows, and three or four buildings between 8th and 13th Streets. When the Pennsylvania Hospital moved there in 1755 from its temporary location in a house located a block from Independence Hall, there were complaints that it was now located so far out in the woods that it was difficult and dangerous to go there. Still another description of the area is evoked by the provision which the Penn family placed in the deed of gift of the land, strictly forbidding the use of the land as a tannery. Tanneries have always been notorious for giving off noxious odors, so most people wanted them to be somewhere else, anywhere else. In any event, the main activity of Penn's "green country town" at that time was concentrated closer to the Delaware River, and the nation's first hospital was definitely placed in the outskirts. Two blocks further West the almshouse was already in place, but not much else. We are told that Benjamin Franklin had flown his Famous Kite at 9th and Chestnut, using a barn there to store his materials. It might be recalled that the population of Philadelphia, although the second largest English-speaking city in the world, was only about twenty-five thousand inhabitants at the time of the Revolution, and in 1751 was even smaller.

In any event, the first and oldest hospital in America was built on 8th Street between Spruce and Pine, and the Eighteenth Century buildings on Pine Street still present a breathtaking view at any season, but particularly in May when the azaleas are in bloom, and fragrance from the flowering magnolias fills the evening atmosphere for blocks around. Although some people today mistake the Pennsylvania Hospital for a state hospital, it was founded in the reign of George II, decades before there was such a thing as the State of Pennsylvania. The Cornerstone was laid by Benjamin Franklin, with full Masonic rites. Most doctors regard a hospital as a mere workshop, but the affection with which many Pennsylvania physicians regarded their special hospital is indicated by the number who have requested that their ashes be buried in the garden.

For two hundred years, beginning with the first American resident physician Jacob Ehrenzeller, the interns and residents were paid no salary, so they had to live on the grounds. An Internet was just that, interned within the four walls for at least two years. Because the resident physicians had no money, they stayed in the hospital at night and on weekends, playing cards and swapping stories. The hospital was home for them, as it was for the student nurses, likewise unpaid but more strictly confined and supervised. This penury seemed acceptable because the patients were mostly charity ward patients, otherwise unable to pay for their own care. Ehrenzeller finished his medical apprenticeship and went to practice for many decades in the farm country of Chester County, but gradually upper-class Philadelphia moved from 4th Street westward to and beyond the hospital, and two of the richest men in American history, Morris and Biddle, had houses within a block of the hospital, although Morris never lived in his house, having more pressing matters in debtor's prison. Therefore, later resident physicians at the hospital had the potential of setting up a private practice in the area and becoming society doctors as well as academically prominent ones. Being a charity hospital in a rich neighborhood created the potential for volunteer work by the town aristocrats and large bequests for charity. The British housed their wounded in the hospital during the Revolutionary War and shot deserters against the red brick wall of the small cemetery to the north. A century later, there were a couple of dozen rooms for private patients in the hospital for the convenience of the doctors and the neighbors, but everyone else was a charity patient. And a century after that, the hospital still did not have an accounting department to collect bills and tended to regard people who asked for a bill as a nuisance. Benjamin Franklin is regarded as the Founder of the hospital, and his autobiography famously describes how he fast-talked the legislature into matching the donations of the public, not mentioning to them that he had already collected enough promises to see the project through. This seems in character; Franklin's biographer Edmond Morgan summed up that, "Franklin doesn't tell us everything, but what he does tell us, is straight." The idea for the hospital was that of Dr. Thomas Bond, whose house is now a bed and breakfast on Second Street, but it was characteristic of Franklin to be the secretary of the first board of managers of the hospital. In Quaker tradition, the clerk of a meeting is the person who really runs the show. It thus comes about that the minutes of the founding board were recorded in Franklin's own handwriting, among them the purpose of the institution, which is to care for the Sick Poor, and if there is room, for Those Who can pay. This tradition and this method of operation continued until the advent in 1965 of Medicare when charity care was displaced by concepts which the nation had decided were better. The Pennsylvania Hospital was not only the first hospital but for many decades it was the only hospital in America. Its traditions, sometimes quaint and sometimes glorious, cast a long shadow on American medicine.

REFERENCES

A Toast to Doctor Franklin

Benjamin Franklin

Benjamin Franklin's formal education ended with the second grade, but he must now be acknowledged as one of the most erudite men of his age. He liked to be called Doctor Franklin, although he had no medical training. He was given an honorary degree of Master of Arts by Harvard and Yale, and honorary doctorates by St.Andrew and Oxford. It is unfortunate that in our day, an honorary degree has degraded to something colleges give to wealthy alumni, or visiting politicians, or some celebrity who will fill the seats at an otherwise boring commencement ceremony. In Franklin's day, an honorary degree was awarded for significant achievements. It was far more prestigious than an earned degree, which merely signified adequate preparation for potential later achievement.

And then, there is another subtlety of academic jostling. Physicians generally want to be addressed as Doctor, as a way of emphasizing that theirs is the older of the two learned professions. A good many PhDs respond by rejecting the title, as a way of sniffing they have no need to be impostors. In England, moreover, surgeons deliberately renounce the title, for reasons they will have to explain themselves. Franklin turned this credential foolishness on its head. Having gone no further than the second grade, he invented bifocal glasses. He invented the rubber catheter. He founded the first hospital in the country, the Pennsylvania Hospital, and he donated the books for it to create the first medical library in the country. Until the Civil war, that particular library was the largest medical library in America. Franklin wrote extensively about gout, the causes of lead poisoning and the origins of the common cold. By inventing bar soap, it could be claimed he saved more lives from the infectious disease than antibiotics have. It would be hard to find anyone with either an M.D. degree or a Ph.D. degree, then or now, who displayed such impressive scientific medical credentials, without earning -- any credentials at all.

College of Physicians of Philadelphia

College of Physicians of Philadelphia

The College of Physicians of Philadelphia is the oldest medical organization in America, or even the Western Hemisphere, having been founded in 1787, the year of the Constitutional Convention. The CPP, located on 22nd Street near Market, is not to be confused with the American College of Physicians (a much more recent organization, formed in 1923 and located at Fifth and Arch Streets). The term "Physician" was then much more specific, and Philip Syng Physick, now known as the father of American Surgery was not considered eligible for membership because he was a surgeon, not a physician.

The general idea of the founding of the College seems to have been to focus on the physicians who had attended medical school (usually in Edinburgh), as distinguished from the general run of a physician at the time, who had merely served an apprenticeship. The first medical school, at the University of Pennsylvania (then at Ninth and Walnut Streets, but now at 36th and Spruce) caused the College of Physicians to turn away from pedagogy to the direction of setting standards and providing a forum for the "better sort" of the profession to be self-governing. At one point, there was even a real possibility that the College of Physicians of Philadelphia would become the credentialing agency for the whole country, but licensing took the direction of state boards during the Nineteenth Century. Every book and journal must have a Library of Congress number. The Transactions of the College of Physicians of Philadelphia has a Library of Congress number, all right. Number one. Jonathan Rhoads, the giant of 20th Century surgery and the only person to be president of the College twice, once remarked that being first may not be terribly important in the greater scheme of things, but -- it's awfully hard to imitate.

The College was a very strong guiding force in the development of a system of medical ethics for the profession. A curious false turn was taken in the direction of Lambda Chi, a secret society of physicians for the purpose of invisibly policing medical conduct, but the College soon recognized this was the wrong direction to take, and eventually, it assumed the lead in forming the American Medical Association in 1848. The portrait of Chapman, the first President of the AMA, hangs above the mantle in the fellows' reception room, the original minutes and rolls of the delegates are found in the library. Half a dozen presidents of the College were also presidents of the AMA, but for some curious reason the College never became the local branch of the AMA, reserving that for the State and Pennsylvania County Medical Societies.

Every year a number of the most distinguished physicians in the world address the College, and an annual lecture by a Nobel Prize winner has been established. The College had the largest medical library in the country until recently, and it is still one of the largest. The present building is a Carnegie Library, in a sense. Andrew Carnegie was a patient of S. Weir Mitchell at the time Mitchell was president of the College and donated a large sum for a new building. The present elegant marble and the walnut-paneled structure was built in 1905, fairly recent by Philadelphia standards but nevertheless a national landmark.

With all this dignity, history and tradition, it likely comes as a surprise to learn that the College building has sixty thousand paid visitors each year. The source of this popularity is a combination of medical exhibits for the public, and the Mutter Museum. In the late Nineteenth Century Thomas Dent Mutter gave his large personal collection of anatomical specimens to the College for a museum in the style of the medieval European medical schools, where the students could learn from specimens on display because anatomical dissection was discouraged if not forbidden, and Kodachrome slides had not been invented. Mutter's collection is a combination of believe-it-or-not "freaks", anthropological studies of human variations, and a museum of medical history. The former curator, Gretchen Worden, has produced an illustrated book of the exhibits which quickly sold out and must be reprinted, and a yearly illustrated calendar which is quite popular. The doctors are a little bemused by the popularity of this material with the public, but tolerant.

Among the odd features of this collection is the brain of Sir William Osler, the giant of modern medical education. Osler belonged to a club of people who had such a high opinion of their own genius they pledged to donate their brains after death to the collection of specimens, in the hope that eventually science would be able to determine the anatomical source of their talents. Most people today are a little staggered at the arrogance of such an idea, so widely at variance with the concept that all men are created equal. Albert Einstein is another acknowledged genius whose brain is still floating in a pickle jar, waiting for its unique properties to be discerned. Presumably, time will eventually tell whether even the greatest intellects suffer from unconquerable hubris, or whether the envious rest of us must adapt to the consensus of political correctness, just to avoid facing the reality of our own inferiority.

The University City

University of Pennsylvania

In 1920, the University of Pennsylvania graduated 34 students with B.A. degrees, and 134 with M.D. degrees. Today, the campus is a little self-contained city of 50,000 inhabitants. The transformation of the campus during that period is an outward expression of revolutionary expansion of the student body, involving demolitions, restorations, new construction. And the nearly constant shortage of parking space.

David Hollenberg

David Hollenberg, the University Architect, recently gave the Franklin Inn Club an interesting description of the University from the point of view of bricks and mortar. Since almost every building on the campus is undergoing or plans to undergo a major building project, he had a lot of material to cover. The disappearance of the railroad-based industrial area of West Philadelphia has been an economic problem for the city, but of course, this abundance of vacant land has created a major opportunity for the University of Pennsylvania. One reflection of this abundance is the opportunity to become the developer for much of the whole region around the campus, working with private developers who wish to be in the University area, and are therefore willing to coordinate their plans with those of the University. It's a remarkable opportunity. Since it comes at the time of a major economic downturn, one can only hope that the University does not impoverish itself taking advantage of this good luck.

Jonathan E. Rhoads

As the graduation statistics illustrate, not so long ago the University was largely a medical school, with appendages. There are rumors of considerable friction from time to time, between the President of the University and the Dean of the Medical School as to who was boss; it is easy to imagine the trustees swinging from one side to the other. The most notable Provost of the University in modern times was Jonathan Rhoads, who also happened to be Professor of Surgery. If you know Quakers, you know that disputes were seldom rancorous. And if you know Jonathan, you know he almost always won the disputes.

Cira Center

While today, the dominant change is caused by the Cira Center buildings and the acquisition of the former Post Office building, it is well to keep in mind that the new Cancer Center is a billion-dollar project. A great deal of the medical school expansion is centered on burgeoning research, particularly in molecular biology, largely financed by the National Institutes of Health. While the leaders of the NIH have long struggled with Congress to keep politics out of both the administration and the substance of research, it seems to old-timers that the politicians are slowly winning. Senator Specter's seniority on the Appropriations Committee may have had as much to do with the prosperity of West Philadelphia, as the quality of research, however eminent. We are about to find out, and if things go hard with us in favor of say Chicago, it could be a wrenching experience. Most of those research buildings cost more to heat, air-condition, insure and clean than the entire tuition base of the students; and they wouldn't be good for much if you tried to sell them.

The University is almost unique in being located on contiguous land, near existing public transportation, and occupying substantial old structures capable of renovation to new purposes. Mr. Hollenberg was asked whether it was cheaper to grow like this within a city, or whether it is cheaper to plant a totally new university in several open corn fields, as we often see happen. While this is a hard question to answer, and depends to some extent on the type of architect in charge, it is his view that big-city restoration is a considerably cheaper way to expand than building from scratch on open land, although if you are starting the institution itself from scratch, there isn't much choice but the cornfield.

And then, there is the ancient argument between academics and bricks and mortar. Development officers agree that it is easier to raise donations when you can name a building for the donor; grand visions for new frontiers of teaching are a much harder sell. So a question does hang over this expansion, however exciting, whether the endowment will keep up with the structures, once the excitement of physical expansion dies down. These are definitely things to worry about, but right now you seize the opportunities as they go past, leaving integration to your successors to figure out.

Eakins and Doctors

The Gross Clinic

A Christmas visitor from New York announced he read in the New York newspapers that Philadelphia's mayor had just rescued a painting called The Gross Clinic, for the city of Philadelphia. The Philadelphia physicians who heard this version of events from an outsider reacted frostily, grumpily, and in stone silence. To them, the mayor was just grandstanding again, and whatever the New York newspaper reporters may have thought they were saying was anybody's conjecture.

Thomas Eakins is known to have painted the portraits of eighteen Philadelphia physicians. Several of these portraits have been highly praised and richly appraised, seen in the art world as part of a larger depiction of Philadelphia itself in the days of its Nineteenth-century eminence. That's quite different from its colonial eminence, with George Washington, Ben Franklin, the Declaration and all that. And of course entirely different from its present overshadowed status, compared with that overpriced Disneyland eighty miles to the North. Eakins depicted the rowers on the Schuylkill, and the respectable folks of the professions, every scene reeking with Victorian reminders. It's a little hard to imagine any big-city mayor of the present century in that environment. Indeed, it is hard to imagine most contemporary Americans in a Victorian environment -- except in Philadelphia, Boston, and perhaps Baltimore. So, Mayor Street can be forgiven for not knowing exactly what stance to take, and was not alone in that condition.

S. Weir Mitchell, for example, became known as the father of neurology as a result of his studies and descriptions of wartime nerve injuries. But the repair of injuries is a surgical art, and many novel procedures were invented and even perfected, many textbooks were written. Amphitheaters were constructed around the operating tables, for students and medical visitors to watch the famous masters at work.

In The Gross Clinic, we see the flamboyant surgeon in the pit of his amphitheater at Jefferson Hospital, in the background we see anesthesia being administered. Up until the invention of anesthesia, the most prized quality in a surgeon was speed. With whiskey for the patient and several attendants to hold him down, the surgeon had one or two minutes to do his job; no patient could stand much more than that. After the introduction of anesthesia, it might overwhelm newcomers to observe leisurely nonchalance, but in truth, the patient felt nothing, so the surgeon could safely pause and lecture to his nauseated admirers.

Operating Amphitheater

What made an operation dangerous was not its duration, but the subsequent complications of wound infection. By 1876, Eakins could have had no idea that Pasteur and Lister were going to address that issue in four or five years, making operations safe as well as painless. But his depiction of a surgeon with bloody bare hands, standing in Victorian formal street clothes, gives the most dramatic possible emphasis in the painting to the two most important scientific advances of the century. Modern medical students spend days or weeks learning the ceremonial of the five-minute scrubbing of hands with a stiff and somewhat painful brush, the elaborate robing of the high priest in a sterile gown by a nurse attendant, hands held high. The rubber gloves, the mystery of a face mask and cap. In some schools, the drill is to cover the hands of a neophyte with charcoal dust, blindfold him, and insist that he scrub off every speck of dirt that he cannot see before he is admitted to the operating theater for the first time. If he brushes some object in passing, he is banished to the scrub room to start over. So the Gross Clinic has an impact on everyone who sees the surgeon in street clothes, but it is trivial compared with the impact that painting has on every medical student who has been forced to learn the stern modern ritual. For at least fifty years, that painting hung on the wall facing the main entrance to the medical school, where every student had to pass it every day. To every graduate, the lack of clean surgical technique by the famous man was a wrenching sermon on every doctor's risk of trying his utmost to do his best, but doing the wrong thing.

That painting, hanging quite high, was rather cleverly displayed to the public through a large window above the door. With clever lighting, every layman who walked along busy Walnut Street could see it, too, and it became a part of Philadelphia. That was a feature the medical community barely noticed, but it was probably the main reason for public uproar when a billionaire heiress offered the school $68 million to take the painting to Arkansas. The painting was not just an icon for the medical profession, it had become a central part of Philadelphia. Philadelphia wanted to keep that painting for a variety of reasons, and one of the main ones was probably a sense of shame that we were so poor we had to sell our family heirlooms to hill-billies.

The doctors didn't pay much attention to that. They were mad, plenty mad, that a Philadelphia board of trustees would appoint a president from elsewhere who would give any consideration at all to such an impertinent offer.

New Museum of Chemical Heritage

Arnold Thackray

Eighty percent of the ethical drug industry is located within a hundred miles of Philadelphia, and the whole chemical industry has had its center here for two centuries. The chemical industry is the region's largest manufacturer, now that locomotives and beer brewing have come and gone, but its profile remains low. In fact, chemists personally have a low profile too and harbor a smoldering annoyance about it. No one has been more determined to change that nerdy image than Arnold Thackray, the recently retired President of the Chemical Heritage Foundation. He's not only a big idea man but bubbles with energy and persuasiveness. That largely accounts for the fact that CHF has the second largest endowment among public institutions in Philadelphia, the best library of chemical history in the world, and a growing reputation for fine art concentrated in the field. That's not enough for him, so it came about that a new museum was envisioned, funded and created. But not built; building it was assigned to Miriam Schaefer, a famous go-getter who had the unusual qualification of being squeamish about chemistry. It was her assigned task to find a way to make chemistry exciting to people who were not instinctively excited by it, just exactly because she was the world's authority on that point of view. What was vital was that she was the sort of person who can't resist a challenge, and was capable of thinking, well, big.

With the unlimited backing of Arnold and his board and their almost unlimited financial support, Miriam set about soliciting big ideas from uninhibited people all over the world, and some of their suggestions were even a little too wild to be acceptable. But since the whole idea was to awaken the enthusiasm of anybody, however sullen, who happens to shuffle through the museum, many outlandish suggestions were forced through the filter of a skeptical, conservative, Philadelphia establishment. The result is a series of pleasant surprises, ranging from fine art with a focus on alchemists trying to make gold out of lead, to astonishing computerized graphic displays of the elements of the periodic table fifty feet high, to depictions of Joseph Priestly known as the father of chemistry, a personal friend of Benjamin Franklin, the founder of the Unitarian Church, and a resident of Philadelphia. There's Arnold Beckman's original Beckman spectrophotometer which made hundreds of millions of dollars, was a major factor in the Twentieth century blossoming of biochemistry, and is here shown to be a clever elaboration of a simple idea. Meanwhile, the museum is housed in a massive old bank building, with it is interior reamed out and replaced with as much transparent glass as could support the weight. Inga Saffron the architectural critic, more than foamed over with praise in her review of just the structure itself. Don't neglect to notice the stunning portrait of Gay-Lussac, the man who discovered that water is H2O. The pigments of his portrait were mixed with beeswax, and with clever lighting have an astonishing luminosity.

The museum is part of an emerging conference center, which should attract audiences of chemists for decades. But that's not entirely the whole idea. The underlying vision is to convince those skeptical, non-chemical bozos that not only are chemists rather richer than the rest of us, and smarter, but clever and fascinating, too. Go visit this museum, before everyone else does.

Link to Nobel Prizes

To skip back to Nobel Prizes, click the indicated place below:

» Click here for NOBEL PRIZES «

Link to PHILADELPHIA PHYSICIANS

To skip back to GENERAL TOPIC OF PHILADELPHIA PHYSICIANS, click the indicated place below:

» Click here for PHILADELPHIA PHYSICIANS «

Link to:Medical Club of Philadelphia

This concludes the general topic Medicine in Philadelphia. The more specific topic area of the Medical Club of Philadelphia (founded 1892 and still operating) can be reached by clicking on the title below. It's large, so wait a moment for it to come up:

» Click here for THE MEDICAL CLUB OF PHILADELPHIA «

Philadelphia Chromosome

Every Spring for the last 185 years, the Franklin Institute has honored the most distinguished scientists alive; Franklin would certainly be proud of the Institute named after him. In recent years, many awards were combined into two categories, the Bower Awards and the Benjamin Franklin gold medals. Unlike the Nobel Prize, the Franklin Institute Medals are not given for eminence in a designated field of science, but rather are given out by a hard-working committee of scientists who ask themselves What are the really hottest scientific fields at present, and then ask panels of international referees Who is most eminent in that field? The awards thus effectively avoid fields that are temporarily stale and static, by being unrestricted in advance to particular fields. The approach of searching for the greatest minds rather than greatest achievement may well lead to the same award, but the method of choice seems more harmonious with the spirit of Benjamin Franklin, who not only excelled in the field of electricity but actually invented that whole field. The subtle shift in emphasis seems to have been well received; this year's Awards Banquet was over-subscribed before the invitations were printed, and a capacity audience of 800 attended a superb reception, dinner and audio-visualized live ceremony. Actually, the ceremony extends for a whole week, with scientific symposia and in-person meetings with high school students designed to interest them in science.

This year eleven scientists, the most prominent of whom were Bill Gates and Peter Nowell, received the medals. We'll get to Bill Gates in a while; for the present, let's concentrate on Peter Nowell, who invented the Philadelphia Chromosome. What's that?

The Philadelphia Chromosome

Well, from 1921 to 1955, it was generally held that people, members of the human race, contained 48 chromosomes in every cell in their bodies. The chromosomes were thought to contain the genetic code governing our biological construction, explaining the difference between us and fruit flies, which for example only have four chromosomes per cell. After painstakingly examining the appearance of the chromosomes in different people and in cancer cells, it was then generally held that cancers never seemed to have any genetic abnormality. After all, the chromosomes of cancer cells looked exactly like those in normal tissue: Forty-eight chromosomes, never differing in cancers, so go look somewhere else for the cause of cancer. Unfortunately, the state of scientific development fifty years ago can be summarized by noting that about that time it then became established we really only had 46 chromosomes, not 48. As for cancer, the M.D. pathologist Peter Nowell, then noticed in 1956 that a patient with chronic myelogenous leukemia had an extra translocation on one particular chromosome, giving it a funny shape. This translocation was furthermore present in every single other leukemic cell suggesting that one cell had somehow undergone a single mutant change, and all the rest were its descendants. At least in CML (chronic myelogenous leukemia), it suddenly looked as though the cause had been found since the further study revealed the same was true of just about everyone who had CML. At first, it was felt that while maybe the cause of this particular type of cancer had been found, every other cancer might still be caused by something else. Not so. From believing no cancers were genetic in origin, Peter Nowell started us on the path of now being confident all cancers have a genetic cause.

Dr. Peter Nowell

How could we all have been so wrong; can't scientists even count up to 46? No, as a matter of fact, in 1955 it was pretty hard. If we couldn't even tell how many of them were there, it's obvious the comment they all looked alike wasn't worth very much. As Peter shyly admits, his discovery was a result of being trained as a physician rather than as a life scientist; he knew what leukemia looked like, but at that time he didn't know very much about chromosomes. It happens chromosomes spend most of their lives expanded into tiny filaments too small to examine under the microscope. But as they enter the stage of cell division called metaphase, those filaments shorten and thicken up, becoming a lot easier to examine. As a pathologist, Peter didn't bother to stain his slides in dilute salt solution, but just washed them in tap water. The tap water had caused the cells to swell up and burst; those that happened to be in metaphase dumped their stubby chromosomes out where they could be stained and looked at. Simple. Doesn't everyone wash slides in tap water?

So fifty years ago, the general question of what causes cancer finally narrowed down to the right sort of specific question. Thousands of scientists, spending billions of dollars from the National Institutes of Health, sharpened the focus of their search considerably. It certainly looks as though someone is going to carry the search the final step, pretty soon. However, the fact that fifty years of intensive study still hasn't quite found the answer is an illustration of how fiendishly difficult the search really is. Each year that might have been spent futilely avoiding genetic searches would have added one year more before the answer was finally found. By the way, why is it called the Philadelphia Chromosome? In 1955 it had been decided by the scientific community that every genetic abnormality would be named after the city in which it was discovered. Dr. Peter C. Nowell of the University of Pennsylvania and the late Dr. David Hungerford of the Fox Chase Cancer Center were the joint discoverers, so obviously it was entirely a Philadelphia discovery; at that time it had been made a custom that genetic abnormalities were named after the city where they had been first found.

It would be a mistake to conclude that nothing new has been discovered in half a century of research. It has been established that not only Myelocytic Leukemia but essentially every cancer starts with some genetic abnormality, which triggers the expression of "mini RNA". These abnormalities then apparently express a cancer-producing action by triggering an abnormal factor in the cell signaling system, called tyrosine kinase. Drugs with the effect of paralyzing that enzyme have been found to be curative in 95% of cases of chronic myelogenous leukemia, and some other forms of lymphoma. We're certainly getting closer, step by unexpected step, to the answer. In fact, we may be getting even closer to a point where drug research can jump to seeking cures without precisely defining how the cancer was caused. After all, if cancer is caused by a chain of cellular events, it may not matter where you break the chain. That realization appeared with, first aspirin and then the statin drugs, for treating heart attacks and strokes, even though we are still not completely clear about how atherosclerosis is produced. Meanwhile, the death rate from hardened arteries has dropped by half.

It wouldn't be right to omit mention of Peter Nowell's Quaker heritage. Although he isn't a Quaker, his mother was a Matlack, a direct descendant of Timothy Matlack, the Haddonfield Quaker who was the scribe for the first writing of the Declaration of Independence. Sitting in silent Quaker meeting, polishing and simplifying one's message before delivering it, is very good training for a habit of simple, direct thought. As Dr. Nowell phrases it, he is a chronic "lumper" of ideas, when so many scientists are content to be "splitters". Splitting complexity into its essential components is a useful approach. But somewhere, someone has to get to the heart of the matter.

Lumpers In Constant Combat With Splitters

James Boswell's Book

Some colleges produce managers by teaching management theory, but in certain Ivy League colleges it is thought to be more useful to teach how to dominate a committee, eventually perhaps a board of directors, or a board of trustees. The handbook of instruction is James Boswell's Life of Johnson which is a rather large book of verbatim notes that Boswell took of his many lunches at a London club in the 18th Century. Boswell was a quiet mouse privileged to sit in the company of the great Dr. Samuel Johnson, surrounded by the most eminent intellects of the Enlightenment. Boswell carefully manages the background of each episode, describing the issue and the various arguments, and then -- Sam Johnson's booming voice settles the matter. After he speaks, the meeting is over.

Dr. Samuel Johnson

"Why, sir", says Johnson, and then look out for the one-liner to follow. We get the impression that Dr. Johnson used that "Sir" signal to indicate he had enough of these dumb arguments, and soon would come the growled epigram that scatters any token resistance. Boswell may have neglected to record instances where the great Johnson was defeated in debate, who knows. We are left with the distinct impression that if you engaged in lunch table conversation with Sam, you were almost certain to lose. So that's what Ivy League students are being taught: how to win a debate at a committee meeting, in the expectation they would spend much of their lives in committees, boards, and even cabinets. That's how the English-speaking world gets its work done and its decisions made. That's what lunches at the Franklin Inn Club, or the club tables of the Union League, are trying to do for the education of neophytes.

As the goggle-eyed student of the great Chauncey Tinker, who gave young Pottle his start in life, it was an awesome performance for me to watch. But the rules of this game never became entirely clear to me, I'm afraid, until the other evening when I listened to Peter Nowell describe in a half-dozen brief paragraphs how he had revolutionized prevailing theories of the cause of cancer. The Franklin Institute then followed the award ceremony by putting on an all-day symposium of notables who run elaborate enterprises in cancer research, essentially funded by the National Institutes of Health, your tax dollars at work again. Last year, the NIH dispensed thirty billion -- you heard me -- dollars in research grants to internationally known research entrepreneurs, and if you can stay awake during their talks, there must be something the matter with you. So far as I could see, they were painstakingly describing every grain of sand on the beach, whereas Peter Nowell made the whole beach electric and clear in ten minutes. Essentially, he was saying that each patient's cancer is caused by a long chain of events, starting with a single mutation within a single cell. All the other cancer cells of a patient are descendants of that first one, which triggered the cascade of chemical events now repeated by the descendants. To stop the process, you probably only have to find a way to break the chain at one vulnerable point. Then you have a cure, without necessarily understanding every other link in the chain.

Peter Nowell described himself as a "lumper", admitting that most scientists are "splitters". A splitter quite reasonably attacks a complex problem by isolating one small piece of it at a time; that's really a pretty good way to address overwhelming complexity when you encounter it. But you can be sure that people of that mindset should not be found in a President's cabinet, deciding how to save the world from impending disaster. Whether by their own genetic predisposition or as a result of peer pressure in their profession, they are habitual splitters. And it suddenly occurred to me why Sam Johnson's one-liners always won the argument; he was a lumper. Usually right, sometimes wrong, never in doubt. Witty as a Frenchman, but as quick as a rattlesnake. Cordial, perhaps, unless you disagreed with him.

We need more lumpers. If they get that way from the likes of Chauncey Tinker, we need to print more copies of The Life of Johnson. If they are born that way, maybe we need a breeding farm for lumpers, which is what the Assembly Ball amounts to. But don't get me wrong, we need more splitters, too. They just have to learn their place at the table.

Atlantic City, Brigantine and the N.I.H.

Dr. William Osler

It would only be honest to say that Atlantic City was a rundown mess after World War II, cheap, sleasey and dispirited. But for academic medicine during a period of thirty or forty years, one small nook of A.C. was the most exciting place in the whole world. Only during several days at the beginning of May, however. The reason it was so attractive to scientists was that beach hotels were cheap and dilapidated; Atlantic City probably contained the worst on the East Coast. The Haddon Hall was an exception, rather elegant and far too expensive for most physicians in training; research is a young doctor's game. The medical profession's annual beauty contest for medical research was headquartered in Haddon Hall next door to the Steel Pier, surrounded by hundreds of cheap lesser hotels. The professors all stayed at Haddon Hall, but few others could afford it. Indeed, resident physicians from Philadelphia mostly found it cheaper to commute from home for ninety minutes than to stay overnight, residents and fellows from more distant cities stayed in the dumpy hotels. Nobody in that age group had much money to spend, so the commuting Philadelphians didn't miss out on much nightlife at the shore by going home every night.

New Atlantic City Skyline

Before the spring meetings got popular after World War II, a hundred members of the most elite society of academic research professors on the East Coast assembled in Haddon Hall, all of them quite able to afford to stay in the headquarters hotel. This had been going on since William Osler founded it in 1885, at first in Washington, and then migrating to Atlantic City. As medical research began to flourish, the society grew a little, but at a pace too slow to keep up with the growth of medical scientists, so a second group of "Young Turks" formed a competitive society which met the next day, and ultimately a third group, the "Young Squirts", felt excluded by the old has-beens, and met on the third day of what eventually turned into a week-long parade of scientific presentations, each ten or twelve minutes long, starting before normal breakfast time, lasting until 10 PM, with occasional breaks. That is to say, the medical papers that everybody wanted to hear grew from thirty or forty a year to nearly a thousand. If a young fellow did well, the older professors would notice, and he would get employment offers. That kept the eminent older doctors around for the whole session and provided an informal ranking of the worth of the program. Everybody wanted to advance up the ranks of prestige, and this system roughly sorted them out. However, it was an exhausting experience just to sit through all that and listen; the old professors tended to drop out and go home a little early. No matter how many outstanding papers were clamoring to be heard, no one could endure more than a week of straining for attention. It was strictly forbidden to present a paper which had been published or presented anywhere else, so it was usually difficult to guess in advance whether a paper was likely to be exciting. You could go home early if you wanted to, but at the risk of missing the real blockbuster of the year, tucked away on the program with a bewildering scientific title. The younger wise-apples had a formula, that if one paper in three was outstanding, you were having a good meeting; you just had to grit your teeth and try to stay awake during the other two-thirds. Still, that got to mean that the reward for pursuing this grinding ordeal was to go home after learning about three hundred outstanding scientific advances that no one else knew about; knowing three hundred cutting-edge things that other doctors didn't know really did put you well ahead of the pack. Keep that up for ten or twenty years, and notable differences among colleagues would relentlessly emerge.

Old Steel Pier

From the lounge of the Haddon Hall, with non-members forced to stand in the back, the meeting moved to the 2000-seat movie theater in the Steel Pier, at about 1950. Things then came to equilibrium; the movie theater was never completely full. We were told there were seven or eight even larger auditoriums on the Steel Pier, but it was never necessary to move to them. The first four years I attended these sessions I was being paid no salary at all, and most of my contemporaries were only getting token amounts beyond room and board. The eminent professors who were real members of the top society would find their way to front-row seats where they could ask questions, having had a chat with colleagues at breakfast in the Haddon Hall. But they had once been impecunious, too, and wore their brand-new Ivy League plaid jackets rather uncomfortably. Doctors who (gasp) worked for drug companies also gave signs of affluence, but they tended to drift over to the barber shop and have a shoeshine, where they picked up the gossip for their employers. Over a period of fifty years, I can recall first hearing of the wonders of several new antibiotics, a strange chemical called cortisone which seemed to cure rheumatoid arthritis, the introduction of the birth-control pill, the introduction of polio vaccine, the first drugs in the treatment of tuberculosis, and a vast array of novel explanations for disease phenomena that had seemed mysterious for centuries. In those days, a year without a new medical miracle was a very lean year, indeed. During this interval, the basis for curing at least thirty common diseases was first presented at the Spring Meetings in A.C., and since then medical practice looks nothing like it did in 1947.

Gradually the audience changed, too. At first, the people presenting papers came from at most ten medical schools, and mutterings of discrimination could be heard. In fact, it was plainly true, because only about ten schools had any extra money to fund research. When this news reached the U.S. Senators from the Mid and Far West, federal research money started to be spread around more evenly, just like the distribution of Senators. It was the appointment of one of the members of the original small nest of clubs to the Directorship of the N.I.H., the National Institutes of Health in Bethesda, Maryland, which really got the research spigot to flow. The point man was James Shannon, who knew what was what in cutting-edge research, and he sat there in the audience making up his mind who was who. For all the time of his directorship and for long afterward, he enforced, really enforced, the rule of "no political influence in research grants". Lots of congressmen came to the N.I.H. with the news that their relatives had such-and-such a disease, and so they thought more money should be diverted to research in that area. Nothing doing. Shannon held the keys to the kingdom, and he knew it. He had a deft feel for how much money the research industry could usefully absorb, and then he went to Congress and demanded it. The purity of this process has frayed at the edges somewhat as the amounts of money grew to what is now thirty billions of dollars a year. Most experiments, unfortunately, fumble or fail, so a lot of money gets spent on blind alleys before someone gets it right. It takes a tough-as-nails idealist like Jim Shannon to survive the temptations of an N.I.H. Director, and among the temptations is just to give up and give out money indiscriminately to people who want to count all the grains of sand on the beach. If your idea was a good one, you got all the money you could possibly spend; if the idea was mediocre, in those days you got nothing at all. On the other hand, the estimation of overhead costs is something other mortals can quibble about. Shannon demanded and got about a third of the grant money to be given to the medical school administrations. That was barely enough in a research establishment emerging from the Depression of the 30s, and the World War. However, now that the pipeline is filled, it is increasingly doubtful that ten billion a year needs to go to administrators; the bean-counters took over, and the results are more open to criticism. After all, after someone finds a cheap cure for cancer, some disadvantages of perpetuating an aging retiree population start to emerge and may outweigh the arguments for spending quite so much doing it. That may well be what the advisors to President Obama are growling at, but for now, the example of his nose poked into the hornet's nest of favoring research for certain population (voter?) groups will restrain others who were once inclined to agree. After cancer is cured, perhaps then everything will seem different.

Dr. James Augustine Shannon

Well, let's tell one story out of many that could be told. Around 1965 there were two competitive polio vaccines rumored to be in the pipeline. Jonas Salk had an injection method, and Albert Sabin had an oral vaccine. Anyone who had watched children run shrieking from a needle knew that Sabin had the preferred method, but Salk got to Atlantic City two years earlier than Sabin. The auditorium was filled with rumors of very dubious precision to the effect that Salk had used unfair methods to get to the stage of public announcement. For example, it was growled he gave the vaccine to the Russians to test, but they were afraid of it and gave it to the Poles. Regardless of such scurrilous gossip, which is here repeated only to show how hysteria can occasionally agitate even scientists when Salk gave his paper at the Steel Pier, the standing ovation was thunderous. And so, as the meeting broke for dinner the crowds migrated over to a huge seafood restaurant named Hackney's and watched the new scientific hero get a little tipsy in public. That seemed to revive the rumors which became even less factual. But there is no doubt that by the time Sabin stood at the same podium and gave his presentation of the oral vaccine, the crowd had switched to his side, the ovations were unlike anything the scientists had ever heard. Anyway, as emotions now settle down in retrospection, we are all pretty happy that polio is nearly eradicated from all but a few corners of the earth, and these two men are both responsible for it. But so is Jim Shannon responsible for it, and he never got the ovations he deserved.

Mr. Peanut

When the gambling casinos came to A.C. the cheap boarding houses were swept away, doctors in the research were incidentally better paid, and the Spring Meetings migrated back to Washington. The dumps on the beach have been replaced by gleaming multistory hotels, the place looks much more prosperous. Doctors are in a position to know about the drug and alcohol addiction, the venereal disease and crime among the casino employees, and the personal tragedies among the gamblers. But anybody can see the new buildings and clean streets. When a group of eight of us took a nostalgic trip to revisit the place, no doctor even mentioned the idea of going in to drink and gamble -- even the suggestion was preposterous. So we wandered over to Brigantine where there appears to be a large retirement community, where gambling and drinking seem equally unlikely. The elementary school in which we heard a talk about the old days was splendid beyond anything I remember in an elementary school. Among the audience, the questions revealed there were many former employees of the old A.C., people who ran shops to sell salt water taffy, fudge and the like to crowds on the boardwalk. Some of them may have once driven Jitney buses or pushed sightseeing wheelchairs. But not one of them showed the slightest sign of recognizing that on the first weekend in May, every year, a crowd of nerdy-looking serious fellows would move into familiar boarding houses for a few days, remaining mostly invisible during daylight hours. That was the academic doctor crowd if anyone had bothered to ask, pouring into the Steel Pier movie theater, having the time of their lives listening to medical history being made. After a week they all went home, and nobody in A.C., later Brigantine, paid any attention to any of it. After all, A.C. is about salt water taffy, right?

Nanoparticles: The Dwarfs are Coming

Professor Shyamelendu Bose

Professor Shyamelendu Bose of Drexel University recently addressed the Right Angle Club of Philadelphia about the astounding changes which take place when particles are made small enough, a new scientific field called nanotechnology. In one sense, the word "nano" comes from the Latin and Greek for "dwarf". In a modern scientific sense, the nano prefix indicates a billionth of something, as in a nanometer, which is a billionth of a meter. Or nanotubes, or nano calcium, or nano-anything you please. A nanometer is likely to be the dominant reference because it is around this width that particles begin to act strangely.

Nanoparticles

At this width, normally opaque copper particles become transparent, the cloth becomes stain-resistant, and bacteria begin to emit clothing odor. Because the retina is peculiarly sensitive to this wavelength, colors assume an unusual brilliance, as in the colors of a peacock's tail. The stable aluminum powder becomes combustible. Normally insoluble substances such as gold become soluble at this size, malleable metals become tough and dent-proof, and straight particles assume a curved shape. Damascus steel is unusually strong because of the induction of nanotubes of nanometer width, and the brilliance of ancient stain-glass colors is apparently created by repeated grinding of the colored particles.

Richard Feynman of Cal Tech

Practical exploitation of these properties has almost instantly transformed older technologies and suggests the underlying explanation for others. International trade in materials made with nanotechnology has grown from a few billion dollars a year to $2.6 trillion in a decade, particularly through remaking common articles of clothing which were easily bent or soiled, into those which are stain and water resistant. Scientists with an interest in computer chips almost immediately seized upon the idea, since many more transistors can be packed together in more powerful arrangements. Richard Feynman of Cal Tech seems to be acknowledged as the main leader of this whole astounding field, which promises to devise new methods of drug delivery to disease sites through rolling metal nanosheets into nanotubes, then filling the tubes with a drug for delivery to formerly unreachable sites. Or making nanowires into various shapes for the creation of nano prostheses.

Cal Tech on Los Angeles

And on, and on. At the moment, the limitations of this field are the limitations only of imagination about what to do with it. For some reason, carbon is unusually subject to modification by nanotechnology. It brings to mind that the whole field of "organic" chemistry is based on the uniquenesses of the carbon atom, suggesting the two properties are the same or closely related. For a city with such a concentration of the chemical industry as Philadelphia has, it is especially exciting to contemplate the possibilities. And heartening to see Drexel take the lead in it. There has long been a concern that Drexel's emphasis on helping poor boys rise in the social scale has diverted its attention from helping the surrounding neighborhoods exploit the practical advances of science. The impact of Cal Tech on Los Angeles, or M.I.T on Boston, Carnegie Mellon on Pittsburgh, and the science triangle of Durham on North Carolina seems absent or attenuated in Philadelphia. We once let the whole computer industry get away from us by our lawyers diverting us into the patent-infringement industry, and that sad story has a hundred other parallels in Philadelphia industrial history. Let's see Drexel go for the gold cup in this one -- forget about basketball, please.

Wistar Institute, Spelled With an "A"

Dr. Russel Kaufman

The Right Angle Club was recently honored by hosting a speech by Dr. Russel Kaufman, the CEO of the Wistar Institute. Dr. Russel is a charming person, accustomed to talking on Public Broadcasting. But Russel with one "L"? How come? Well, sez Dr. Kaufman, that was my idea. "When I was a child, I asked my parents whether the word was pronounced any differently with one or two "Ls", and the answer was, No. So if I lived to a ripe old age, just think how much time and effort would be wasted by using that second "L". In eighty years, I might spend a whole week putting useless "Ls" on the end of Russel. I pestered my parents about it to the point where they just gave up and let me change my name". That's the kind of guy he is.

The Wistar Institute

The Wistar Institute is surrounded by the University of Pennsylvania, but officially has nothing to do with it. It owns its own land and buildings, has its own trustees and endowment, and goes its own academic way. That isn't the way you hear it from numerous Penn people, but since it was so stated publicly by its CEO, that has to be taken as the last word. It's going to be an important fact pretty soon since the Wistar Institute is soon going to embark on a major fund-raising campaign, designed to increase the number of laboratories from thirty to fifty. The Wistar performs basic research in the scientific underpinnings of medical advances, often making discoveries which lead to medical advances, but usually not engaging in direct clinical research itself. This is a very appealing approach for the many drug manufacturers in the Philadelphia region, since there can be many squabbles and changes about patents and copyrights when the commercial applications make an appearance. All of that can be minimized when fundamental research and applied research are undertaken sequentially. Philadelphia ought to remember better than it does, that it once lost the whole computer industry when the computer inventors and the institutions which supported them got into a hopeless tangle over who had the rights to what. The results in that historic case visibly annoyed the judge about the way the patent infringement industry seemingly interfered with the manufacture of the greatest invention of the Twentieth century.

Patents are a tricky issue, particularly since the medical profession has traditionally been violently opposed to allowing physicians to patent their discoveries, and for that matter, Dr. Benjamin Franklin never patented any of his many famous inventions. But the University of Wisconsin set things in a new direction with the patenting of Vitamin D, leading to a major funding stream for additional University of Wisconsin research. Ways can indeed be devised to serve the various ethical issues involved since "grub-staking" is an ancient and honorable American tradition, one which has rescued other far rougher industries from debilitating quarrels over intellectual property. You can easily see why the Wistar Institute badly needs a charming leader like Russel, to mediate the forward progress of our most important local activity. From these efforts in the past have emerged the Rabies and Measles vaccines, and the fundamental progress which made the polio vaccine possible.

It was a great relief to have it explained that there is essentially no difference at all between Wisters with an "E" and Wistars with an "A". There were two brothers who got tired of the constant confusion between them, see and agreed to spell their names differently. When the Wistar Institute gathered a couple of hundred members of the family for a dinner, the grand dame of the family declared in a menacing way that there is no difference in how they are pronounced, either. It's Wister, folks, no matter how it is spelled. Since not a soul at the dinner dared to challenge her, that's the way it's always going to be.

Martin Feldstein Does It Again: Eliminate Tacit Tax Exemption for 70% of Workers Denied To the Rest

Headlines in the Wall Street Journal announced collapse of Congressional healthcare reform. In the same edition, a small short article buried in its depths described a possibly major step toward its reform. Martin Feldstein calmly observed, a tax exemption for healthcare insurance of 2.9% really amounts to a wage increase whose elimination might go a long way toward paying for the eighty-year mess Henry J. Kaiser had created. (In fact, it was effectively taxable income of 4%.)

It was all so simple: healthcare extended longevity, created thirty years of new retirement cost. In turn, exempting the premium for healthcare became a tax-exempt increase in wages -- for the 70% of employees getting insurance as a gift. Maybe not at first, but wages adjust to expect it during eighty years. Social Security could not cope with an extra thirty years, so SSA was going broke, while health insurance was actually the main cause of increased longevity.

But notice how unused Health Savings Accounts automatically turn into retirement accounts (IRAs) for Medicare recipients. So if you are lucky and prudent with healthcare, or if you overfund an HSA, unused healthcare money makes a reappearance in retirement funds where it belongs. If you have used up the money, you have probably been sick, and maybe won't need so much for a shortened retirement. Increasingly, expensive healthcare hits the elderly hardest, so there are many years during which compound interest overcomes inflation. At the rate things are going, retirement may become four times as expensive as Medicare, so let's consider that future.

Medicare doesn't save its withholdings, it uses "pay as you go" and spends the money on other things, like battleships. Therefore, to make any use of this windfall, it is necessary to save it, invest it, and use it for retirement. Just doing that much might redirect the other 30% of the withheld tax to its intended purpose. So the economic effect would be considerable, just by stirring around in that corner of it.