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NOTES ON THE EVOLUTION OF A MEDICAL SPECIALIST : 1907~1965 BURRILL B. CROHN, M.D.


NOTES ON the EVOLUTION of a MEDICAL SPECIALIST

1 9 0 7 ~ 1 9 65

by B U R R I L L B . C R O H N , M .D .


Second edition published by

THE BURRILL B. CROHN RESEARCH FOUNDATION For a complete bibliography, please contact The Burrill B. Crohn Research Foundation at: Division of Gastroenterology Mount Sinai Medical Center One Gustave L. Levy Place New York NY 10029–6574 Edited by Ruth Crohn Dickler and Abby Pratt; designed by Sam Pratt

© 1984 & 2010 BY THE ESTATE OF BURRILL B. CROHN


CONTENTS

Introduction I. II.

Early Education and Internship

1.

Private Practice

31.

III.

A Scientific Career

61.

IV.

Inflammatory Diseases of the Intestines

89.

V. VI.

Later Years

105.

L’Envoi

115.

Epilogue

117.


INTRODUCTION

Just a few years after the turn of the last century, my grandfather, Burrill B. Crohn, having graduated from medical school at Columbia College of Physicians and Surgeons in New York City, began an internship at The Mount Sinai Hospital there. It was 1907, and the available diagnostic tools, procedures and drugs to identify and treat illnesses were, by today’s standards, nothing less than bare bones. “Baba,” as I knew him until his death at the age of 99, never stopped trying to improve on that. Eventually, he and two others at Mount Sinai wrote a paper describing regional ileitis, now known as Crohn’s Disease. It was his best known achievement; but hardly, as you will see if you read on, his only one. The republication of this brief memoir of practicing medicine in the Olden Days is an attempt by his family and the Burrill B. Crohn Research Foundation at The Mount Sinai School of Medicine to bring to the latest generation of medical students, interns and residents, as well as practicing physicians and lay readers, a vivid picture of how medicine has evolved over the last century. Burrill Crohn was a Renaissance man: in addition to his contributions to medicine, he loved and collected paintings and sculpture; he listened with great pleasure to classical music and


taught others to appreciate it; he read and read and read— especially about the Civil War; he grew vegetables and fruit at his house in Connecticut. “Here,” he used to say as we were leaving after a visit to his country place. “Have some currants. Good for constipation.” If that isn’t the sendoff of a great and generous gastroenterologist, I don’t know what is.

ABBY PRATT

West Stockbridge, Massachusetts October 2009


{I} EARLY EDUCATION AND INTERN YEARS

T

O M Y S U RP R I S E , a personal question came from the floor:

“Is it true that for years you attended all the autopsies at Mount Sinai?”

Questions were, of course, welcome at the panel discussion following the reading of papers at a meeting of the American College of Physicians. In my previous experience, however, these queries were always of purely scientific portent. The realization that there was interest not only in my lecture, but also in me, my training, my experiences impressed me. But writing these memoirs has not been an attempt at autobiography. It is the story of the phenomenal development of medicine—and particularly gastroenterology—from the beginning of the 20th century to the present. I was there at the beginning, and these are recollections of practicing medicine through those extraordinary years. Today the lay public and the medical profession do not, cannot realize how primitive were our means, how limited our diagnostic armamentarium, how completely devoid we were of the modem therapeutic drugs. In my first professional decade (1903-1911)


there were no transfusions, no intravenous infusions, no sulfonamides, no antibiotics. Not even as simple a drug as aspirin was commonly used to reduce a fever! We had to rely on primitive x-rays and on crude anesthesia. Medicine has moved from “clinical” to scientific. Born and nurtured in an atmosphere of education and religious orthodoxy, my interest in a medical career came about quite naturally. The years at the College of the City of New York awakened my scientific interest. American medicine was a field in which a bright boy could hold his own and possibly attain eminence that was impossible in the Europe his forebears had so recently left. In much of Eastern Europe during the 19th century all professions, as well as farming and land owning—almost all vocations with the exception of money lending and peddling— were proscribed for Jews. My father, Theodore, born in Posen, Germany, was typical of the young immigrant who adapted quickly and well to the ways of the New World. He established businesses in Central City, Colorado and Rockdale, Texas. But when the time came to raise a family, my parents returned to New York City and settled down. Bringing up 12 children—six boys and six girls (one sister died at 13 years)—on the earnings of a Wall Street broker, on “eighths and quarters,” as his trade was termed, meant that while we had all the necessities and lived well, we lacked luxuries. My mother, Leah, had a gift for music and a genius for motherhood. A natural soprano, she sang at Temple Emmanuel on Saturdays 2.


and at St. Bartholomew’s Church on Sundays. She sang in Walter Damrosch’s Oratorio Society. She sang at home. Her big soul loved children, loved all people. As many as we children were, her spirit folded us all in her embrace. She died in 1923 of acute gangrenous appendicitis, peritonitis taking her life in those days before penicillin. I gave her the last injections of morphine so that she would not linger in agony. At the age of 13, I passed the citywide examination for admission to City College. In 1902, at the age of 18, I graduated as a Bachelor of Science. But my education was very broad. My father did not believe in spoiling his children with pocket money. He considered my 50 cents carfare a week a goodly sum. City College was at 23rd Street and Lexington Avenue; we lived on East 82nd Street—60 city blocks, or three miles, away. If I walked I saved a nickel! A nickel bought two pretzels and at least three over-ripe bananas for lunch. That bit of austerity served two ends—it was healthful, and it was pleasant to walk three miles with my schoolmates every day. What’s more, it taught me the value of a nickel. City, a public college, was a fine institution with every opportunity for intensive study. In my day the president, “Prexy” to us, was General Alexander S. Webb, the brigadier general who had held the “Bloody Angle” against Pickett’s Brigade at the Battle of Gettysburg in 1863. He was an austere, awesome man who brooked little breach of discipline. The training was superb, particularly in mathematics, humanities and languages. While waiting for admission to medical school, I joined my classmates to earn some tuition money. Every day there were 3.


absentee teachers in the public school system, and this was our opportunity. As a substitute teacher we could earn three dollars a day! One was lucky to be on the spot early enough to gain a day’s work. I once met my old classmate Felix Frankfurter, the late renowned Justice of the U.S. Supreme Court, on such a mission. The College of Physicians and Surgeons of Columbia University accepted my baccalaureate diploma without question. Nobody asked me about my background, my religion, my interests—I was in! And an excellent school it was. Attempting to help pay my medical tuition ($400 a year) by teaching English to foreigners in night school was an ambitious scheme and not too successful. Something happens to memory when you overwork and under sleep. Study of the intricacies of anatomy and the complexities of physiology required full-time concentration. Throughout the last two years of medical school, the subject of biochemistry held a big attraction for me. Under the guidance of Professor William J. Geis, my colleague Fred S. Weingarten and I carried out a research project on the biochemistry of experimentally induced intra-abdominal hemorrhage. In addition to our M.D. degrees, this work earned us an M.A. and a Ph.D. But the M.A. parchment cost $25, and the Ph.D. cost $35. My father had been sufficiently encumbered with my essential expenses: I had no heart to ask him for the extra fees. The thesis was accepted and published. The laboratory experience was most rewarding, and the training invaluable. The parchments were dispensable. Looking back, it is interesting to reflect on changes. That time-consuming piece of research required two years’ work. 4.


Today the entire project could probably be finished in weeks. In 1910, a calcium or a potassium estimation might take days of precipitation, washing, drying, incinerating and weighing on a most delicate balance scale. The methods used—or we beginners— were so inaccurate that every procedure had to be performed in duplicate to ensure against error. Today the flame photometer can closely estimate most minerals in a half hour without any human effort. The cumbersome, hotboiling Kjeldahl estimation for nitrogen that took hours when I was a student has been replaced by a simple calibrated procedure. Obstetrics was taught in a very practical manner. Third- or fourth-year medical students were sent to deliver, on their own, parturient mothers in the tenements nearby the Lying-In Hospital on 18th Street and Second Avenue. My first experience was most difficult for the mother-to-be and me. The patient went into labor but was having a hard time delivering her first child: labor continued all the first day, through that night, all the second day and into the second night. The family were foreigners—we had no common language. The tenement was dirty and bug-ridden. It was hot, humid and trying. On duty one was not supposed to sleep; at any rate, the insectivora made it impossible to lie down. My coat and hat hung from the chandelier, the one place inaccessible to the arthropods. Every six hours I reported to the hospital by messenger: for ten cents a street urchin would carry my status report. An extra few cents brought me a sandwich. Hour after hour passed with little progress. As yet no technical assistance from the hospital was offered or deemed necessary—I was truly on my own! 5.


The morning of the second sleepless night exhaustion overcame me. Seeking some cool fresh air at about dawn, I retired to the fire escape outside. Leaning back against the wall of the house, I fell almost instantly (though unwillingly) into a sound sleep. Apparently my head fell forward on my chest, for some short time later I was awakened by a gentle stream of warm fluid on the back of my neck. Just then I heard a woman’s voice above me shout: “Shame on you, little boy, to pee on the doctor!” Help finally arrived in the form of the Emergency Squad from the hospital. The baby was safely delivered by forceps in the hands of an expert. My job was to hold a candle. Demoted, from chief deliverer to torchbearer! Another incident illustrates the mores of those days. This time the home delivery of a very quiet and attractive woman was easily accomplished. The next day I made my rounds and visited the woman and her lusty baby. The second day I noted that the woman looked drawn and the baby was clawing incessantly at the breast and screaming. Was it, perhaps, unsatisfied hunger? “Have you had anything to eat?” I asked. “Oh, yes,” she said. “Are you sure?” No answer. My suspicions were awakened. The cupboard was absolutely bare. Suspecting just plain poverty, I hurried down and bought milk, bread, butter and eggs to cover the immediate famine. Passing downstairs through the tenement hall into the vestibule, I saw a group of middle-aged women. They were gesticulating and talking loudly. I stopped to explain to them the predicament upstairs and to beg for their help. No answer—only a cold silence. 6.


By experience I knew that in any grave medical emergency, when women like these were appealed to, they would solicit one dollar from each apartment until $25 was collected to send for a bearded consultant or other necessary aid. But no appeal in this case seemed to evoke a response. Finally, one woman spoke scornfully in answer to a direct question: “She has no husband!” “Oh, I see!” An illegitimate child. The woman’s lover had deserted her. With her last resources she had rented the room for her delivery, far from her home and from critical eyes. How different from today. A proper internship is sine qua non to a good scientific medical career. The Mount Sinai Hospital in New York City had a splendid record for achievement in scientific research, as well as for its staff of attending physicians and surgeons. Its renown awed a beginning intern. Gossip had it that only those related to the president of the hospital or in the family circle of a trustee had any chance whatever of achieving the prized internship. I had neither of these social qualifications, but my classmates at the College of Physicians and Surgeons adamantly refused to go up for the competitive examinations unless I accompanied them. They overcame my timidity. Eight internships were open; there were 120 applicants! We three musketeers—Murray H. Bass, Morris Munker and I—made first, second and third place for a two-and-a-half year mixed internship, medical and surgical. There was still one more prize position open. An internship in pathology was to be appointed, again by competitive oral 7.


examination, for an extra year of service in the various laboratories. All applicants were extremely intelligent; all answered the questions correctly. Dr. Emanuel Libman, conducting the examination, seemed stumped for a choice. Suddenly, assuming a crippled pose, bent to one side and dragging half his body, he stamped up and down the room. “What disease does this gait suggest?” Nobody answered. Then my hesitant voice spoke up: “Spondylitis rhizomelique” (a rheumatoid inflammation of the vertebra, also known as Strumpell-Marie’s Disease). He was apparently astounded because the disease was so rare. “How did you know?” he asked. “I read it in Striimpell,” was my answer. Striimpell was the German textbook equivalent to the American Osler we had used throughout medical college. The fact that a New Yorker could and would read the German as an accessory to Osler’s classic gave me the prized position. Thank City College for its excellent language teaching staff! The pathology internship, which preceded the medical period, was probably the finest possible background for a scientific career in medicine. Bacteriology, surgical pathology and autopsies were all part and parcel of my duties. We were unpaid. The only salaried position was that of the chief pathologist, and he generously donated his salary to the hospital. Volunteers worked part time to assist in the heavy routine of that large and busy institution. The work and our exceptional findings were constantly surprising. After 6 p.m. the laboratories were all mine, and I often stayed on till 2 a.m., which was my closing time. I learned to sleep only six hours a night. 8.


In those days, with only crude x-rays, without precision instruments or the modem technical achievements of biochemistry, the only check on an obscure diagnosis was by exploratory operation or, if the unfortunate patient died, by autopsy. Exploratory abdominal operations were commonly practiced as a necessity to prove or disprove a diagnosis. Now the procedure is, for all practical purposes, a relic of the past. An autopsy was always exciting, the clinical men vying with each other to foretell the exact pathological diagnosis, competing and crowding toward the front of the autopsy room to get a better view of what was to be found in “Pandora’s Box.” Consent for autopsies was difficult to obtain from many of our patients. The Orthodox Jews were usually adamant about defiling the body. Autopsies were therefore “stolen,” occasionally surreptitiously, through a recent surgical incision or by other devious means. Once, egged on by the intense interest and sadness of the intern staff at the loss of a young woman after a thyroid operation (thyroid crisis is fortunately no longer a crisis), I was able to perform a full autopsy through the six-inch incision in the neck. Probably the most exciting incident of this rewarding year was the case of an old man whose high temperature baffled all the clinicians. It was my job to enter the wards and take the blood cultures. On the second day, when viewed under the microscope, his culture media were swarming with large gram-positive bacilli, completely unfamiliar. The bacilli were not motile, were not encapsulated, were like nothing I had encountered before. Punctually at 2 p.m., Dr. Libman, who because of his exceptional ability doubled as associate pathologist and associate physician on the wards, entered the laboratory. In a moment he decided that 9.


what I was viewing was glanders bacillus, Malleomyces mallei, an organism producing a fatal infectious disease in horses. Since it involved the respiratory tract, it could be caught by man and was invariably fatal. The proof of the diagnosis was to inject the culture material into a male guinea pig. If after two days the testicles became swollen (the Straus phenomenon), the test was positive. Because glanders was so easily communicated, the head of the laboratory warned me that any breach of carefulness, any fault of technique, any breakage of utensils would not only threaten my life and that of the staff, but would necessitate closing the laboratory for days of fumigation. The patient was transferred to the isolation ward, and I, of all people, was assigned solely to his medical care. When the end came for the poor man, the Board of Health, which had been notified, insisted upon an autopsy. In this case, there being no relatives or friends, there was no hindrance. But who was to perform the autopsy? I insisted that Dr. Libman was too valuable an individual to risk his life. He maintained that he was responsible to my parents for me and therefore would not let me take such a risk. (What an amazing statement and attitude this is, compared with today’ s impersonal teacher-student relationships in our supposedly better, bigger “modem” teaching hospitals!) A compromise was reached—we both performed the autopsy, gowned from head to foot, hooded, gloved and masked. We saw intimately, for the first time, a case of human glanders. The important aspect of the case was, of course, the mode of transmission. How did this old, bearded pushcart peddler, who 10.


spent his days in the ghetto streets selling his wares, contract the disease? How, when and where was he exposed to glanders? That was a vital concern of the Board of Health. The immigrant in those days was usually very poor, often without a roof over his head. The owner of a warehouse trucking concern, a stranger, had kindly given the peddler permission to sleep in the stable loft. One of the horses had been coughing and sick— unrecognized glanders! The hay had become infected. The sleeping man was exposed and paid with his life. My publication, “Positive Blood Culture in Human Glanders,” was the first in medical literature to deal with this phenomenon. Sunday mornings were occasionally given over to the transfusion of blood from donor to patient. No way was known at that time to prevent fresh blood from coagulating in minutes. The obsolete method employed was to insert a tube into the artery of the donor and into the vein of the recipient. A human chain linked the two. Blood from the donor was drawn with a syringe, quickly handed from intern to intern and infused as rapidly as possible. If the syringe used was of 20 cc. capacity, this primitive performance had to be repeated fast, fast, fast, 25 times, to achieve the necessary 500 cc. of blood. Each time a fresh sterile syringe was used; at the end the recipient was weighed accurately—the difference in weight before and after transfusion represented the amount of blood gained. It took all morning. What a crude, costly and tedious performance for both patient and doctor! In 1914, Dr. Richard Lewisohn (Lewisohn’ s method of indirect transfusion) of our staff devised the method of adding a small amount of sodium citrate to blood drawn from the donor, 11.


thus preventing coagulation of blood outside the body. The fluid could then be run into the vein of the recipient at a leisurely pace, by gravity. This simple and safe procedure was one of the epoch-making discoveries in medicine. It is impossible to estimate the lives it saved. Equally valuable were the introduction of intravenous saline and other life-saving infusions (in 1904 at Mount Sinai), whereby fluids could be entered into the vein of the patient by gravity, hour after hour. Before intravenous therapy we often lost two or three children on a hot night in August from so-called cholera infantum—infantile diarrhea and dehydration. After Nathan Straus’s successful campaign for laws requiring the pasteurization of milk and with intravenous therapy, the “summer complaint” was overcome. These lives were all saved. Internship is always very arduous. We 34 interns covered the duties of that large (for its era) hospital of 400 beds. We received no salaries, only upkeep, board, uniforms and laundry! No married man could serve and, of course, no women. Social intercourse of any kind whatever between staff doctors and nurses was absolutely forbidden. To be seen in the company of a nurse outside the walls of the hospital meant the end of both careers. What a temptation it was—those charming, well educated nurses in their long dresses, most of them fresh, pretty, pink-cheeked country girls. There were transgressions: we were human. Opportunities were few—we worked six-and-a-half days a week with only one night off for visiting family and friends. Besides, the girls had to be in, behind the locked gates, by 10 p.m. The curfew was enforced. I was in love with a girl from Michigan. Despite our differences in background and religion, we might have married. But in her 12.


second year of training she developed a severe cold and cough. She was sent to the nurse’s dormitory and examined by the Big Chief with his stethoscope. He heard rales, or crackles, at the base of her chest, posteriorly, when she coughed. A diagnosis of incipient tuberculosis was made by stethoscope—there were no chest x-rays in those days. Although Mount Sinai’s first x-ray machine was purchased in 1900, and there was a separate x-ray department after 1901, those early films were mostly for diagnosis of broken bones. A tentative clinical diagnosis of tuberculosis was, perforce, final. Cassy was sent home to Michigan, her career as a nurse ended and, eventually, our romance. The travesty was that she never had tuberculosis! In the vernacular of today, it probably was only a “virus.” Cassy and I corresponded for quite some time. She married a wealthy, much older man who was eager and able to wed her, tuberculosis or no tuberculosis. Shortly thereafter she gave birth to a retarded child. What a tragedy! Cassy spent the rest of her life nursing and caring for her child. One of the most brilliant interns was indiscreet enough to write a personal letter of affection to one of the probationary nurses. The letter was discovered; both were abruptly dismissed. (He was later acknowledged—elsewhere—as a most successful surgical specialist.) Such a restriction was not peculiar to our institution. It was generally accepted and enforced at all similar hospitals. We were, in addition to our other hardships, obviously supposed to take monastic vows! Education is the essential word in medicine. We learned by osmosis, by listening carefully to every word dropped by the chiefs, by our own discussions and experiences. Formal lectures or 13.


formal conferences were practically non-existent. Each department now is headed by a full-time professor whose main function is administration and teaching. The modern intern and resident must attend lectures and demonstrations given by the attending staff. Students are spoon-fed by constant on-the-spot instruction. A hospital with a university affiliation is required to teach. Whereas the primary object of the hospital was once to care for the sick, the education and training of young members of the profession have now taken a position of at least equal importance! One can well imagine what this necessary program of education does to inflate the annual budget of a medical center and how this is reflected in the expanding cost of medical care. During our internship, Murray Bass and I lost our best friend, one of the Three Musketeers who had entered The Mount Sinai Hospital in 1907. Morris Munker was a brilliant student from Steubenville, Ohio. He was taciturn, conscientious and able, but little given to unnecessary conversation or the lighter side of life. Morris seemed to be fading away. He was obviously losing weight and appeared listless. Both symptoms grew increasingly severe and could not possibly be ascribed to study or overwork. We, his close friends, suspected diabetes in a severe progressive form. Morris denied our suspicions. We put our heads together and demanded that Morris give us a urine specimen. He brushed us aside, first with an amused refusal and then, after repeated urgings and pleadings, with, “Leave me alone, for Pete’s sake—I told you, no!” Soon Morris lapsed into a diabetic coma. We catheterized him and withdrew a urine specimen loaded with sugar. The end was 14.


inevitable. This was before insulin, and adolescent diabetes in the severe form was fatal. Morris knew what was wrong with him from the beginning. His fortitude, his sterling quality kept his fatal secret from us. We mourned his loss but admired the character and strength that hid from us his knowledge until almost the last moment. Duties on the ward service were strenuous. Sleep was at a premium. One worked six-and-a-half days a week with one night off. No pay, no emolument. At the end of two-and-a-half years of service we received a munificent bonus of $50 and a little black bag containing the few instruments absolutely essential to start a practice. (How different from today, when interns are paid a minimum salary from the start, and residents and senior residents are paid a living wage for themselves and a beginning family.) The interns spent the morning feverishly “working up� the cases, particularly the new admissions. Promptly at 2 p.m. the attending physician or attending surgeon strode into the ward and began his rounds, surrounded by his entire staff. The discussions were usually on the highest scientific levels, often brilliant, and the intern was encouraged to offer his original view. One learned by listening, by observing, by discussing. Unlike today, there were no didactic lectures. On Wednesday of each week one attended the pathological conferences at which autopsy and surgical pathological material were presented and discussed. Here was the final evidence on the clinical case previously studied. Happy the face of the intern who had been correct in his diagnosis; unhappy he who had missed the point. As an intern my attention was attracted by the high incidence of old injuries among the male Russian immigrants in our wards: a 15.


clumsily amputated thumb or index finger, a stony case (scar tissue) in one eye, a complete loss of hearing in one ear. Later I understood: these were instances of self-inflicted mayhem in order to escape 25 years of compulsory military service in the Army of the Czar! During ward service as senior intern (1910-11 for me), fall was usually the most difficult season. It might find us saddled on a single service with as many as seventeen very sick cases of typhoid fever. In those days there were no antipyretics in general use to reduce the 105° to 106°F continuous fevers which lasted days. Before the introduction of antipyretics the only way to reduce fever was to immerse the patient bodily in a portable tub of cold water—the so-called Brandt baths first introduced in Germany. To immerse such an utterly sick, stuporous patient required two porters, one or two nurses and an intern to stand by in case of shock from a too sudden drop in temperature and blood pressure. Every four hours the immersion was repeated. Throughout the night the intern was awakened, had to dress fully in his uniform, repair to the ward and stand sleepily by. Fortunately, just about this era or shortly thereafter, antipyretics [fever reducers] came into general use—antyipyrine, acetanilide, pyramidon and particularly the safer aspirin. With one tablet of aspirin, temperature could be reduced safely. Aspirin had been synthesized in 1856, but to me, as an intern, its use as an antipyretic was quite new. It was the rule, since the time of Galen, to treat diarrheal cases (of which typhoid was one of the most severe) by strict limitation of all solid food and to forbid even milk. Patients were fed, when they could swallow, only pea soup and “slops” so as to avoid 16.


so-called irritation of the small intestine, the seat of the typhoid plagues. Coleman and Schaeffer had just published their work advocating a complete reversal of this program. They urged full feeding, up to 3,500 calories a day. Permission was granted to me by Dr. Nathan E. Brill, the attending physician, to try out the program on our ward. Special nurses were assigned to feed these stuporous, almost semi-comatose patients full meals, fever of 105째 Fahrenheit notwithstanding. It was an interesting and profitable experience. The course of the fever may not have been shortened, but our patients, when convalescent, were not skin and bones. They survived better nourished and with less weight loss, and they made a more rapid and satisfactory recovery. The importance of vitamins was just starting to be appreciated and reported. Perhaps, beside the full nourishment, the more adequate quota of vitamins in the forced diet was the real answer. The intern, young as he was, was supposed to carry full responsibility for his patients. We were under the learned guidance of our attending physicians and surgeons, who visited the hospital during afternoons or mornings. Otherwise, we were on our own and had to resolve the intricate problems of emergencies. The woman in Ward K was my responsibility. She had severe ulcerative colitis, uncontrollable diarrhea and, as a complication, ulceration and clouding of the cornea of her eye. She was admitted from another hospital as a hopeless case. In that institution she had been maintained on a liquid diet devoid of milk. It was either during or just after World War I, and the foreign 17.


literature was interesting. During the War the supply of milk to England from the Danish herds of cows had been cut off by submarine warfare and epidemics of xerophthalmia (Dry Eye) had been noted in the English population. Correctly, this was now being attributed to lack of vitamin A. The patient was immediately given a full diet, with milk and cream. In a matter of days, to the surprise of the ophthalmologists, the corneal complication cleared and the corneal ulcer healed. Complete vision was restored. Not only the eye, but miraculously the whole woman became well and stayed well for the rest of her life. She became a friend to me, and I became her idol. Every year in June, on my birthday, she would appear from far-off Long Island with two boxes of the most perfect strawberries imaginable from her own garden patch. Every year after her illness this was a ritual—the happy smile, the presentation of the strawberries with a kiss, the assurance that she was well with no recurrence of her colitis. Then, in June 1960, she did not appear. I dreaded to phone, but it was all too true. She had become an old lady and, unhappily, had passed away. Who says that ulcerative colitis cannot be cured? There may not be many such startling and durable cures, but a sufficient number exist to give hope for a miserable disease. Did not God save Sodom and Gomorrah for the sake of a few righteous? One Saturday night when I had been assigned to the Emergency Reception Ward downstairs, the telephone awakened me and a harassed voice requested my immediate presence. Before entering the ward, I could hear the bellowing of a madman. He was a powerfully built young individual—drunk, obstreperous, unruly 18.


and belligerent. Any attempt on my part to take a history, to examine him, to even take his temperature was met with resistance. Getting him under control was the immediate problem. The nurse on duty was a young student—pretty, charming, but completely nonplussed. Nevertheless, the wild man seemed a bit less hostile to her than to me. I asked her if she would consent to “play the game� for me. I wanted her to entice him with all her feminine charm and attempt to draw his attention away from me while I sidled up with a hypodermic. She consented and acted her part well. She approached him with timidity, but with quiet concern. She fondled his forehead. She rested her arms about his shoulders. He seemed mesmerized by the perfume of her hair and the shapeliness of her figure. Meanwhile, I approached from behind with an overload of the strongest sedative we had in our pharmacy chest. As he was about to throw his arms around the enchanting nurse I plunged the needle through his nightshirt into his flesh and administered the drug. Before he could bellow he was asleep and moved to the main ward. Nine nights later I was awakened by an urgent call to come immediately to Ward C. Dressing rapidly, I rushed down, and as I approached the corridor noted that the door of the ward was closed. Something most unusual must be happening! Outside were huddled all the nurses and two male orderlies; from inside came the bellowing of that raving, maniacal voice. Quickly I surmised what had happened. Having been very sick with pneumonia, the patient had been under constant sedation and without whiskey. Regaining consciousness after the crisis of the pneumonia, he had suddenly developed delirium tremens and was hallucinating. 19.


I was implored by the nurses and orderlies not to attempt single-handed to quell him. Nevertheless, relying on the sense of authority that I presumably carried, and expecting him to recognize in me his physician and friend, I entered the ward. He was standing stark naked, six feet of powerful virility, wielding a large, heavy, glass inkstand. I approached slowly, but I admit fearfully, and looked him straight in the eye. When I was within three feet of him he raised his weapon and said, “One step more and I’ll brain you.” He meant, I am sure, just what he said. I backed out of the ward. I could see those patients who were half ambulatory cowering under their beds. The completely bedridden patients were huddled under their blankets. No one made a sound, but the smell of fear was in that ward, and even in the dim night light I could see panic in the eyes riveted on me. In this critical situation, even at 3 a.m., only the director of the hospital could advise me. To awaken him at that hour was truly an act of temerity, and his answer was, “Doctor, this is your responsibility. You are in charge of the ward.” Shortly after a telephone call to the nearest police station, the clang of a police car was heard in the entryway. A lone old reserve cop slowly ascended the stairs. Remonstrances were in vain. “You are old; he is young and powerful and terrifyingly insane. Alone, you can’t possibly overpower him.” “Show him to me,” was the calm response. He entered the ward alone, dignified and absolutely self-confident. He approached the maniac with slow steps. “Put it down,” he ordered, “Put it down!” In a trice the man dropped his weapon. “Follow me.” And quietly, without turning around, the officer walked out the door, the man 20.


silently following. As the officer passed me I fell in step with him and asked softly, “How did you do it?” “The buttons,” he said, pointing to the gilt buttons on his uniform, “The buttons.” Such is the influence of authority! In my senior year as an intern we had the honor and excitement of a visit from Sir William Osler, the great Canadian clinician. Invited by Dr. Libman, we made clinical rounds of the medical wards with the author of the physician’s bible. The impressions of the day, the details, remain as vivid as if it were yesterday. Osler’s clinical acumen, his diagnostic ability, his broad experience made him unsurpassed as a diagnostician in his day. And always, with a touch of medical history, he made references to the great masters of the past. If I learned nothing else that day I learned from him that on palpating an abdomen, if one felt the spleen one could rule out a neoplasm or malignant growth. Two years later he repeated his visit, calling me by my name, as if he could remember my insignificant self! (Years later, when conducting graduate courses for Columbia University College of Physicians and Surgeons, my most popular and oversubscribed course was “On Abdominal Palpation.”) I can never hear the name of the great William Osler without recalling a humorous incident, well authenticated, told by his students. Traveling through Europe, he reached Leyden in Holland, visited the famous library of the University and asked the librarian if he would allow him to view the copy of the Bible annotated by the very hand of Erasmus, the Renaissance scholar whose edition of the New Testament from the ancient Greek into vernacular Latin is renowned. 21.


This was a rare and extremely valuable manuscript. Osler expressed great appreciation for the privilege extended to him. The librarian was puzzled and asked, “How does it happen that an Englishman [sic] knows of this ancient treasure which is in our possession?” Osler answered simply, “I read it in the Baedeker coming up on the train.” One of his students, hearing the story, suggested that this was just another of Osler’s humorous remarks, since Osler was so very learned. They looked it up: sure enough, it really was in the everyday Baedeker. A few years later, after a meeting at the Academy of Medicine, Dr. Libman asked me to drive him and William Henry “Pop” Welch, the great pathologist of Johns Hopkins University, and Fielding H. Garrison, one of the great recorders of medical history and medical events, to the University Club. Never was I so impressed and overcome as with the precious cargo in my little Ford. That night I learned a lesson. In the course of conversation with Dr. Garrison, I said that the classical Greeks did not possess a musical scale. Later, seated at a piano at the University Club, Dr. Garrison discoursed in a most erudite way on early Greek music, confounding me greatly for speaking carelessly on a topic that was beyond my ken. Rare cases appeal to the house staff because of their unusual interest and because they relieve the routine of the daily round. A man in Ward C, Bed 17, was running a peculiar fever. His temperature would rise higher and higher each day for seven days and then would drop, by crisis, to normal. The man would then be well for several days, when the cycle of rising fever and eventual 22.


crisis would repeat itself. Blood counts, taken from blood drawn from his fingertip, gave no clue to the nature of the patient’s infection. In those days we had no special hematological laboratories, and the blood counts were routinely carried out by the youngest and often the least experienced member of staff. My curiosity was aroused. I did the next blood count myself and, searching the glass slide, saw what were apparently numerous small scratches on the stained glass. Thinking that the slide was an old one, possibly scratched in the course of repeated scrubbings, a brand-new slide was taken and the process repeated. There again were the thousands of small bodies. Each day I would repeat the examination, and as the fever rose these strange bodies increased by the millions. The day after the next crisis, with the abrupt drop of temperature, these unusual bodies had disappeared. Relapsing Fever was a disease rare in this country, if ever seen at all, but common in Russia and called Famine Fever. It was transmitted by the human body louse. Now, finally, we knew we were dealing with an extreme rarity. The “scratches” on the glass slide were Obermeyer’s spirillum, Borrelia recurrentis, a spiral bacterium somewhat similar to the spirochete of syphilis. No one could be readily found who had seen such a case to verify diagnosis. A call was made to the New York Board of Health, which in turn referred us to the immigration medical authorities. Yes, one of them had had such an experience. They would send him. The next day, respectfully awaiting the honored guest, I saw a dignified old man mounting the steps, clad in a high hat, cutaway coat, striped trousers and carrying a gold-headed cane. The last was the insignia of age, experience and success typical of a British 23.


gentleman. Yes, during the Civil War, in 1863, when he was serving as commissioner of Immigration, he had seen a case of Relapsing Fever in a Russian refugee. Our case was identical and verifiable. The smirks, the raillery of the younger staff members who had doubted my diagnosis were stilled. The patient made an uneventful and complete recovery. Another rare experience was the study of two patients with Rat-bite Fever who were admitted to the ward service almost simultaneously. The bite of a rat, usually on an extremity, is followed by an ascending infection of the limb, with swelling of the regional lymph glands in the groin or the axilla, continued fever and pain. The actual bacterial or other direct etiologic cause was then unknown. The symptoms resembled, though distantly, the ascending infection of the lesion of syphilis and gave rise to my scientific conjecture that perhaps this, like syphilis, was a spirochetal disease. It had been only in 1905 that the German bacteriologist Schaudinn had demonstrated that syphilis was caused by a spirochete, a spiral-shaped bacterium. Specialists were summoned, and we attempted to prove, by microscopic examination, my hypothesis regarding rat bite. The reasoning was sound but the microscopic examinations were fruitless. No luck. One day, on the 86th Street crosstown trolley, I met Dr. Hideyo Noguchi, the famed pathologist of the Rockefeller Institute. In the course of conversation I related our interesting problem. Like most Japanese, he was non-committal, yet smiling, and evinced interest but offered no opinion. I suspected he knew more than he was saying. A few weeks later the Japanese Medical Journal 24.


announced the discovery of the spirochetes that were the etiologic agent in the production of Rat-bite Fever! Why had we failed when our reasoning was so logical and the methods employed so correct? Because ours were old cases, ill for weeks before they came to us. The spirochetes were found by the Japanese only in the cases tested immediately after being bitten. Rat Bite Fever was common in Japan since babies slept in open cribs in bamboo-like huts, and rats frequently attacked the sleeping children. My only satisfaction was the request, complied with, to write in a large medical encyclopedia the authoritative, up-to-date article on Rat Bite Fever in this country—all on the limited experience of two old, attenuated cases. Another incident illustrates how alertness and persistence can save a life. A man was admitted to the ward as a case of typhoid, running continuous fever, stuporous and apathetic. But many of the requisites for a diagnosis of typhoid fever were missing. In the course of a very complete physical examination it was noted that the man had a “running ear,” associated with an old, chronic mastoid infection. Suspecting a possible meningitis or brain abscess, a tap of the spinal fluid was made. No turbidity was apparent to indicate infection. It would seem that my suspicion was unfounded. It was probably typhoid fever after all. The surgical staff was notified and summoned in consultation, but the young surgical intern scoffed at my far-fetched hypothesis. I could not sleep that night, thinking of this sick man. At midnight, with my pass key, I wandered over to the laboratory. Though not then on service in the laboratory, and actually intruding, I knew 25.


from my long experience where to locate the flask of spinal fluid. Under the microscope, streptococci could already be discerned in the spinal fluid culture. I needed to find a surgeon immediately, for a brain or spinal infection was a true emergency. It was the Fourth of July weekend, and everybody but the basic staff was away for the holiday. It has often been said, and was true then as now, that one can easily die unattended in New York City over a holiday weekend! In this case, since the mastoid was apparently the source of infection, the operative field belonged to the Ear, Nose and Throat service. We reached by phone the Associate Attending Surgeon, Dr. Seymour Oppenheimer, at Red Bank, New Jersey. It was 1 a.m., and Red Bank was 30-odd miles away, with transit facilities at that hour almost nonexistent. (In 1909-10 the automobile was still unusual, and the roads primitive.) Dr. Oppenheimer flagged the milk train, rode the caboose to New York, and arrived at about 4 or 5 a.m. The emergency intern staff was routed from bed. By good fortune, good luck, good judgment and technique, or a combination of all four, the skull was trephined (opened with a cylindrical saw) and the introduction of the first probe entered a brain abscess. The recovery of the patient was immediate and complete. Did I receive great commendation for a smart diagnosis? No! On Monday, charges were brought by my medical attending physician against the surgical staff for neglect and procrastination. Counter charges were brought that I had not been sufficiently impressive and convincing when stating what I thought was the diagnosis. The Trial Board of Attending Physicians and Surgeons were all close personal friends. The verdict was “a curse on both your houses� and a mild whitewash reprimand to each of us. 26.


How precarious is the career of an intern! The patient who was carried in on a stretcher and placed in Ward C one cold, wintry morning presumably had tuberculosis of the larynx and was suffering much pain. He was extremely hoarse and had great difficulty breathing. His distress touched me deeply, and I prescribed a solution with codeine for his pain. Within minutes of his dose an alarm message reached me. The patient was in serious condition—pale, blanched, almost unconscious. His life seemed to hang in the balance. Panicked and apprehensive, I telephoned my chief, the venerated Dr. Libman. He said he would take a taxi to the hospital immediately. By the time he arrived the paroxysm had passed and the patient had revived. It was a false alarm, fortunately. No one could offer an explanation. Weak and weary, I pondered this phenomenon. What in the mixture could have produced the near-fatal catastrophe? My scientific curiosity was aroused. After some days I decided to dilute the mixture several times to observe its effects again. The solution was now so weakened that its administration would be absolutely safe. But to my dismay, the same phenomenon repeated itself, only slightly less severely. Terrified for my patient’s life, I telephoned Dr. Libman. This time he refused to come; he said the responsibility was mine and mine alone. Next day he suspended me from rounds for two weeks. Why this strange reaction to codeine? In those days we knew little or nothing about allergy. It was only years later that I again encountered a patient, this time a woman, with an allergy to codeine. After an infinitesimally small dose she went through the same critical seizure. I then understood the episode in Ward C years before. 27.


In recalling my years as an intern I remember being concerned and impressed with the importance of the “crisis” in cases of lobar pneumonia. Today antibiotics control the infection so promptly that the crisis—the severe critical period around the seventh day—is never reached. The temperature drops by lysis, that is, slowly and continuously. In 1910, a pneumonia patient in Ward C, Bed 16, was approaching crisis, and I left strict orders that I was to be notified immediately when it arrived. During the next morning’s ward rounds Bed 16’s temperature was normal. The man had survived the crisis, and I had not been notified during the night. The night nurse was, of course, off duty by that time and could not be reached. But I was angry and threatened, in a temper, to bring charges against her. The day supervisor calmed me down and urged that we wait until 7 p.m. to give her the opportunity for self-defense. As she entered the ward that evening I was waiting. I lit into her: “Why did you not let me know of the pneumonia crisis? You had your orders, distinctly stated. What kind of neglect is this? It might have had serious results!” She quietly replied, “I did let you know,” “You did not!” “I did,” she reiterated, rather too warmly, “and if you wish to see them, I can show you your own orders.” With this she opened the order book and to my astonishment produced the page, written in my own handwriting at 4 a.m., clearly stating that I had ordered a hypodermic injection of caffeine, strychnine and digitalis. To say that I was nonplussed was a great understatement. Apparently, as was the custom and the rule, the orderly had 28.


entered our staff bedroom, shaken me quietly by the shoulder, and produced the note from the night nurse. In my sleep, so it seemed, I had written the orders. It had been automatic, and from long experience the orders were correct. I had no memory whatsoever of the whole transaction. Hard, continuous work, long hours, disturbed nights, exhaustion—and yet, a subconscious, routine efficiency that left absolutely no memory. My face was red, and my apology swift and humble. The nurse was gracious—she, too, found the story hard to believe.

29.


{ II } PRIVATE PRACTICE

A

F T E R T H R E E -A N D -A -H A L F Y E A R S , the intern must give

up the protective atmosphere of the hospital that has been his home and the sole center of his scientific (and, for that matter, social) activities. The outside world beckons and must be faced. The intern must now be ready and willing to stand on his own two feet, to make his own unaided decisions and willynilly to earn a living, modest though it may be.

A tiny room in Manhattan, sublet from a friend, became my home and office—a room just large enough to allow for examination of the occasional patient, a couch serving equally well at night for sleep. One or two dollars was charged for office examinations, two to five (!) dollars for an outside call. The first year’s earnings were $940; the second year’s, $1,450—total. But fortune graced my first year. I was engaged as part-time assistant to a general practitioner with a very large and lucrative practice who needed an assistant with some special laboratory experience. The mornings were occupied as a volunteer assistant at the biochemistry laboratory at The Mount Sinai Hospital—a fascinating job. It consisted of examining the routine biochemical

31.


tests and allowed sufficient time for such research as presented itself. In addition, I was placed in charge of a medical outpatient clinic three afternoons a week—as well as having to earn a living wage in between. While very new in practice, I was called by the hall boy across the street to a medical emergency. Entering the apartment, I found rolling on the floor a completely nude female, frowsy and disheveled, brandishing a large kitchen knife and obviously totally intoxicated. “You Jew doctor, you get out,” she cried hoarsely at me. It was not very difficult to disarm her. Her sister and I put her to bed; she slept off her drunken state. We became the best of friends, and for years thereafter I visited this former patient and her husband for bridge and fun. However, the alcoholism became a serious problem. I warned her about alcoholic cirrhosis of the liver. Her husband now agreed to abstain from liquor completely if his wife would do the same. The experiment was a complete success: in six months they were allowed very moderate social drinking, which they never exceeded. It was a singular and striking example of a personally conducted rehabilitation. During my first or second year of practice, 1911 or 1912, a young man approached me with a proposition. Would I take care of his parents, who lived in the Bronx, and accept an annual fee of $100? The parents seemed to be in good health on my first examination, and $100 was, in those days, a huge amount of money. Within a month’s time the father had a stroke and was critically ill. It was my obligation to take care of him, and naturally, in those days, in his home. Twice a day I had to visit the old man, each visit 32.


having the following itinerary: 86th Street crosstown trolley, Ninth Avenue smokey elevated train to 155th Street, across the Harlem River Bridge on foot and a trolley up the steep hill to Pinehurst Avenue. Then a return trip by this same arduous course. How many hours I spent caring for this old man and restoring him to health would be difficult to estimate. After about three weeks I met the son and asked him, with some hesitancy, whether he did not think I should be more liberally indemnified. “No,” he said, “a contract is a contract.” And that’s where it remained until the end of the year! In 1912, after only two years in the practice of medicine, I married Lucile Pels. I was attracted by her beauty and her ability to play Beethoven’s Appassionata Sonata. A little black-haired, blackmoustached doctor with a little black bag, I was not made very welcome by Lucile’s affluent family. We had two children, Ruth and Edward, now a fine medical internist in his own right. Our marriage was not a happy one; I partially blame my preoccupation with medicine. My wife could never understand why I had two or three house calls to pay after dinner almost every evening; why the days were spent at the laboratory; why I had to spend every leisure moment for two years writing Affections of the Stomach, published in 1928; why there was no time for me to join the family for vacations. In 1927, we decided unhappily on a divorce, and we chose Paris in order to escape any implications of scandal. Of all the farces, a French divorce was about the greatest. My so-called residence in Paris for the previous year, was, of course, fictitious, as was my adulterous liaison there. 33.


After the divorce, I plunged into work. Several of my confrères intimated that Mount Sinai would never tolerate a divorced person on its staff, such was the prejudice of the day and the stigma attached to divorce. I am happy to say that this was not the case. The subject was never mentioned by my superiors. The First World War found me in a very embarrassing position. World history had always been my avocation. Whenever I was fatigued by medicine, I could always find intense interest and diversion reading Macaulay, Motley and above all Gibbon’s Decline and Fall of the Roman Empire. Chekov said, “Medicine is my lawful wife and literature my mistress,” and I felt similarly regarding history. Besides which, being a Civil War buff, armies had always held a fascination for me. But I was badly situated. Financially, I was at the very beginning of a career, and not only without any family or friends to fall back on for money, but on the contrary loaded with responsibilities. My rich father-in-law was a proud German, who not only would not assist me but threatened my wife, his only daughter, and my newborn child with starvation if I fought against his countrymen. Four of my brothers enlisted immediately. But my father, over 70 years of age, was losing his grip in the stock market and calling on me regularly, not only to make good his losses but for active support. The First Mount Sinai Unit (Unit A) left for the front rapidly. I handed in my name and did volunteer work for the Second Hospital Unit. Fortunately, the war ended before the formation of a second unit to serve abroad. It was still wartime when I learned that my friend and patient, Bert Morse, on a motor tour through the Berkshires, had been 34.


seriously injured in an automobile accident. The car had skidded and crashed against a stone piling. Bert had broken ribs and was in shock; he had been taken to the Sharon Hospital in Connecticut. How he had escaped death was beyond comprehension. He was about 56 and a bachelor. He was an insurance broker of sorts, but he had inherited wealth that took the edge off necessity and permitted him to work when he liked and loaf when the urge overtook him. He was a good-natured fellow, witty—not too wise—but an attractive and sympathetic personality. Answering the urgent call to Bert’s side meant driving the 115 miles there in my little car. When I arrived I found him suffering from traumatic pneumonia—pneumonia induced by concussion and chest injuries. He was very sick and my duty to patient and friend was obvious. Every day for the next week I left the city in the late afternoon, motored to Sharon, saw and left orders for my delirious, fevered patient, and either slept in a ward bed or returned to the city late at night. There were, in 1917, no highways in the modern sense, but I was young. Physical effort meant little to me, and I was very fond of Bert. One factor, however, did produce complications in the situation. Bert was a bachelor, with lots of girl friends. Two were resolved to show their love by going to Sharon to see him. It took Machiavellian diplomacy on my part to keep them from paying him visits at the same time. I told one of his admirers that visiting hours were in the morning only; another, that only the afternoon was available. Happily, never the twain did meet! After five days I knew Bert was due for a crisis, and a crisis in lobar pneumonia is truly a crisis—one which decides whether a man will live or die. That night I slept at the hospital and had a 35.


conference with the Sharon physician who was also treating Bert. My Connecticut associate said, “Sit down. I have something to tell you. At midnight tonight I must leave the country. My convoy for the war zone sails in the morning. Your patient Bert Morse is not going to make it through the crisis. Since you are a New York physician and not licensed to practice in Connecticut, you cannot legally sign the death certificate. I shall make out a certificate of death, filling in the details, sign it, and leave the date blank for you to fill in.” We parted, and I spent the night and all of the next day at the bedside of my very sick patient. Bert did make it! He passed the crisis successfully and made a complete recovery. For years thereafter, Bert would proudly show the certificate to his friends, the date still blank. It was some time during the First World War that Mr. Teitlebaum brought me his wife, Rachel, as a patient. She had severe gall bladder disease and needed surgery. Mr. Teitlebaum was a very busy small businessman, who, as I remember, made and sewed buttonholes in Brooklyn. Yes, he gave his vocation as “buttonhole maker.” Apparently, the war effort required many buttonholes. Mr. Teitlebaum was very reluctant to consent to the operation; he could not risk the life of his beloved Rachel. Was there risk? Was there great danger? Was the operation absolutely necessary? What great surgeon would do the operation? Finally, after much emotional verbiage, Mr. Teitlebaum (I don’t think I ever knew his given name) consented on one condition: I, personally, would guarantee his wife’s life and the success of the operation. Any hesitation on my part would have convinced him not to try surgery at all. Under the circumstances, I gave my guarantee. 36.


With Dr. A. A. Berg as the surgeon—and he was a great surgeon—and me alongside, I felt the” guarantee” was legitimate. Rachel was taken to a comfortable room in the Private Pavillion at Mount Sinai and duly operated upon. The post-operative period was unfortunately beset with complications—such complications as were common in those years, what with the crude anesthesia and the lack of antibiotics. Three days later she developed postoperative pneumonia; she was running a moderate fever, but she was not dangerously ill. A week later, emphysema (pus in the pleural cavity) developed, and a second operation, again not dangerous in itself, became necessary in order to drain the cavity in the chest. During all this time—about two weeks—Dr. Berg and I were in constant attendance. But nothing could equal Mr. Teitelbaum’s staying power. He seemed to live at the hospital. Whenever, and no matter how often, you entered the sick room, he was there; and it took far more time, patience and self-control to answer his flood of questions than it did to examine and prescribe for the patient. “How’s the pulse? How’s the fever? How’s her appetite?” and so forth and so on. Each time he ran the whole gamut of vital signs as if he understood their significance. But he did love Rachel, and we were bound to understand and tolerate him even if he was irritating. As day after day passed, Mr. Teitlebaum became an increasing nuisance. It was a chore even to enter the sick room if he was there—and he was always there! One day during the third week I met Dr. Berg coming out of the sick room. “See here, Dr. Crohn, if you don’t get rid of that Mr. Teitlebaum I won’t go into that room. He drives me crazy with his questions! I just can’t take it any longer.” With that he angrily 37.


strode away. As I entered the patient’s room I was surprised to find no Mr. Teitlebaum. Evidently Dr. Berg had laid down the law. Three days passed and still no Mr. Teitlebaum. A miracle! That afternoon as I left the sick room and strolled down the corridor, my attention was attracted by an odd phenomenon: the door of the men’s room seemed to be opening automatically, at a very slow rate, then closing again. I stopped to look and behold! The grizzly head of Mr. Teitlebaum slowly protruded through the crevice. The face was greasy, covered with a three-day beard, the hair disheveled, the clothes unpressed. Mr. Teitlebaum emerged, looking surreptitiously up and down the corridor to see if his enemy was anywhere. Beckoning, he drew me out onto a fire escape. “Dr. Crohn, do you know what has happened? That Dr. Berg, he sent me a bill for $500! $500! You see, Dr. Berg is to me like a stranger, but you ….” Drawing me over by the lapel of my coat, he said, “You are to me like a friend. So, do me a favor. Lend me the $500 to pay Dr. Berg!” Rachel recovered and went home. My guarantee had been made good, and eventually Dr. Berg was paid, and, I presume, so was I. In 1922, I moved my office to 1075 Park Avenue, a new apartment house. The ground floor was fitted out as a spacious set of rooms, including a small laboratory and a large x-ray department. Short, pudgy Dr. Samuel Goldfarb was my radiologist, and an excellent one, too. When we moved in, one of my confrères was heard to remark, ‘What self-respecting doctor would select an office on Park Avenue north of 86th Street?” Below 86th Street, Park Avenue was “plush,” like Harley Street in London; above it were no apartment buildings or homes de luxe. In fact, however, 38.


almost immediately, upper Park Avenue became one of the most desirable locations for a doctor’s private practice. When the ten-year lease expired, the Depression was upon us and a renewal of the lease without an increase in rent was greedily accepted by the landlord. I remained there until almost 1960. Special appointments for five o’clock in the afternoon were always suspect, but this request was made by an influential friend. We were alone, the lady and I. She was well advanced in years, somber, dressed all in black, with a small, pinched face, delicate hands, a hat drawn down tightly over her head. She spoke little and haltingly. She was ill. Her symptoms, as she described them, seemed vague. She had only one request: Could I send her to The Mount Sinai Hospital? There, so she had heard, they possessed “radium water” that could renew and prolong life and health. It was a strange request: radium water was a vague concept fostered by newspaper stories. At any rate, it was essential to determine whether she was really ill or just neurotic. In the examining room, she declined to undress, but upon my insistence finally did allow a partial examination. My attention was immediately attracted to strange looking lumps in her neck, lumps that resembled enlarged lymph glands. On palpation it was obvious that they were not enlarged glands. “What is this?” I asked. “Paraffin,” was her answer. At the moment, it seemed better to reserve comment and proceed to uncover her chest. The atrophied breasts had lumps in them built up by paraffin. The shins and thighs had been made plump by the insertion of paraffin. Cautiously, the information was elicited that the cosmetic attempt had been carried out in Paris. 39.


She was admitted to a private room at Mount Sinai. When I called on her to prescribe orders, I entered a darkened room. She lay in bed, fully clothed. Angrily, I rang for the nurse who disclosed that all orders, all importunings had been in vain. The patient simply would not undress and had ignored all other orders. What kind of psychoneurosis were we dealing with? Was this an anxiety state, and was the enlarged liver in any way responsible for her strange, neurotic behavior? At any rate, we had no “radium water,” and she was so resistant that it was impossible to penetrate her silence. I transferred her to St. Luke’s Hospital, where she was among friends, and washed my hands of an enigma. At St. Luke’s, she died a few weeks later. Only then did I hear the true facts underlying this bizarre case. A brilliant nephew, her sole relative, was an author of note who wrote for current periodicals. At the time of his death he was feverishly preparing a manuscript for publication. It was his custom to write all night; in the morning his aunt would find the hand-written pages thrust under the door of her bedroom. She would then spend her days typing. One night, seeking refreshment, he broke his routine of working steadily until daylight and took a stroll in the cool night air. He was accidentally killed by a stray bullet. The grief-stricken aunt, in a pitiful attempt to perpetuate her nephew’s memory, had bought his apartment. The rooms were left exactly as they had been his last night—the books open, the pen where he had put it down, the ashtray unemptied, the unfinished cup of black coffee—were her private memorial to their life. Her Paris experience was bizarre self-delusion. She had hoped that with paraffin treatment the creases of old age in her neck 40.


would be erased; the breasts stand out like a virgin’s of seventeen; the thighs, no longer spindly, would, she hoped, be like those of a fashion model. This self-delusion was to be perpetuated now by drinking “radium water“ to extend her years and make her “youth” everlasting. It was a strange though harmless psychosis. I recalled H. Rider Haggard’s weird tale, “She Who Must be Obeyed,” about the queen who lived forever by the light of a living fire. When the spell of the centuries was broken, she died and her “body” instantly became a mummy. On Friday nights, in my childhood home, my mother would light the candles to greet the coming Sabbath—four white candles, two for her mother and two for herself. We children would sit around the table while Father read several chapters from the Bible, the five books of the Pentateuch. It was difficult for young ears to concentrate on the “begats” and the interminable Semitic names. Our attention would wander. The main source of interest to us children was speculating on which of the candles would stay lit the longest. They would flicker, die out, flare up again, until, finally, it would seem that the last one would never be extinguished. When I was a grown man and practicing physician the tenaciousness of one of my patients made me recall the seemingly eternal flame of the candles on our Sabbath table. The patient was an Italian nobleman, or so I thought, a man of culture and breeding. He spoke no English and lived in a modest hotel in midtown Manhattan. He had come for help in an obviously terminal condition: advanced, inoperable and hopeless cancer of the esophagus. Emaciation was far advanced; the growth in the 41.


gullet made the passage of solid food impossible. He was maintained on intravenous feeding and watched night and day by a nurse chosen because of her Italian heritage. Fortunately, the patient suffered little pain, and morphine assuaged his discomfort. His face was drawn, his distinguished beard gray. He lay most of the time with his eyes closed, but I am sure that he was perfectly aware of the nature of his illness and faced the inevitable with intelligent composure. He had only one request, often repeated: he must see his son-in-law, his partner and companion in business, before the end. We had cabled Genoa and, as the end approached, we knew that the son-in-law was sailing to America. Day after day went by, with the situation steadily worsening. Finally, we heard that S.S. Cante Verde would soon arrive in the lower harbor. The police had been alerted: a motorcycle squad would be at the pier and rush the traveler through the congested city streets. I was waiting at the hotel, counting the minutes. The younger man arrived and went to the bedside. A faint, almost imperceptible smile stole over the sick man’s countenance. His eyes lit up, and at that same moment, the pulse flickered and he died. Such is the power of will to maintain life against all odds. The last man to survive in a group of shipwrecked castaways is, no doubt, the one with the most indomitable will to survive. What a powerful moral is in this tale! There is no doubt but that the man knew his end was near; the very administration of last rites was significant to a devout Catholic. How often and when, if ever, does a physician admit to a sick patient that his illness is terminal? The patient is practically never told; the family always is, in confidence. 42.


Few people can take even a guarded or discouraging prognosis with equanimity. The slightest hesitation on the part of the physician, a doubtful look on his face, may throw the patient into a panic, particularly when the possibility of a malignancy exists. Only the strongest minded or those endowed with great religious faith will ask for and can accept the verdict of inevitability. The physician must know his patient, however. There are some few patients who find it easier to hear and accept a poor prognosis than to be fed palliative half-truths and lies. These people sense the falsehood, and it leads to distrust of the doctor when complete confidence is essential. It is the patient’s life, after all, and if he is still ambulatory, yet has only three or six months to live, it should be his right to settle his affairs and spend those last months in any manner he chooses. One such patient was an old rabbi, full-bearded, his face wrinkled with care, a Talmudic scholar, no doubt. Whenever one entered his room he had his Book of Psalms, his Tefillin before him, silently reading. We spoke little; rarely did he ask a question or a favor. One day I entered his room and stood at the bedside, studying his face. Quietly, he ceased praying and looked up. “Shall I live?” I hesitated a moment, feeling that this philosophic man truly wanted to know his destiny, and make his peace with this Maker, I shook my head, “No.” He gazed at me for a moment, but a moment only. Then his eyes dropped. There was no change of countenance to indicate shock or even to show that he understood the finality. He resumed the reading of King David’s Psalms. During and after the First World War, fortune was good to me, and I attracted a large clientele from South America, particularly 43.


from Peru. Strange, how one favorable case can lead to a large, enthusiastic following. A boy of 17 was sent to me from Lima for treatment of simple constipation. He was a very wealthy orphan, who saw no reason why he should work or study—or even move his bowels! He was made my ward; I, his mentor and legal guardian. He was lazy and indolent, but absolutely charming. He flunked out of the Peddie School in New Jersey; he flunked out of Princeton. During the summer, he was sent to Kennebunkport, Maine, for a change of scene. I would occasionally visit him at his swank hotel, but not stay the night—Jews were not accepted as guests at that hotel. Eventually, he outgrew my tutelage, and returned to Peru when he was 21 years old. Years later, I met him in Lima, a middle-aged man, a scholar, an archeologist, author of a two-volume book on “Human Life Zones.” Never despair of the young, the dropouts. Many of them are late bloomers and create for themselves a very successful career. As a result of my popularity in far-off Peru, I was offered a professorship in medicine at Lima University with a guaranteed salary of $100,000 a year. The hitch: I would be expected, of course, to convert to Catholicism; otherwise, what kind of a social life could one expect? Once, as a special favor of friendship, Dr. Grana—“Pancho,” as we called him—asked me to accompany him, his older brother and his sister-in-law to the Mayo Clinic in Minnesota. Dr. Grana’s sister-in-law was to be operated upon for a chronic gall bladder ailment. (The Granas were truly grandees of old Castillian heritage.) As it was a slack summer period, and a trip to the Mayo Clinic was always educational, I agreed to go along. 44.


The woman’s surgery was successful, and she was making an uneventful convalescence. Entering her sickroom daily, I was struck by the absence of the almost conventional display of cut flowers and plants, so routine with us “enlightened” Americans. Thinking it a nice gesture, I purchased a beautiful bouquet of flowers and had them sent to her room. Next day, no acknowledgement. Nor was there any during the several days thereafter. Finally, I asked the nurse whether or not the flowers had been received. “Oh, yes,” she said. “Would you like to see your flowers?” With that, she drew me into the private bathroom and suggested that I bend down and look under the tub. There were the flowers, all crumpled and withered. Why? The nurse explained that Dr. Grana, entering the sickroom just ahead of his dignified brother, had spied the flowers and quickly ordered the nurse to hide them. His alertness had avoided a duel! In his country, a jealous husband would not tolerate a man’s surreptitiously sending his wife flowers. Other times, other manners! In contrast to the sadness and anxiety that characterized the majority of any doctor’s cases, that of Mrs. Lewen offered a bit of comic relief. Mrs. Lewen was a widow. Her husband had come to this country from Hungary. He was a waiter, a caterer and, eventually, he built up his own prosperous restaurant. His untimely end left his widow financially well fixed, but unprepared for the practical parts of life. She was a woman, wife and the mother of his two grown sons, and to him that was enough! Mrs. Lewen was lost without her Adolf, and the boys were no help. On the contrary, they were heavy liabilities. The elder, 45.


about 23 years of age, was supposedly a ticket agent for a theatrical concern. The younger, whom I shall call Eli, was a ne’er-do-well, untrained for any significant job. He had merely a grammar school education and was unable to concentrate on any long-range objective. But he was the light of his mother’s eye and could wheedle money from her wholesale. One afternoon I received an urgent call from Eli. His mother was very sick, possibly having a stroke, and my presence was requested tout de suite. As I entered the rather de luxe apartment, hysterical weeping from the bed chamber was plainly audible. Mrs. Lewen was pacing the floor, bewildered and completely helpless. I entered the bedroom, closed the door, sat down and listened to a not-unusual tale of domestic infelicity. Obviously, she was not paralyzed—she was thrashing her hands and feet, moaning and crying. After a time, she quieted and assumed some semblance of self-control. She was sure she was having a stroke. Would I tell her son that she was? I had just broken the news to his mother that he was getting engaged to the daughter of a distant acquaintance, but he was proposing to marry out of the Jewish faith. Mrs. Lewen, who had never previously demonstrated any concern for religion, whose life had been spent in the world of good food and epicurean living, suddenly discovered her heritage. She was adamant, angry, screaming and hysterical. Assured that she had suffered no stroke, she agreed to control herself and allow me to treat her, but only on the condition that I tell Eli that she might have had—or would have or could have— a stroke if the marital plans were not cancelled. The Riverside Nurses’ Registry said they would send over a nurse 46.


immediately—to leave these two alone was out of the question. The nurse, a Miss O’Connor, arrived promptly, a cheerful young woman who, in uniform, seemed pleasant, intelligent and probably able to understand or at least to minister to the physical wants and emotional needs of my patient. My instructions were given at the bedside—food, rest and medication were discussed. My only private admonition was this: “Miss O’Connor, you are not to discuss with the patient or anyone else any personal matters that led up to this situation. You may discuss the news, the weather, the food; you may talk about your own personal affairs, but not the personal affairs of the patient.” And with that I left. The next day at three o’clock, I made my daily visit to the Mrs. Lewen. Miss O’Connor was off-duty for the four hours of the afternoon. Repeated knocks on the bedroom door were unanswered. I cautiously entered to find Mrs. Lewen lying with her face to the opposite wall, huddled up, covered up, not moving. “Good afternoon,” I said, cheerfully. No answer. Remembering Elijah chiding the prophets of Baal, “Call him louder, perchance he sleepeth,” I called more loudly. Still no answer, but I knew she was awake—she was in a fighting mood, making herself obnoxious. “Mrs. Lewen, please turn around and talk to your doctor. Tell me what has happened, and what your troubles are.” She sat up abruptly, her eyes blazing and thrust her face at me. “Did you tell that nurse to talk to me?” I said I had. “Even to tell me her own troubles? Did you not? Do you, doctor, know what are her troubles? I’ll tell you,” she said, almost spitting at me. 47.


“She is engaged to marry the son of a rabbi in the Bronx, and the rabbi won’t give his consent!” What were the chances that the nurse’s troubles would so closely coincide with those of the patient? One in 10,000? One in a million? Consultations in hospitals other than my own often fell to me. Brooklyn particularly beckoned. In spite of the complexities, I soon learned my way around that borough and could drive without difficulty to any of the better-known hospitals. It was late one evening when a request for a consultation came, and it was very, very urgent. It would be almost midnight before I could reach the hospital, but they agreed to wait. This was a case of hepatitis—inflammation of the liver with jaundice. The patient, a young woman, was semi-comatose, deep yellow in color, with a high fever. She had been ill for only a short time. Returning by ship from a holiday in Mexico, she had eaten what was purported to have been a tainted sandwich, and soon became very ill. She was truly moribund. The family had been notified that there was no hope—my visit was simply to back up the staff and assure the family that everything known to science had been done. I could add little but solace. Walking toward the exit, accompanied in courtesy by the staff, I was thinking that some of the details of the history did not satisfy me. What could there be in a sandwich that could cause this illness? Better to discard this explanation as gossip. Suddenly an idea struck me. She was returning from Mexico. Malaria was rife in that country, and I knew that there was a form of Mexican malaria so severe as to cause fatal hepatitis, or even 48.


“black water” nephritis (kidney trouble). It was long after midnight, but I asked whether one of the staff—just as a favor to me—would prick her finger and examine the blood for malarial plasmodea. Next morning a courtesy message from the staff at the hospital informed me that they had followed my suggestion and had found the blood specimen to be teeming with the malarial plasmodea. An intravenous dose of quinine had been given immediately, and by this morning the patient was sitting up in bed, eating breakfast with gusto! If I remember correctly, my charge for the midnight visit was $50, which the family protested was an overcharge. It has been my misfortune (or perhaps my fortune) to spend most of my professional life as a student of constipation or diarrhea. Sometimes I wished I had chosen ear, nose and throat as a specialty rather than the tail end of the human anatomy! Constipation in a domestic or wild animal is a serious, often fatal malady, but the same does not apply to the human animal. A daily bowel movement is most satisfactory, but not essential. Sir Arthur Hurst, in his book on constipation written years ago, recounts cases where normal persons relieved themselves once in a few days or once in one or two weeks and yet remained well. But for the neurotic woman or man, with a bitter taste in the mouth and queer pains all over the abdomen, a regular daily bowel movement is a sine qua non for happiness. How often have I repeated the jovial axiom, “There is nothing in the Constitution of the United States that guarantees the right 49.


to a daily bowel movement.” On the other hand, all those cases of colitis and ileitis are dominated by diarrhea, sufficient to bedevil one’s mental composure. They have led me at times to exclaim: “When I die, I hope to be sent to a Heaven where even the angels are constipated.” The cathartic industry is one of the oldest and largest in the history of medicine. A perusal of the labels on advertised drugs hawked by itinerant peddlers of the last century, before the Pure Food and Drug Act became effective, will show that the main ingredient in remedies for the cure of spring fever, tiredness, poor blood, or depression was a cathartic ingredient such as was contained in Lydia Pinkham’s Pink Pills for Pale Ladies and the many varieties of high-proof “vegetable” compounds, There is no excuse for habitual constipation. It is entirely due to poor exercise, irregular habits and diets that do not include sufficient roughage. Let me cite two cases. The first was an overweight, middle-aged executive, a cigar smoker and heavy feeder, who complained of habitual constipation to his physician, the venerable Dr. S. J. Meltzer. That sage suggested the following: buy eight marbles and one reeler (for the new generation, let me describe the “reeler” as a shining, semi-translucent, oversize marble employed as a “shooter”). The eight marbles were to be placed in a line at the far end of the bedroom. The patient was to take his stance at the near end with the reeler and shoot at each of the eight marbles until he had hit every last one. This, of course, necessitated shooting, walking, retrieving the reeler, etc., bending each time he shot. 50.


I asked the patient whether this had worked. “At first, it worked fine. But later it failed. I was soon able to hit each marble at the first try.” The second man was a Wall Street broker who lived in New Jersey on the rail line. He had learned a solution for his constipation. “Every morning,” he explained, “I take the Delaware, Lackawanna and Western Railroad at 8:00 a.m. to the Hudson River Terminal at Jersey City. Then I take the Desbrosses Street Ferry to the pier in Manhattan. Then I walk from Desbrosses Street to the Exchange, and I’m still in time for the opening gong at 10:00 a.m.” “Good,” said I. “A fine, an excellent solution.” Then a thought came to me. “What do you do on Sundays?” A long pause followed. I waited, for he was evidently embarrassed. “On Sunday, I take the 8:00 A.M. train to Jersey City, the Desbrosses Street ferry, etc., etc.” He was back home in time for a game of golf! Dealings with insurance companies, with the courts and with litigation often place a doctor in embarrassing difficulties. The doctor, even if a specialist, can be confused and made to seem uncertain and contradict himself in the hands of a skilled lawyer. Most physicians are unwilling to undergo the ordeal of court testimony and lack the self-confidence to maintain their composure and clear thinking, competent as they are, when being cross-examined by an attorney whose profession is to attempt to disconcert the expert. When I was still in general practice, in 1930, I was forced against my will to testify for a patient who had fallen on the icy pavement in front of her apartment and was suing her landlord for negligence. Because I was her physician, I knew she was an old syphilitic, that 51.


her gait was uncertain, her memory poor from advanced cerebral arteriosclerosis. I tried to beg off, but her lawyer sent a subpoena. A cantankerous, officious attorney was cross-examining me with a volume of Osler’s Textbook on Medicine open before him. He read a passage from the famous book. “Do you agree, doctor?” “No,” said I curtly. “I’ll read you then another passage,” said the attorney with irritation. “Surely, doctor, you agree with that!” “No.” “Doctor, you recognize this as the standard textbook on medicine. I read from it and you disagree?” “Yes,” I replied. At this point the judge asked me to explain how, if I considered the book authoritative, I could deny its contents. “Because, Your Honor, that textbook in the hands of the attorney is an old edition, quite out of date.” The attorney slammed the book closed and said, “The doctor is excused.” How did I know at the distance separating the witness box from the attorney, that the book in his hands was an old edition? Simple! The new editions of Osler were bound in green; the old bindings were dark red! Miss X was a spinster, with a small face, slightly greying hair and a slim figure. If anything, she seemed prim. She was secretary to a physician who occupied adjoining offices, and we had some professional acquaintance. One night, about midnight, the telephone rang. To my complete surprise, it was Miss X. Could I come to her apartment immediately? Not could I, but I must come! She offered no information other 52.


than her address, refused to answer my questions and, in an emotional voice, repeated: “You must come now!” This was a rather startling request. I was not going to put my neck into a noose by going alone, after midnight, to the apartment of an unmarried woman—a single man myself, divorced and not yet remarried. I decided to call upon the nurse in our x-ray department, a widow who was both intelligent and understanding, to help me out of this awkward situation. I phoned her, asking her to be dressed and ready to accompany me on a house call as soon as possible. She was waiting on the steps of her apartment house when I arrived, and as we drove she tried to pry some explanation from me. But I was as perplexed as she was. When we reached the modest apartment, Miss X was in a dressing gown, hair in disarray, face taut, obviously repressing extreme anxiety. She could hardly compose a sentence. As she stammered, we followed her to a bedroom. The body of a man wearing evening clothes—white tie and tails—lay on the floor. He was well past middle age, bald and portly. It was not necessary to seek a pulse or examine his pupils or hold a mirror to his nostrils. The man was dead. “He” had been to a banquet, had eaten well and drunk liberally, had visited her apartment before going home, complained of indigestion and keeled over without another word. In order to help in so serious a situation, it was essential for me to know his identity. Finally, and very reluctantly, Miss X disclosed the name of an eminent scientist whose name and reputation I knew well. The necessary legal steps of notifying the police and the coroner’s office had, of course, to be taken immediately. But how were we to cover up the scandal? 53.


My call to the Police Department brought a cop of middle age, probably on reserve duty. He entered, quickly took in the situation, understood and agreed to cooperate, as much as he could. Naturally, the coroner’s office had to be notified in any case of sudden death. But, not knowing the dead man personally and not having been his physician, I was in no position to sign a death certificate or assign the legal cause of his demise. Miss X did know who his regular physician was—one of my old instructors. He hesitated to answer my cryptic telephone request that he pay an urgent house call, but after I identified myself he did remember me as his former student, and complied. By the time he arrived, the coroner’s representative was there. We four held a conference. It was agreed to take the body to the nearest police station and that the story be given out that he had been found by the police on the sidewalk, prostrate, had been transported to the station house, stated the name of his physician and expired. His doctor and friend, having treated him previously for high blood pressure and coronary symptoms, was permitted to fill out and sign the final certificate by an understanding and sympathetic coroner who waived the legal requirement that he had seen the patient within the last 24 hours. The laudatory obituaries, the pomp of a chapel burial, the notices in the papers impressed both those of us who knew the truth and those who would never know. Thank the Lord for an understanding police force and for an intelligent and knowing coroner’s office! Never had I so much appreciated the quick comprehension, tolerance and cooperation of our civic forces. Every doctor loves to be appreciated for his efforts to alleviate distress and cure by his skill and judgment. Sometimes—in fact, 54.


often—gratitude is withheld. But on the other hand, the physician is often credited with too much. He is smothered with love and adoration evoked by his bedside manner more than by professional competence. The doctor who treats the human being and the disease is the physician rightfully appreciated. The doctor who talks to family and patient, who takes the time to explain, to give a favorable prognostication is the one who approaches the standards of a Hippocrates or a Sydenham, the “English Hippocrates.” Under the strain and pressure of our modern lives, with the daily round of irritating cares, this often become nearly impossible. Our old-time G.P.s who knew their patients and their families routinely met this standard. Our modern-day specialists rarely do. This particularly is held against the surgeon who has little time or inclination for conversation. An elderly lady who appeared at my office as a new patient, on being asked the routine question concerning who had referred her, said: “My sister, Mrs. Warwick. Doctor, don’t you remember her? You saved her life 20 years ago!” I was very curious to see how I save lives. The secretary produced the old, faded history: “Diagnosis: psychoneurosis. Treatment: phenobarbital.” Rather early in my practice a little man from the Bronx consulted me. He was not well-dressed or well-educated, judging by his speech. A quiet person, he wore an expression of perpetual worry and gloom. His hands were those of an industrial worker, and I suspected he pushed a needle in a sweat shop or in some part of the needle trades. His complaint was simple: he was very nervous, very sleepless, very weak. Would I write him an affidavit to take to his union declaring that he was too sick to work? I explained that this was 55.


not possible: if I wrote such an affidavit for everyone who was not physically ill but was nervous and claimed to be unfit for work, we would soon empty the shops of workers. He left my office, very disappointed. Next day, I received the following letter, written in a large and careful hand on a piece of lined paper: Dear Doctor: Yesterday I saw you at your office. I asked you to give me an affidavit to my union because I am so nervous I can’t sleep. I am so nervous I can’t eat. I am so nervous I can’t talk. Please write me an affidavit. I can’t work because I am so nervous. Yours truly, Abraham Cohen P. S. If you want to know, it’s things like this that make me nervous On a very warm August day my newest patient was announced— a middle-aged woman, well dressed, attractive. Before she would allow me to proceed taking her history, she asked with apologies what the charges were likely to be. This was rather unusual, for a woman of her apparent circumstances, but not unwelcome by me. “What is your husband’s business?” I asked. She answered, “He is a baker.” “Under such circumstances,” I replied, “your bill will be moderate,” and I quoted a figure, which she immediately accepted. Two days later, as she was leaving the office, a sudden downpour occurred. She started out of the door without an umbrella or a 56.


raincoat when I demurred, “You cannot go out in the teeming rain like that! Wait a moment, and I’ll get you an umbrella or a taxi.” I held her arm and called the secretary to bring an umbrella. The patient seemed disconcerted that I insisted, but raising the umbrella, she held it over her head and turned the comer. At that moment a magnificent chauffeur-driven car pulled up to meet her. As she opened the door of the car she turned to me and said, “I suppose you think I told a lie?” I said nothing. She volunteered: “You asked me what was my husband’s business, and I truthfully answered, ‘He is a baker.’ He is a top executive of the National Biscuit Company. I can still remember a pneumonia case under my care when I was an intern. I lavished much solicitude and personal care on the patient in Ward C, Bed 18, until the crisis of his illness had passed and he was well on his way to recovery. He was discharged after a two-week convalescence, and I happened to be standing on the steps of the hospital when I spotted him, dressed in his now oversized street clothing, slowly coming down the long corridor. I was delighted to see him now able to leave the hospital, well at last. I smiled at the man, but he came closer and finally passed me without even a nod of recognition. My anger flared and, catching him by the shoulder, I said: “Mister, don’t you know I saved your life?” That was perhaps an exaggeration, but I felt I deserved at least an “E” for effort. He paused, looked at me coldly and said, “You didn’t, God did.” He was probably right. God or Vis Medica Matrix Maturae— natural curative forces—or such therapeutic science as we had in that day. 57.


Occasionally I have been asked if I ever encountered anti-Semitism in my professional career. “No, of course not,” was my immediate response. It seemed such an unnecessary inquiry. Of course not! Then the memory of a long forgotten incident occurred to me. The executive board of one of the national medical societies was to hold its semi-annual meeting in Pittsburgh. As a member of the committee, my presence was expected. The eight other committee men had been professional associates for many years. My instructions from the chairman were to register at the Hotel Port Duquesne in Pittsburgh, where a message would be waiting for me. On arrival, I found myself alone—the only committee member registered there. The message informed me that early the next morning the committee would call for me and transport me to a nearby club, where the business proceedings would take place. This was a strange situation. They were all staying at the club while I was alone at the hotel. There could be only one explanation: club regulations forbade that I, a Jew, lodge on the premises. Only a day visit would be possible. I can’t say that my annoyance was very great; in fact, I was more amused than hurt. Reviewing the names of the committee members, I found that, as a group, they did not impress me. They were not a very progressive lot, but rather routine practitioners. Deadwood, I decided, about to be replaced by my more enterprising younger generation. I slept well. In the morning, my associates called for me. We spent the day at the golf club very busily and pleasantly: morning meeting, lunch, chatter, more business all afternoon, and then dinner. We were all in good humor. Dinner, an excellent one, was served. This happened to be during Prohibition but, besides the pocket flasks 58.


which the waiters carried, the meal included an excellent wine. Everybody appreciated the wine. It seemed to me, however, that the taste was somehow reminiscent. I was curious and asked the waiter to bring me the bottle for inspection. I unfolded the napkin and discovered that the label read: “Kosher Wine for Pesach.� It was the sacramental wine drunk at Passover services.

59.


{ III } A SCIENTIFIC CAREER

T

H I S C E N T U R Y I N M E D I C I N E —the

20th century—is characterized by study of the physiological bases of our modem theory of disease. Its biochemical sub-strata, its radiographic appearance have been succinctly elucidated. Today the American Board of Internal Medicine recognizes “The Sub-Specialty of Gastroenterology.” National and international societies devote research to developing all aspects of a true scientific foundation for the cure of this group of diseases. At The Mount Sinai Hospital, the establishment of the Wimpfheimer Ward for the Surgical Treatment of Diseases of the Stomach and Intestines (1917) gave a remarkable stimulus to work in this broad field. But as early as 1913, a specialized division of the Out-Patient Department had been assigned to Dr. Edward A. Aronson for the treatment of gastrointestinal disorders. My job as a young assistant to that internist lasted for only two years. He confronted me one day with the loss of my job. I was non-plussed and embarrassed but rapidly reassured: “Young man you are too good for this job. You have a scientific career ahead of you!”

The biochemical laboratory was already presenting research problems. Everywhere there were questions to be answered, clinical problems on the wards calling for special investigation. 61.


My “Pancreas Period” dated roughly from 1913 to 1921. The study of the functions and diseases of this organ occupied a great deal of my time and thought. The diagnosis of the functional activity of the pancreatic gland was of great interest to me. This all stemmed from the long rubber tube Dr. Max Einhorn had devised and given me in my senior intern year. My interest in gastroenterology arose perhaps from a single incident that seemed to be just a passing experience. Dr. Einhorn, of the German Hospital (now Lenox Hill Hospital), was visiting Dr. Nathan Brill, who was well known as one of the discoverers of endemic typhus, called after him “Brill’s disease.” In the course of the visit, Dr. Einhorn exhibited a rubber catheter (a thin tube), about 36 inches long, which he had devised and used for study of liver and bile secretions. The tube could be passed easily through the nose or swallowed, the end traversing the stomach and entering the duodenum. A small aspiration bulb on the other end would suck out the upper intestinal bile for study. Dr. Einhorn generously offered to present a tube to anyone interested. Dr. Brill looked bored but thanked him; no one else spoke up. Gladly, I became owner of this new playtoy, which offered so much for speculative study. A similar type of rubber tube had been devised by Dr. Martin E. Rehfuss of Philadelphia and is still known as Rehfuss’s tube. In order for me to study the diseases of the pancreas, it was important first to establish the norm. To put ward patients through the test, which is uncomfortable, even for healthy persons, seemed an injustice. Who was more normal and more accessible than me? 62.


Night after night, at bedtime, I would swallow that 36-inch-long rubber catheter, drink a glass of milk to stimulate pancreatic secretion and go to sleep. In the morning I would aspirate the pancreatic secretions and the bile from my duodenum. The tube constituted no great discomfort or inconvenience, and every afternoon the secretions were tested and the normal pancreatic enzymes evaluated at the laboratory. My first paper, in 1913, was “A Study of the Pancreatic Secretions in Gallstones, Liver Disease and Acute Pancreatitis.” In 1914, I used the same methodology and published a study on the early identification of “New Growths Involving the Terminal Bile and Pancreatic Ducts.” A new, comprehensive monograph, “Studies in Pancreatic Disease,” followed in 1915. The methods employed in those years were crude indeed. At The Mount Sinai Hospital today, the pancreatic laboratory and the efficient modem studies of Drs. David D. Dreiling and Henry Janowitz are a far cry from those primitive beginnings. And yet, 1913 and 1915 were an earnest presage of the diagnostic possibilities for the study of the function and the diseases of the pancreas and the bile ducts. One warm spring day in 1921, I received a telephone call from Boston. Dr. Joseph H. Pratt, founder of the Pratt Diagnostic Institute, was editing a comprehensive work on diseases of metabolism. The man who was to have written the chapter on the pancreas had been taken sick and would be unable to contribute. Could I take over and write the chapter? Speed was of the essence: the volumes were to go to press in two months. That summer was intensely hot. My vacation was, perforce, cancelled. The long, humid evening hours were spent in the library collecting and 63.


sorting the data and literature necessary for a comprehensive and encyclopedic article. The effort was worthwhile. In 1926, Dr. Emanuel Libman read a paper entitled “Pain Sensitiveness� before the Association of American Physicians. He demonstrated that persons vary greatly in their susceptibility to physical pain; some are very susceptible while at the other extreme there are people able to tolerate physical insult without consciousness of the hurt. The Libman Test is done by pressing firmly and strongly on the styloid process, behind the ear just back of the mastoid. It is graded on a scale of zero through four. This index of pain sensitivity has great application in clinical medicine and in everyday life. A person like me who is fortunate to be almost insensitive to pain can approach the dentist’s chair with complete aplomb and even have teeth drawn without local anesthesia. My special project was to apply the test to patients suffering from a peptic ulcer. Every patient in the office was first tested for pain sensitivity and symptoms evaluated accordingly. In a patient highly sensitive to pain the symptoms may be quite easily interpreted. In a person who is insensitive, every small suggestion of subjective pain must be closely evaluated. Such an insensitive individual may have had illness for years and never even been conscious of its warning pains. A large series of ulcer cases provided a field for clinical observation. Ulcer cases follow the overall pattern of pain sensitivity as distributed through the control population. But an ulcer patient insensitive to pain must be watched because he or she does not know when the ulcer is active! The patients with hemorrhage from ulcer were particularly enlightening: over 80 percent were 64.


insensitive to pain, and the gross hemorrhage came upon them as the first serious manifestation of disease. For years, cases of obstruction of the ulcer—pyloric obstruction— resulted in a scar for each recurrence. The scar gradually retracted, eventually closing off the exit to the duodenum. In my studies, 100 percent of these obstructed cases were pain-insensitive. My conclusions were reported in the medical literature in 1929 and amplified and elaborated in the Libman Festschrift, published in the doctor’s honor in 1932 and entitled, “Contributions to Medical Sciences in Honor of Dr. Emanuel Libman by his Pupils, Friends and Colleagues.” (A Festschrift. a publication by students and admirers of a great clinician or scientist, usually has limited circulation.) Such is true clinical acumen in the grand old manner, before the days of laboratory neurosis and computer medicine. Such examples on the part of Dr. Libman are legion. To have been one of his protegés was a rare privilege and a real education. I do not think that the importance of pain sensitivity has been sufficiently recognized and accepted. (The word “ouchless,” as applied in television ads for the painless removal of band-aids, could well be applied to these complicated ulcer cases!) Not only ulcer, but every other physically painful disease, should be evaluated according to the pain threshold of that individual. Pain is purely individual. Conversely, many patients who are accused by unsympathetic or unperceptive physicians of “carrying on” during a particular ailment—fussing about pain and discomfort in a manner disproportionate to the norm—may merely have a high pain 65.


sensitivity. Their doctors have never bothered to do this simple test and thus properly evaluate the situation. My indebtedness to Dr. Libman, a mentor and friend, can never be repaid. His brilliance in diagnosis, his remarkable memory, his kindness and helpfulness to younger men were all striking. He searched for ability and, finding it, would encourage and place every facility for study and research in the hands of a beginner. This was before the days of scholarships and fellowships. His work with endocarditis (Libman’s disease), his comprehensive and masterly studies with diagnostic blood cultures and his concentration, over a long period of years, on coronary angina made him a great authority. As an example of his remarkable memory, I recall, when an intern in the bacteriology laboratory, finding a bacterium that coagulated milk almost as soon as the milk was inoculated. Dr. Libman recognized it at once, quoted its Latin name and its reference: “The Bulletin of the Johns Hopkins Hospital, 1906, probably June, a small notice in the upper section of the double column, near the top.” This was four years after the publication! (I only encountered one other man who had a memory as immediate and accurate as this. He was Bernard Berenson, the great authority on art, whom I visited at his villa near Florence, Italy, and who, at the age of 84, had equally exact memory for the printed page.) Another example of the amazing faculties of Dr. Libman is the story about a consultation held in an elaborate mansion on Fifth Avenue. Many notable authorities were present, but none of them had as yet seen the seriously sick child in the bedroom above. As the consultants ascended the broad staircase, a short, sharp cough was heard from the upstairs room. “Ah,” said Dr. Libman, “I see, 66.


or rather hear, that you have here a case of meningitis.” Respiratory illness often precedes the characteristic symptom of acute meningitis. This is the true clinical acumen in the grand old manner, before the days of laboratory neurosis and computer medicine. Such examples on the part of Dr. Libman are legion. To have been one of his protegés was a rare privilege and a real education. During these years, under the auspices of the Columbia University School of Graduate Medicine, annual courses were given at The Mount Sinai Hospital in all subjects of medicine. They were planned as refresher courses for practicing physicians eager to maintain a relationship with a scholarly institution. Gastrointestinal courses were always popular, the subjects being of both theoretical significance and practical utility. I particularly recall at least one of my own courses on abdominal palpation—how to feel a belly and recognize pathological masses and other deviations from the norm—a most important practical subject. Unhappily, in our present day of computer and essentially laboratory-minded interests, the manner and matter of abdominal palpation with skillful fingers has suffered a deep decline. The American Gastroenterological Association represented the best of the physicians devoted to the study of diseases of the stomach, pancreas, liver and intestinal tract. Limited originally to only one hundred prominent specialists, it grew rapidly but still included only the most select applicants. It was truly a brilliant assembly of clinicians and scientists. Included in its leadership were such outstanding physicians as Sara Jordan, Henry Bockus, Russell Boles, Abraham Aaron, Frank Lahey, Charles Flood, George Enstennan and Jacob Borgen. We were a close, friendly 67.


body and welcomed the increasing number of young physicians who aspired to membership. A personal friend, Dr. Walter C. Alvarez, president of the Association in 1928-29, was determined to remove the dead wood from the organization and institute a lively and enterprising young governing board. In 1933, when the presidency was bestowed upon me, I thought that the pinnacle of recognition had been reached for me and that, thereafter, everything would be anti-climactic. At the annual banquet, the speaker, by my invitation, was the Reverend Paulist Father from a nearby Catholic school, who chose as his topic “The Growing Threat of Communism in Russia and the Rising Threat of a Corporal in Germany named Adolf Hitler.” The next few years in the chemistry laboratory were fascinating ones. In cases of jaundice, liver disease or dysfunction or pancreatic disease, Libman’s tube could recover intestinal secretions for diagnostic and functional research. Or, with the tube in the stomach of a willing patient, one could study the effect of alkalis or acid secretions in the stomach—how much alkali, sodium or magnesium was necessary to control heartburn; how much was necessary to neutralize the natural acid of the stomach without inducing a reversed response; how much acid therapy was necessary to restore acid and pepsin digestion; what were the variations of the stomach secretions in ulcers, in dyspepsia, as the result of surgical procedure and so on. There was just not enough time for the eager researcher to study! A clever device for the study of peristaltic rhythm (the propulsive muscle waves of the stomach) had also been devised. The patient 68.


swallowed a small, deflated balloon attached to a thin rubber catheter. Once in the stomach, the balloon could be inflated and connected to a recording, rotating drum, and a marker would record the muscular waves of the digesting stomach. At this time gastric (stomach) and duodenal ulcers were commonly treated by a simple surgical procedure. A new opening was created by the surgeon, who connected a loop of small bowel to the wall of the stomach, “short-circuiting” the ulcer and allowing it to heal. In some cases this was truly curative, but the operation was abused and used for all sorts of dyspepsia and stomach diseases, even when an ulcer could not be clearly demonstrated. In the course of studying the physiology of the stomach by means of tubes and balloon and x-rays, before and after operation, it became apparent to my associate, Dr. A. O. Wilensky, and me that the surgical procedure was often unsatisfactory. Our hypothesis was really heresy in those days. Quietly, we two young men carried out our researches, too intimidated to openly state our disagreement with the current orthodoxy. One day, while I was working at my laboratory desk, my mentor, Dr. Libman, appeared. He introduced a stranger and suggested that the visitor might be interested in our studies. The visitor was none other than Dr. William J. Mayo himself, the head, with his brother Charles H. Mayo, of the famed Mayo Clinic in Rochester, Minnesota. Dr. Mayo sat down, listening and questioning for an hour. “Would you two young men be willing to address the American Gastroenterological Association in May at Atlantic City and present your studies before that body?” 69.


What an opportunity, what a compliment to youth! In May, we appeared before that august body, the only registered and representative exclusive sectional organization of gastroenterologists, a society at that time was limited to only one hundred specialists. Our paper was received with attention and discussion. After the customary applause had subsided, Dr. Mayo called for a rising vote of thanks. The eminent body rose en masse. I, not knowing the proper behavior, began to rise too. A quiet but firm hand from behind forced me down. The next year, 1917, I was elected to that organization, thus becoming a recognized gastroenterologist. On our return to New York, we were greeted by a storm of disapproval from a senior surgeon. We were accused of heresy and unorthodox work. The storm, however, subsided. Soon after, the scientific world was startled by the introduction, by the Austrian surgeon Dr. Von Haberer, of a new operation for the cure of ulcer—a partial removal of the lower part of the stomach and of the ulcer itself. From that time on, a radical resection was advocated rather than bypassing the ulcer. My friend and senior associate, Dr. A. A. Berg, and his associate Dr. Richard Lewisohn, particularly the latter, became quick converts to the new surgery, and the three of us tramped the country, speaking at medical meetings and surgical conclaves, making converts, introducing the new method and denouncing the old. To this day, with some additions and modifications, it is the operation of choice for peptic ulcers. It was quite apparent that there was a need for an organization of some type at Mount Sinai for gastroenterology. In spite of the senior internists’ reluctance to recognize any sub-specialties of 70.


internal medicine, such an outpatient department was established under Dr. A. A. Berg in 1918. Dr. Edward A. Aronson was its medical head. This group of clinicians had the privilege of studying ward cases. I, still being in bad grace because of my heresy concerning gastric surgery, was just a follower. Unfortunately, Dr. Aronson died of acute pancreatitis in 1922, the year after this group was organized. Through intervention on my behalf by many staff associates, Dr. Berg was mollified, and I became medical head of the new department. Our Sunday morning rounds were a delight, always interesting, with free and open discussions from 9 a.m. well into the lunch hour. The clinic and interest in the department grew rapidly. It was during one of the annual meetings of the American Gastroenterological Association at Atlantic City that an episode occurred that left a lasting impression on me. One day, having become bored with the scheduled proceedings, I wandered across the avenue, hoping to find a more interesting topic being discussed at the Society for Clinical Investigation. They were discussing, for the first time, the discovery of insulin. At that time, in 1922, I myself was treating a case of juvenile diabetes. The patient was a boy of 12, certain to die shortly. Until then no cure or control of juvenile diabetes was known. One day, the boy’s mother approached me with the front page of The New York Times describing the discovery, in Montreal, Canada, of a substance called “insulin.” Would I advise her? Would I consent to her going to Canada and bringing some back? I told her I would be eager to try it. She returned in a few days with a bottle containing a clear solution that looked like water—quite unimpressive. 71.


That boy’s life was saved by the insulin—the first miracle of its kind in my experience. The Society for Clinical Investigation meeting was crowded. All scientific doors by tradition being open, I entered the hall, quietly took the last seat in the last row and listened. The lights were darkened at the time, as lantern slides were shown. A young man entered and sat down alongside me. Suddenly, the lights went up, and the chairman abruptly stopped the speaker. “Gentlemen, I perceive in the audience Dr. Frederick G. Banting himself! Will he please come forward and take a seat on the dais.” There was a pause. The quiet young man next to me rose and walked down the aisle to thunderous applause. Never was true modesty better illustrated than in this unobtrusive physician who, together with Drs. Charles H. Best and James Macleod, discovered and introduced insulin, one of the greatest life-saving drugs known to medicine. Drs. Banting and Macleod won the a Nobel Prize winner in 1923. In 1925, a leading medical publisher, Saunders & Company of Philadelphia, approached me about writing a comprehensive textbook on diseases of the stomach. They stipulated, however, that the manuscript be done within one-and-a-half years at most. A herculean task, but I was not unprepared. For years, my files had contained reprints and abstracts of international medical literature—plus my own experiments and observations, both in the laboratory and the clinic. It was a hectic year, working at medicine all day and writing far into the night. The Academy of Medicine had an extensive library and was most gracious in granting me special privileges. This 72.


again was a long period of shortened sleep, no time out for recreation, no relaxation. The manuscript was done within the allotted time, accepted and published in 1928. My book, Affections of the Stomach, was well received and creditably reviewed. I refused to do a second edition—it was too much work! Had the manuscript never been published and recognized, it would still have been a valuable experience for me. Each topic required a personal evaluation, a stand on debatable issues, an opinion. The author learns as much, if not more, than his readers. In 1941, an invitation came to me to address a dental association meeting in New York. It was a flattering offer, but what was there in gastroenterology that would interest a dental society? The teeth, as foci of infection in arthritis and associated disorders of metabolism, might make an interesting talk, but I was skeptical and not at all convinced that I had anything to offer that was related both to my field and to the practice of dentistry. Eventually, an interesting subject suggested itself: halitosis, or bad breath. Would the dental society be interested? They accepted the offer with enthusiasm. Until then the cause of bad breath had never elicited more than a passing thought from me. All the current literature stressed the importance of decayed and carious teeth, infected tonsils, obstructed nasal passages, and local mouth or nasal deviations. Even before serious consideration, these explanations did not make sense to me. The dental association induced Bristol-Myers Company, a pharmaceutical firm that made a popular toothpaste, to grant me $500 as a research fund. There were no conditions or limitations 73.


on the grant. With this money we began experiments to ascertain what really modified the odor of human breath. First, I needed a means of describing an odor: sweet, pungent, acrid, penetrating? How does one express degrees of intensity on some sort of scientific scale? The Massachusetts Institute of Technology had devised such a scale for industrial purposes; they permitted me to visit and spend sufficient time to learn their methods. At M.I.T., they offered a tray of test tubes, each containing an odoriferous solution. (All smells were grouped under four standards which, if I remember correctly, were something like sweet, acrid, pungent, repulsive or nauseating.) Each succession of test tubes was also graded from very faint to overpowering. I attempted to memorize this system by sniffing so that I could apply it to my own research problem. Step by step, we proceeded with simple experiments and observations, using garlic, onions and whiskey as test odors that appear on the human breath. If one chews salami loaded with garlic, or chews onions without swallowing, how long does the odor remain on the breath? Only a very short time, we discovered. Insert into the stomach of a willing subject, by intubation, a solution of garlic or onions and carefully remove the tube, and the odoriferous material in the stomach cannot be smelled on the breath during or shortly after the experiment. But wait a few hours, and the breath will be overpowering. Evidently, the material that taints the breath is neither in the mouth nor in the stomach. The food must pass through the intestinal tract, be absorbed into the bloodstream and, via the liver, eventually its metabolites reach the lungs and are expired on the breath! 74.


A patient on the ward had a colostomy (the creation of an artificial anus by an opening through the abdomen into the colon). At the time we were conducting these experiments, he became interested enough to agree to cooperate in our studies. We inserted into his colostomy a capsule of garlic, and, within hours, his breath was tainted enough to be obvious to the nurses on the ward. The material must, therefore, have transversed the liver. Another patient, who had been operated upon for gall bladder disease, was undergoing surgical drainage of his bile tract—a routine procedure. When this man was given garlic, either by mouth or by rectum, one could distinctly identify the odor in the bile drainage from the liver the next day. Later, it would appear on his breath. We repeated these experiments with whiskey and found that if one rinses his mouth or gargles with Scotch, and then spits it out, the whiskey odor cannot be detected ten minutes later. But go to bed after drinking eight ounces of whiskey, as I did in the course of our experiments, and the next morning there is no question among your friends as to the kind of binge you were on the night before. The final proof that body odors can be traced through metabolism, and not locally in the mouth or pharynx, was arrived at by a simple observation: a pregnant woman about to go into labor was asked to swallow a capsule of garlic (harmless, of course). After a relatively short labor, she gave birth to a healthy baby. On spanking the baby, he emitted a lusty cry that smelled distinctly of garlic. The garlic had entered the mother’s circulation and, by way of the placenta, entered the fetal circulation. It was exhaled on the baby’s breath. 75.


It thus seemed obvious that the determining factor in human breath odor was some product of metabolism. Fats or fatty substances were suspected, but proof was difficult to obtain. I remembered a conversation I had had with the very able Professor I. Snapper, who, during the First World War, had occupied the chair of medicine at the University of Peking, in China. He asserted that the Chinese on the street could detect the presence of a white man approaching from around the corner by his body odor. The Chinese drank little or no milk. The white man drank milk! The suggestion was made to Bristol-Myers that they capitalize on these simple experiments: give a girl who has bad breath a capsule containing a few drops of oil of roses, wintergreen or simple peppermint before going out on her date, and her breath would be guarded by the emanations of this pleasant odoriferous substance. The company, in this instance, was not commercially minded and preferred not to act upon my suggestion. When our paper was published in The Journal of the American Medical Association in 1941, I became an overnight “expert” on halitosis. For months thereafter, patients wanting relief from this complaint sought out my office. I soon learned from bitter experience that most people who thought they had halitosis did not actually have any disagreeable odor on their breath. They were almost all neurotics with delusions of being persecuted be cause of their bad breath! Some well-meaning spouse or friend had accidentally and with good intentions one day dropped the remark, “Your breath is bad,” and the damage was done and could be very serious. An example of this type of patient was a man who was a bank teller. He was convinced that as he counted out money, depositors turned away with disgust and left the bank. He ultimately 76.


resigned from his job and fled to South America. Another man was convinced that every time he entered a public conveyance, the passengers began to leave on account of his breath. Still another patient, a Frenchman, told me how, in his extreme concern over bad breath, he had attempted suicide. He admitted that he had drunk iodine. Undiluted iodine in the esophagus is very, very caustic and produces serious, if not irremediable damage, and yet he had survived. I questioned him closely since such a survival was most unusual. “How did you take it?” I asked, with some curiosity. “Oh, I took it in champagne,” was his answer. The French, even in suicide, must have the best of vintages. Champagne had saved his life—as it no doubt has that of many another Frenchman! Also during the course of my career, I was asked to testify as an expert in the prosecution by the Federal Trade Commission of the asserted claim of an advertisement for Listerine, which said that Listerine killed germs and bacteria in the mouth—to my mind, an absurd assertion. There was nothing in Listerine but diluted alcohol and a flavoring agent and a trace of the mildest antiseptic. One teaspoonful of Listerine, diluted in a glass of water as a mouthwash, could under no circumstances be regarded as a potential “killer of germs.” The hearing I attended took place in an assembly room of one of the midtown hotels in New York City. The room was crowded with representatives of both sides. A long refectory table occupied the center of the room. On one side sat the lawyers for the defense, and on the opposite side, lawyers representing the government. “How long has this been going on?” I inquired. “For years,” was the answer. 77.


The hearing was held long ago. The same advertising slogan is still used today. It is just as untrue now as then. The fortune that the Federal Trade Commission invested in a fruitless prosecution was impressive. Still more impressive was the fact that no federal budget, no matter how expanded, could ever cope with the innumerable and constantly restated false claims made by advertising. This applies particularly to the drug industry. Soon after this I was involved in the prosecution of a vitamin manufacturer for advertising claims for a cure with a ridiculously low dosage of vitamins. The Federal Trade Commission here was quickly successful. But Carter’s Little Liver Pills was a more difficult case, and the defense funds of this proprietary concern were ample. Here, my testimony for the prosecution that the only ingredient (podophyllin) that had any action on the liver, and that a very small and ineffective one, damned the pill with faint praise. The omission of the word “liver” from the advertising was the only victory for the FTC. Like most of these old patent medicines, the chief ingredient was just a plain cathartic. Give a constipated person a daily bowel movement and life is perfect! In 1937, I described for the first time in the American medical literature a case of duodenal ulcer caused by trauma. A fine, healthy lad of 17, while riding in a public conveyance, was thrown violently forward against a projecting arm of the seat before him as a result of a collision. Immediately—within hours—he developed gross hemorrhage and symptoms of duodenal ulcer so 78.


severe as to require emergency operation. This same boy also developed shortly after the trauma symptoms of regional ileitis sufficiently grave as to require a subsequent operation. Both diseases were presumably accepted as instances of disease caused by physical trauma. The European medical literature already contained articles on traumatic ulcer, but not so in this country. Shortly the question of trauma in relation to abdominal disease became a live issue in our literature. The Workmen’s Compensation Boards were naturally vitally interested, and most of the recognized cases came under their supervision and judgment as to proper compensation of the plaintiff. On the urgent and persistent request of my friend Dr. Leopold Brahdy, I consented reluctantly, in 1941, to write the chapter on “Trauma in Relation to Diseases of the Gastrointestinal Tract” in the forthcoming textbook by Brahdy and Kahn on this topic. The undertaking required not only recording my own experiences, but also a complete survey of the world literature, most of which was in German and French periodicals. My daughter, Ruth, was of great assistance in translation because of her proficiency in both foreign languages, as well as her interest in medicine. It was a big chore for me, but a very satisfactory one; and it established in this country what was considered the first and then the standard publication on the subject. Naturally, thereafter, my services as an expert were frequently sought, both by the Workmen’s Compensation Boards and in court proceedings in medico-legal cases. The testimony at the Workmen’s Compensation Boards was particularly satisfying. The plaintiff, the victim of trauma as a result of occupation, was entitled to proper coverage and remuneration for his injury. 79.


I often thought the Boards bent too far backward in granting compensation in doubtful cases, where the trauma seemed insufficient and unrelated, even though the law was distinctly written to favor the plaintiff if the slightest doubt existed. For years thereafter, I sat on the county Medical Qualifying Committee for the admission of physicians applying for the privilege of testifying before the Boards. Abnormal hunger sensations have been termed bulimia. It is known also as heisshunger—canine or wolf’s hunger. It was described in ancient Greek medical literature by Hippocrates and is mentioned in the Talmud as a serious affliction. Hunger and appetite may be defined as the complex of sensations that in man and the higher animals urges and compels the ingestion of food. The hunger urge is a more or less uncomfortable feeling of tension or pressure—even slight pain—in the stomach area. It is a somewhat uncomfortable tension accompanied by a sensation of emptiness in the upper abdomen. A certain degree of nervous irritability is a necessary effect of hunger. This nervousness in neurotic individuals may become so extreme as to crowd out the actual sensation of hunger. One experience with an extreme case of bulimia was very instructive. The patient was a woman 33 years of age, married, with three children. Since the onset of her first menstrual period, she had felt a continual desire for food. This excessive craving for food reappeared in her life at times of great mental strain and disappeared for long periods when peace of mind was restored. She began to eat at 7 a.m., taking coffee and milk. She could not wait for solid foods and ate every hour until midday. At noon, she 80.


had a full meal of soup, chicken, bread and butter, plus dessert. At 2 p.m.. at 4 p.m. and at 5 p.m. she frequently ate another small meal. At 6 p.m. she had eggs and coffee and then ate again at 9 p.m., 11 p.m., and at 2 a.m. and 5 a.m. She slept with one to four quarts of milk alongside her bed, awakening at regular intervals to drink (nocturnal bulimia). “I never feel fully satiated,� she said. Often she might not want the food but ate to satisfy the craving and the sensation of emptiness in her stomach. She slept in a corset to keep her stomach tight. During the day she was weak and trembled so violently that her knees gave way under her. Nonetheless, she was obsessed with the idea of obtaining food however and wherever possible. When the desire came over her, it had to be allayed then and there. She had been known to remove a pot of boiling soup from the stove and, without waiting, gulp two, three or four bowls in rapid succession— so hot that her entire mouth and throat were badly burned. She cried easily and was depressed over her uncontrollable condition. Within the six months before she consulted me she had gained over 50 pounds. She weighed almost 200 pounds and required a new outfit of clothes nearly every few weeks. It was impossible for her to go away from home for no hotel or boarding house would tolerate her appetite. The patient was referred to me to ascertain whether any physical abnormalities could explain her hunger. There were none. Test meals, x-rays, blood studies, kymographic tracings all were within the normal range. This case is classified as truly one of neurosis with a definite compulsion element. It began in youth, was initiated by the 81.


unexpected onset of her first period, information about which had unfortunately been neglected by her parents. She had been in the hands of many neurologists, psychologists and psychoanalysts without relief. When I last heard of her (she had long since passed out of my control), she was still attempting to consult renowned physicians in hope of finding one who held her Aladdin’s lamp. Bulimia is not the consumption of excessive quantities of food at one time (gluttony). It is the constant and imperious desire for food at frequent intervals. Bulimic patients are often afraid to leave the house for fear the desire for food will overtake them; they go walking with a lunch basket. When attending theater, my patient would sit in the last row with a full dinner pail. A case of so-called congenital bulimia was manifested in a girl who from her earliest years had a voracious appetite. She could do no work and was repeatedly arrested for stealing food. During one of her paroxysms of grand faim she ate 32 pounds of food! Death eventually resulted from eating poisonous herbs. Variations of abnormal appetites recognized in the medical literature all are, or border on, the pathological, in some instances true insanity. This even extends to what is termed pica, the depraved appetite for articles that are not food, such as clay, earth, chalk, etc. In a case of appetite-related insanity, death occurred by eating household items. At autopsy, the gut contained fragments of cloth, handkerchiefs, almost a whole shirt. Death resulted from perforation of the cecum by a large fragment of splintered wood. At the International Congress of Gastroenterology in 1958, I offered a paper on the evil effects of rapid reduction in weight. A 82.


weight reduction of more than three pounds the first week and two pounds per week thereafter may invite illness. Two striking experiences had alerted me to the serious illness that could result from an ill-advised maximum reduction of diet over a short period. A fat middle-aged woman entered a fad dietary farm in upper New York State seeking to reduce her weight. She was placed for two days on a distilled-water diet, then given only broth for three days. At the end of that time she began to bleed profusely from her stomach, and had blood in her vomitus, as well as black stools, indicating gross, massive hemorrhage. She was rushed to a small proprietary hospital, poorly equipped for emergencies and blood transfusions. Her blood type was most unusual, the local supply quickly consumed and urgent messengers sent to Albany brought more but not enough. I was called to the case and made every endeavor to replace the blood, hoping that the gross hemorrhage would cease. The situation became critical. Surgery was advised but the facilities in that so-called hospital made a major procedure impossible; nor would her condition allow for transport to New York. The end can be assumed. Either she bled from an acute ulcer brought on by starvation, or she had had an old ulcer reactivated by the starvation diet. When I was just starting in practice, in the years before the First War, the famous German pathologist Dr. Ludwig Aschoff visited and lectured at Mount Sinai. During the question period I stood up and asked, “Professor, how long does it take for an ulcer to form in the stomach?” “Twelve hours or less,” was the answer. Years later, I was called in consultation to see a very stout woman who weighed approximately 280 pounds and was suffering an acute attack of cholecystitis, or inflammation of the gall bladder. 83.


She had fever, a rigid belly and marked sensitiveness over the area of the gall bladder. The history showed that on the advice of misguided dieticians she had lost 65 pounds in three weeks! The surgeons were prepared to operate upon this very bad surgical risk; my advice was to follow conservative treatment since I had the instinctive impression that the process was a chemical one resulting from the excessive weight reduction and that the inflammation would resolve. She improved rapidly and remained well for years, although the gall stones which had formed, or which had been there originally, created occasional symptoms. With these two striking cases in mind, I was able to collect similar examples of the deleterious effects of too-rapid weight reduction. Most numerous were women who followed newspaper ads and fads for restoring slim figures. No paper published by me fell so flat on the ears of my confrères or was so poorly received. I could not substantiate my observations with any chemical or biological data: my thesis was that the rapid liberation of cholesterol and body fats overloaded the gall bladder and tended to gallstone formation since gallstones are essentially cholesterol concretions. The thesis was difficult to prove; none of the common experimental animals are subject to gall stone formation. In 1942, The Mount Sinai Hospital celebrated the 90th anniversary of its founding. As chairman and organizer of the historical exhibit of that properly famous institution, I had the pleasure of mounting an historical display portraying medical accomplishments at Mount Sinai since its foundation as a small hospital and clinic in 1852, on 28th Street between Seventh and Eighth Avenues. The history of the hospital’s staff is truly striking: Abraham Jacobi, father of pediatrics; Karl Koller, the discoverer of local 84.


ophthalmic anesthesia (cocaine); Henry Koplik of Koplik’s Spots in early measles; Nathan Brill of Brill’s disease; Emanuel Libman of Libman’s Risease; Richard Lewisohn’s citrate transfusions; Bernard Sachs of Tay-Sachs disease; Isidore Rubin, inventor of apparatus for testing female sterility; A. A. Berg, for his early abdominal surgery; Howard Lilienthal, pulmonary surgeon and developer of Lilienthal’s Probe; Leo Buerger of thromboangiitis obliterans or Buerger’s Disease; Charles Elsberg, whose Elsberg test is used in differentiating an intracerebral brain tumor from an extracerebral one; George Baehr, coordinator of the new Mount Sinai Medical School. During all these years of scientific activity much else was interspersed in my career. For a time I was national chairman of a committee of the American Gastroenterological Association for the study of gastric hemorrhage. Our committee advocated early surgical intervention in cases of massive bleeding uncontrolled by repeated or constant blood transfusions. In early years such radical surgery, with our crude anesthesia and lack of antibiotics, was hazardous. Today the lives of many such critical cases are being saved by early and prompt surgical resections. A National Committee for the Standardization of the Nomenclature of Diseases and Surgical Procedures was undertaken by the American Medical Association. I served on a panel for the standardization of the names of the diseases of the alimentary tract. In the revised edition of the Nomenclature, my job was to chair the sub-committee of the American Gastroenterological Association. In 1961, we authorized and coded names of diseases of the abdominal digestive organs. This text became standard and recognized as authoritative in all American institutions. 85.


Benign peptic ulcer, particularly ulcer of the stomach and duodenum, constitutes a large section of the practice of gastroenterology. It is a widespread disease, usually of the young, occurring statistically in five percent (autopsy studies say even 10 percent) of the population. I was always impressed by the fact that the average ulcer patient did not know what an ulcer was, nor where it was, nor what it signified. He or she was particularly confused by the details of diet which, in the treatment of ulcer, are all important, more so than any of the multiplicity of drugs advertised for its cure. It seemed to me that a manual written in simple language for the average patient might serve as a “guide to the perplexed.” Understand Your Ulcer (1958) was my contribution to the public. What is an ulcer? Who suffers from an ulcer? What causes it? What causes it to recur? What does the typical x-ray of an ulcer look like? How is ulcer treated, particularly the complicated diet and preparation of food? The book explains the surgical cure, when necessary, and assures and reassures the patient that there is minimal danger to life of such an operative procedure and its almost 96 percent rate of probable and permanent cure. When I wrote Understand Your Ulcer, I had qualms about a recognized physician’s writing directly for the lay public. I anticipated criticism from my colleagues, implications that it was a form of advertising one’s wares; but I was encouraged in the project by Dr. Iago Galston of the New York Academy of Medicine. Since then, writing educational tracts to help the general reader understand illnesses has become very popular— there are enough publications on sex alone to stack a library! 86.


Incidentally, I was called before the Grievance Committee of the New York County Medical Society on charges in connection with the book. My inexperienced publisher, without consulting me, printed two of my titles on the cover, when only one title was allowed. The Grievance Committee held a trial; I, not the publisher, was reprimanded. But it was all among friends and not much more than a technicality; however, it is good evidence of the alertness of the county medical authorities regarding the slightest breach of their high ethical standards.

87.


{ IV } INFLAMMATORY DISEASES OF THE INTESTINE

T

was the annual meeting of the American Medical Association in New Orleans in May, 1932. I read a paper entitled “Regional Ileitis: A New Clinical Entity.” It was a joint contribution of Leon Ginzburg, Gordon D. Oppenheimer and me to the clinical and pathological studies in this as yet undiscovered area. H E S CE NE

The history and method of discovery of a hitherto unnoted disease is in itself interesting. Step by step, the methods are logical and, in retrospect, simple. Regional ileitis is an inflammatory or granulomatous disease of the small bowel, characterized by fever, diarrhea, abdominal pain and fistula formation. It is essentially a disease of youth, slowly progressive and disabling. I recall distinctly that in my medical school days Dr. Evan Evans, our professor of medicine, had suggested that we omit from Osler’s Text Book on Medicine the chapter dealing with the small bowel, “as there are no recognizable diseases of the small intestine except, perhaps, tuberculosis.” And so we passed over that chapter in medicine as of no noteworthy interest! 89.


Nevertheless, at the autopsy studies at The Mount Sinai Hospital, Dr. Libman always insisted that the small bowel be opened and dissected, but only as a discipline in careful routine. Nothing of note was ever found. My first case of regional ileitis, a private patient, was a boy of 17 who had fever, diarrhea and a tender mass palpable in the abdomen. Presumably, this was the dreaded intestinal tuberculosis. In the past, no method of treatment had given either promise or results, but now medical science had newer diagnostic methods. Skin tests and eye tests, using purified tuberculin from dead and sterilized tubercule bacilli, had been devised by Calmette, by Von Pirquet and by Schick. These tests were all negative in my young patient. The sputum examination for tubercule bacilli was negative. Now we also had x-ray, something which, in my medical school days at Columbia, did not for practical purposes even exist. But the chest x-ray was negative. X-ray studies of the small intestine were not well interpreted in those years nor well employed for diagnostic purposes. Perhaps, after all, this was not tuberculosis. Perhaps the patient should be operated upon and the abdomen explored. My appeal to the surgeon, my esteemed friend A. A. Berg, for surgical intervention fell on deaf ears. Under no circumstance would he operate upon a case of intestinal tuberculosis. Previously, at the request of Dr. Trudeau of the Trudeau Sanitarium at Saranac Lake, he had been persuaded against his better judgment to operate and resect five cases of intestinal tuberculosis. Two of the patients had died, two were made worse and, in the fifth case, he did not know the results and never wanted to know. 90.


Against such experience it was difficult to win approval and cooperation and yet the fact that all the recognized tests for tuberculosis were in this case negative was eventually persuasive. The boy was finally operated upon. An inflammatory mass was found to be occupying the terminal 12 to 16 inches of ileum (the small bowel). This mass was removed and sent to the laboratory for intensive study. Tuberculosis was ruled out by any and every laboratory procedure: sections were cut out and stained and pored over for hours, but no tubercule bacilli could be demonstrated. The final test was the inoculation of guinea pigs with part of the patient’s intestinal wall that had been removed at operation. We lived for weeks under tense anxiety, waiting to see if our pigs would live. They did live, and in excellent health. At four weeks, at five and at six weeks, a pig was sacrificed and subjected to careful autopsy. No tuberculosis was found—a conclusive demonstration since guinea pigs are highly susceptible to human tuberculosis. Obviously, we were dealing with a new and hitherto undescribed clinical entity, probably extremely rare, and thus more of scientific than clinical interest. But within a year or two, Dr. Berg and I had amassed 14 such cases, many much more complicated, and all of the same nature, but none of them tuberculosis. Fortunately, all were cured of their disease by an operation that was not attended by great risk. Some of these patients had been lying around in the wards for long periods—cases with fistulas (openings) in the gut walls, the nature of which had never been decided. Some thought they were tuberculosis, some thought actinomycosis, a disease characterized by granulomatous lesions; but nobody knew, and nothing could be proved. Now we understood that we 91.


were dealing with a “new” disease. These cases were operated on, and most of them turned out to be cases of unrecognized regional ileitis. In one case, eleven fistulas in the abdominal wall were present, all cured by Dr. Berg in one operation! The disease was obviously a new entity, and literature about it had to be published. Dr. Berg was the logical co-author; but, in his modesty, he declined and suggested that as co-authors I accept Drs. Leon Ginzburg and G. D. Oppenheimer, who, independently, had been studying the pathology of abdominal granulomas. The paper was read in New Orleans, and the findings were accepted, apparently without the usual scientific skepticism. Perhaps it is a tribute to the world of medicine that within the next year regional ileitis was being discussed in Germany at an international meeting of surgeons. The Mayo Clinic immediately recognized overlooked cases of ileitis. Dr. John Kantor described the “string sign” in the x-ray films that is almost solely characteristic of this disease. Why was it that the recognition of this not-uncommon disease fell to an internist and not a surgeon or a pathologist? The surgeons obviously missed their opportunity to identify the disease. In the early years 25 percent of all cases of ileitis had had the appendix removed for so-called chronic appendicitis. Chronic appendicitis was an extremely popular diagnosis. It covered all sorts of vague, unexplained and neurotic abdominal pains and discomfort. Such a disease never existed. Had the surgeons been slightly more inquisitive and had they, in removing the innocent appendix, let their fingers glide to the small bowel immediately adjacent, they would have felt the characteristic mass. Pathologists missed the opportunity because 92.


regional ileitis is practically never fatal. It is impossible to think of the intensively trained German pathologists missing such an obvious disease, had ever such a case come under their observation at autopsy. One day on rounds, one of our most illustrious chiefs demonstrated a case of “chronic appendicitis” on a ward patient. We all paid close attention and passed on to the next bed. Something about the case aroused my doubts. I went back to re-examine the man’s belly. There I saw a faint line of what looked like a scar from a previous operation. On inquiry, the patient volunteered that some years previously his appendix had been removed! Any questions in my mind regarding the fanciful diagnosis of “chronic appendicitis” were then and there dispelled. The information that I had gained on this case remained my personal secret; I did not embarrass my chief, but the lesson was an important one. Still another fallacy had to be overcome. It was taught in this period that rectal fistulas (false openings about the rectum) were tuberculous in origin in over 99 percent of all cases. This figure was accepted with little question; but many of our new cases of ileitis were complicated by such fistulas, and now we knew that such fistulas were not tuberculous. It was not long before the newer scientific observations completely reversed this figure. Now it is recognized that at least 99 percent of all cases of rectal fistulas are due to ileitis and colitis. If one percent are tuberculous, we have never seen them. A certain degree of healthy skepticism, plus the utilization of newer diagnostic methods, made it possible for us to note a “new” disease and discard the traditions and some of the fallacies that had hampered its earlier recognition. 93.


My own office files include the clinical histories of 1,000 cases of ileitis. Medical and surgical publications the world over indicate that regional ileitis is widespread in all countries, in all climes, among all ethnic groups and in all social or economic strata of society. A comprehensive study conducted at the veterans’ hospitals of the United States found regional ileitis two to four times more common among Jews than in the non-Jewish control population. The fact in itself is interesting; the explanation difficult to come by. The disease is not hereditary, but a definite proclivity to familial incidence does seem to exist. Brother and sister often seem affected, also father or mother and child, or uncle and niece or more than one family member. This is in contrast to the much more common disease, ulcerative colitis, in which familial incidence is relatively rare. Is this a disease new to humanity? Was it always present, but overlooked? Are ileitis and ulcerative colitis the penalty of our modern civilization? These questions must remain unanswered until the true cause, the true etiology of the disease is disclosed. Fortunately, a medical treatment for the disease—corticosteroid— does exist and is successful or partially remedial in about 10 to 15 percent of the cases. The remainder are operated upon without danger to life. The operation gives permanent relief and “cure” in 70 percent of the operated cases. Recurrence in the remaining 30 percent may take place and is usually easily handled conservatively. My case Number One, dated 1930, was well for 25 years after his operation and then developed a mild recurrence. His operation, if only as a palliative measure, seems to have been well justified. Surgical treatment of ileitis has been progressively sound. At first, a two-stage operation was devised—a short-circuiting procedure— 94.


followed within weeks by removal of the original area of inflammation. Today most surgeons prefer a primary radical resection wherever possible—removing the affected portion— and employing the short-circuiting procedure only where the life of the patient may be endangered by a more formidable operation. The most publicized case of regional ileitis was that of former President Dwight D. Eisenhower. I recall it as a hot day in June. It was time for planting sweet corn, and I was out in the corn patch at my country home in New Milford, Connecticut, planting my rows, when the first excited telephone message arrived. The editor of the Washington Post was calling. The President was about to undergo emergency surgery for an intestinal obstruction due to regional ileitis! The New York Academy of Medicine had been contacted and had referred the query via The Mount Sinai Hospital to me. What did I think of his chances? Would he survive, would he be well? Taken utterly by surprise, and not being in possession of any of the salient facts in the case, this was a poser and required some fast thinking. The average age of the ileitis patient at onset is 27.5 years; the President was, I believe, in his late sixties. Ileitis at that late age is always a vestigial remainder of a long course of disease. Obstruction also is a late manifestation, occurring during the healing phase and caused by growth of scar tissue in the intestinal wall. Surgeries for ileitis, and particularly for obstruction, are not dangerous, and the operation of choice under these conditions is almost always a by-pass. With great temerity, I ventured an opinion: the President would survive and would probably, if the facts as stated were true, be well. The stock market was falling rapidly with the news of the 95.


President’s illness; within minutes every word I had uttered on the telephone appeared on the ticker tape on Wall Street. The market rallied to the tune of about two billion dollars based upon my hasty surmise and an unauthorized opinion. The next three days were spent on the long distance telephone. Day and night editors of all the prominent newspapers, editorial writers, news agencies, scientific bodies called continually. I turned down more invitations to appear on radio and television programs, including “Meet the Press,” than a top personality. Finally, with the consent of the New York Academy of Medicine and at the urging of the American Medical Association, a privately taped television program was arranged to take place on an afternoon at my office. What a boring procedure, what a nuisance and waste of good time! Keeping your hands in one position, being made-up for the show, constant interruptions and repetitions because of a slurring of a word or catching your breath at the wrong moment, or a slight cough or inadvertent clearing of the throat—what an annoyance! Thank goodness my brash opinion on the original phone call was correct. And thank goodness that the eminent men who handled the case, particularly Dr. Ravdin, exercised such excellent diagnostic and procedural judgment. Ulcerative colitis is a much more common disease than ileitis, involving, in part or in whole, the large bowel or colon. Knowledge of the disease has always been attributed to Wilks and Moxon, two English physicians who distinguished it from tuberculosis in 1875. However, my interest in our Civil War (for I am, and have always been since childhood, a Civil War buff) led me to read and study the medical history of that war, and among the official 96.


Medical and Surgical Archives of the War of the Rebellion, I discovered that the surgeons in Washington had years earlier had—in 1865—seen, described and illustrated typical cases of ulcerative colitis in their autopsy studies. When, as interns in 1910, we saw a case of ulcerative colitis, it was a rare phenomenon. Dr. Libman, I recall, spent much time discussing the unusual clinical features. Today, ulcerative colitis is a common disease—unfortunately, very common—and unhappily, too, because in adolescent children the course of the disease is debilitating and devastating. My own files of private patients contain the histories of almost 3,000 cases of ulcerative colitis in comparison with I,000 cases of regional ileitis. Are these diseases, again we ask, diseases of our modern civilization? Or have they always been present? I remember that in my intern years, 1910 to 1911, a single case at Mount Sinai aroused intense interest because of its rarity! One possible explanation relating to ulcerative colitis is comprehensible: the modern, electric-lighted proctoscope or sigmoidoscope. This is an apparatus by means of which the interior of the rectal cavity can be clearly discerned and examined. Our earliest sigmoidoscope, in the first decade of the century, was a long, rigid, hollow tube. The lighting apparatus was most primitive: a nurse held a lighted candle or a frosted bulb. The examiner used a mirror on his forehead to reflect that dim light down the shaft of the dull metal tube. It was a most unsatisfactory instrument, almost hopelessly lacking in utility. The modem instrument, with its perfect light, opened up a whole new range of diseases and probably explains why we can now 97.


recognize, in its early stage, the characteristic lesions of colitis. Today, the wards of all hospitals contain many too many cases of this dread disease. In 1925, Dr. Daniel Rosenberg and I described the first case of carcinoma (cancer) in ulcerative colitis. The article originally attracted little attention, but since then medical literature has emphasized the increased incidence of malignancy in longstanding (10 years or more) cases of ulcerative colitis. In 1946, an incident took place in the hospital that attracted my attention. Ward C, Bed 16 contained a very sick man suffering from severe ulcerative colitis. He was without fever, but was emaciated and severely anemic. A blood transfusion was given. Two days later the man had a severe, shaking chill lasting a half hour, followed by a rapid rise of temperature to 106° F. It was logical to suggest that this was just a reaction to transfused blood, not particularly unusual except in its severity. The patient, once his temperature dropped, was well for two days, when, at the same hour in the afternoon, the whole cycle of chill and fever repeated itself. At this point, an alert intern suggested that maybe this paroxysm was due to malaria. The patient had never been exposed to malaria, but now, on following up the suggestion, his blood was tested and discovered to be swarming with malarial plasmodia. The donor of the blood was traced; he was an immigrant who, on being questioned, remembered having had malaria in “the old country.” The patient’s paroxysms were immediately controlled by quinine. What was most interesting was the fact that the man seemed 98.


cured of his symptoms of colitis, too. The diarrhea was controlled, appetite returned and he was quite well. Of course, the idea naturally suggested itself: why not try the same experiment on other cases of severe colitis? To use routinely malarial blood for transfer was too dangerous. I conceived the idea of utilizing dead typhoid vaccine to produce the same reaction. Non-specific protein (viruses are proteins) therapy was at the time popularly in use for the treatment of arthritis; any protein might do, but typhoid vaccine, given intravenously, was safe and handy. This treatment was put into routine use by me for all cases of severe ulcerative colitis. It did not require hospitalization, could be given at home or even in the office and was very effective. A paper on the subject was read before the Society of the District of Columbia in 1947. To this day, patients still remind me of their cure, years ago, by typhoid vaccine. The incident on the ward was an instance of serendipity. Often now I think back to Sir Alexander Fleming and the discovery of penicillin in 1929. How many dozens of times, as an intern in pathology, did I fling a Petri dish into bichloride solution because a fungus had contaminated the culture of streptococci! The fungus was presumed to have originated due to an error of technique, and it caused only annoyance and frustration. Fleming was more astute. Before discarding the Petri dish he noted that where the fungus grew the streptococci were arrested. This brilliant observation led to the utilization of the fungus, as penicillin, to control many types of bacterial infection. How many generations of laboratory workers had observed the same phenomenon, but had not ... “seen!� 99.


Although ulcerative colitis is more serious than ileitis, it, too, is amenable to medical treatment by cortisone or corticosteroid products, intestinal antibiotics and by general supportive measures. However, when the disease threatens life, happiness and efficiency, total removal of the colon, leaving a permanent ileostomy, saves lives and restores health, as well as the prospect of longevity. Patients marry, they bear normal children and are restored to full efficiency—physical, moral and spiritual. Occasionally, though very rarely, the ileostomy may after a course of months or years be taken down and reconnected with the stump of the rectum, thus reestablishing intestinal continuity. Ulcerative colitis is a disease which tends to recur over the course of years. And yet, medical treatment is at times so successful that complete cure is possible. In my files are records of several cases of severe ulcerative colitis that were cured and remained cured for as many as 35 years. These days the psychosomatic aspects of diseases are being introduced and stressed. The psychic irritants of anxiety, nervousness, chronic tensions, of unresolved conflicts in life can cause disease and, if not, can cause real pathological changes. They certainly influence the course of a disease. Peptic ulcer of the stomach and duodenum and the diarrheal diseases, particularly ulcerative colitis, became the foci of intense study and thought. At first skeptical, I concluded that the subject certainly merited deep consideration. The increasing number of cases of ulcerative colitis in our time and the severity of this debilitating disease were alarming. Still more alarming was the increased number of cases in children and adolescents. The disease seemed to affect the more alert, the more 100.


intelligent and the more emotionally labile of both children and adults. They were often high-strung, emotionally disturbed students with imagined animosities, unreasonable prejudices and disturbed relationships with their parents, particularly the mother. An adult woman with ulcerative colitis, who had been free of symptoms for years, saw her child run over by a truck. By a miracle the truck ran “over” the child without injury, the child’s body lying between the wheels. Within hours the mother suffered a relapse of ulcerative colitis brought on solely by fright. Many physicians have dealt with the problem of the overprotective mother and the resentful, ill child. North Carolina provided such an example. A girl with ulcerative colitis was brought to me in New York by her mother. It was immediately apparent that the mother was a dominant, overprotective and overly solicitous parent, constantly hovering and forcing her captious behavior on the probably (though unconsciously) resentful child. In the treatment of any case such as this, it is essential to establish a close rapport between physician and patient; with the mother constantly intruding, that would be impossible. The absolute condition of treatment was that the mother return to North Carolina. Reluctantly, she agreed. After several days in the hospital, it was apparent that the child was not improving as expected. Some days later the nurse assigned to the case queried, “Doctor, do you really want to know what is wrong with your case?” The mother had not returned to North Carolina. Every day she had hidden in the linen closet on the floor until my rounds had been made; the remainder of the day and night she hovered over the child. Under such circumstances, the best medical aid was of course circumvented. 101.


Ulcers of the stomach or duodenum are often typical examples of psychosomatic influence. This was particularly impressed upon me by an example early in my experience. A man who had been treated previously for duodenal ulcer had remained well for years. Awakened at midnight by a fire in his hotel, he was carried down the ladder eight stories by firemen. Within hours, he suffered a massive hemorrhage from the reactivated ulcer. Also instructive was the case of a boy, scion of his family, who was attending one of the stylish private schools in Connecticut. His father and the school pressured this young man to produce a perfect record. Unfortunately, he flunked the final mathematics examination. I was called in consultation to advise on the treatment of a very severe hemorrhage he suffered from a duodenal ulcer. Granulomatous colitis is another in the triad of inflammatory bowel diseases, recognized more recently by the profession. In 1938, Dr. Berg and I first described a segmental form of colitis involving the right colon or segments of the proximal colon without rectal or ileum involvement. This disease, of which I saw 300 cases, is relatively rare (about 10 percent of regional enteritis cases), but who knows how many such cases went unrecognized in the decades preceding its definition? British clinicians insist on calling this “new” malady Crohn’s Disease of the Colon despite my oft-stated reluctance regarding the use of my name, this time for a second disease. They explain and insist that using the name signifies clearly, to their students, the pathological nature of the disease as allied to regional ileitis, namely, a granulomatous disease process. Much of the development of the successful surgical cure of granulomatous colitis is due to the late Dr. John H. Garlock. Not 102.


only was he a master technician at the operating table, but his scientific judgment was keen, and he had a distinctive clinical acumen unusual in a surgeon. He always carried a stethoscope in his back pocket, and he was as outstanding a medical man as he was as a surgeon. His sudden death was a great loss to the scientific world. The description of granulomatous colitis awakened much scientific interest. As a result, vast demands were made on my time, both as a teacher and a lecturer. But having another disease named for me did not go to my head. My great friend in London, Dr. Bryan N. Brooke, professor of surgery, asked his graduating class, “In what century was Crohn, of Crohn’s Disease, born— 17th, 18th, 19th or 20th?” The answers from the students were almost uniformly, “18th century”!

103.


{V } LATER YEARS

I

N 1941, directly following Pearl Harbor, went to the Office

of the Surgeon General in Washington and requested a commission. The day was spent arguing and getting nowhere. I was 57, “too old,” they said, and my country would be best served by me as a civilian. Finally, reluctantly, late in the afternoon, they made a tentative counter-offer—I could serve as medical director of a 2,000-bed military hospital. “Good,” I said. “What an opportunity to see clinical material and to conduct research on ulcer under army conditions.” They answered, “Doctor, from the first day of the year to the last day, you will sit in an ivory tower signing papers. You will never see a clinical case.”

That was the end of that for me. My incurable urge always to conduct some type of research queered me for a commission. The veterans’ hospital at Halloran on Staten Island, where I became gastrointestinal consultant, represented my best contribution, although it was an insufficient substitute for active service. In 1947, my daughter, Ruth, and son-in-law, Gerry Dickler, purchased a refurbished old colonial house in New Milford, Connecticut, from a lady named Rose Elbogen. She had sold the 105.


little house beside a river reluctantly because she was having so much fun rebuilding it. Together the family built a large stone terrace from flat rocks pilfered from the roadside stone walls, dammed the stream, and cultivated the hillside. I had the second floor of the barn on the property rebuilt as bachelor quarters for my son, Woodie, and me. I had been single since my divorce from my children’s mother 20 years before. Woodie and I visited New Milford on weekends. In October of that year, Rose was suddenly and unexpectedly left a very sad widow. Her husband, Paul, had died after a bout with pneumonia. I climbed up the long hill to her house to pay a condolence call, and then another and another. Like the man who came to dinner, I stayed and married my most charming wife, Rose, in June, 1948. The condition of marriage pivoted around my projected trip to Buenos Aires for a lecture tour. It was the bait that enticed my wife, a veteran traveler. Since then, the honeymoon has been continuously extended, all over the world, always ostensibly for lectures and teaching but actually for most interesting adventures. When we were home, we drove from our apartment in New York City to our house in New Milford, Connecticut, almost every weekend. During the Civil War Centennial, it was my pleasure to speak at the Merryall Community Center in New Milford. Since childhood, when I watched the Zouaves and the veterans of the Grand Army of the Republic march down Fifth Avenue on Decoration Day, the history of the Civil War has always engaged my interest. 106.


Though I rarely observe the rituals of my Jewish faith, my heritage has always been a source of pride. For several years, I served as chairman and leader of the medical section of the United Jewish Appeal. For the Joint Distribution Committee we raised funds from our professional brothers to help relieve the disastrous plight of Jewish refugees in Europe and Africa following the Second World War. My confrères were truly generous. When I first took over, the yield was barely $50,000 per year; after three years, we actually raised $450,000 annually by persuasion, and at times by moral pressure. In following years I succeeded in performing the same service for the Federation of Jewish Philanthropies, the organization that aids and helps to support the 50-odd institutions under its able agency. And to this there is no end! It was 1960 and time for a breathing spell. I had completed 50 years of continuous medical practice. At the age of 65, retirement from ward service at the hospital was compulsory so after 1949 all my activities could be devoted to my lucrative and scientifically satisfactory private practice. But 50 years of practice call for a year of jubilee. Accompanied by my fond wife, Rose, and our friends and neighbors in New Milford, Fredric and Florence March (Florence Eldridge was her stage name), we four planned and executed a four-month trip around the world. An exciting and exhilarating trip it was: Israel, Iran, India, Singapore, Indonesia, Bali, Ceylon, Hong Kong, Taiwan, Japan and home. Stopping frequently along the way for medical lecturing was a source of satisfaction, particularly in Israel, as well as at Shira in Iran, in Bombay and New Delhi and elsewhere. It was difficult to hide Freddie or Florence anywhere 107.


in this world; they were always spotted, recognized and lionized. We were invited to a luncheon given by Mr. Nehru himself, and the Marches renewed their friendship with the Shah of Persia. One incident in India brought us international notoriety. We were traveling in southern India, had been in Cochin and were making our way north to Madras. We stopped to visit the Maharaja of Mysore and listened to his learned disquisitions on modern philosophy. We were also guests of the Maharaja of Jaipur, who unfortunately was ill with measles; his delightful wife made up for his absence. The car and our guide had just passed under an archway traveling toward Madurai. The guide explained upon questioning that the arch indicated the border between two provinces, a fact that at the time seemed to be of little significance. Suddenly, a roadblock appeared, and police sprang from the bushes. They stopped the car and searched it thoroughly. The trunk was opened, our personal bags riffled through, our belongings scattered in the dust. A sudden excitement! My medicine bag containing four ounces of Scotch whiskey, against a possible medical emergency, was discovered. We were all under arrest, taken by police escort to the nearest town, Gudule, in the province of Madurai. It was by now about 11 in the morning, approaching noon in southern India, and it was dry, hot and dusty. It appeared, so the guide now told us, that we had passed from a “wet” to a “dry” province and were illegally in possession of that stuff called “whiskey.” Carelessly, my permit as a foreigner to carry liquor, which had been signed in Bombay, and was good for 30 days, unbeknownst to me had just lapsed. 108.


The police sergeant was still at breakfast and could not be disturbed so early. Finally, he arrived and wrote out a detailed arraignment in quadruplicate. The writing paper was coarse brown wrapping paper; the ink was applied with a quill and a bottle; there was no carbon paper so that each copy had to be handwritten. “What was your father’s name? What was your mother’s maiden name?” were some of the questions we were asked. Meanwhile a crowd gathered, the village quit working to view the proceedings, the midday sun turned up its burning heat and the dust grew thicker. Our guide spoke only Hindi; the proceedings were in Tamil. Fredric March tried to argue that I was famous as physician to President Eisenhower [sic!]; I tried to explain that Fredric March was one of the greatest living actors and movie stars. But since we could speak neither Hindi nor Tamil, our excited words evaporated in the hot air. We were truly in a mess for we were on our way to catch the 5 p.m. plane from Madurai to Madras and, from Madras, the oncea-week plane to Ceylon! The day was passing fast. As for me, I was to be arraigned before the only judge in the village, but he was ill, and his wife would not allow him to be approached even to sign papers of release. The next nearest judge was 32 miles away; they would send for him by bullock cart. If only we could reach Mr. Nehru, with whom the Marches had lunched and been cordially entertained but a few days before! The village possessed exactly one telephone, and that phone was in the post office, which was open from 8 to 9 a.m. daily. Freddie and I planned to steal a jeep that was standing by, but that escape plan was foiled. Finally, I, as the culprit, signed a bond of $17,000 109.


to reappear the next day for trial and agreed to a possible fine of approximately $400, if found guilty. We were thus released and just made the plane at Madurai. While waiting for the plane, however, a heated argument started between our guide and one from another travel agency, whom our guide suspected of having tipped off the police as part of a competition for business between the two agencies. We got into the fight ourselves, angry, tired, annoyed, incensed. Furious words flew. At that moment I happened to notice a little man alongside me, taking notes. “What business is this of yours?” I asked. “Oh,” he said, “I represent the U.P. and A.P. and Reuters Dispatch.” And that is why that petty incident made headlines in The New York Times and apparently the world over, as evidenced by the correspondence and apologies that came for weeks thereafter, mostly to Fredric March. Even one of the senators from Connecticut brought up in Congress the indignities that his constituents had suffered in India. The next day, the U. S. consul in Madras caused the provincial authorities to nullify the offense, and apologies came from all over, including explanations and apologies from Mr. Nehru himself. Since then the law in India has been modified, so I am told, to allow foreigners or tourists to carry four ounces or more of Scotch. But of all the deeds, successes and accomplishments of my whole lifetime, none has exceeded the public notice and notoriety of my arrest in India for carrying illicit liquor! Traveling is Rosie’s and my greatest source of interest and recreation, as well as a welcome opportunity for me to lecture and promote the mission of scientific progress. We found 110.


ourselves two years later in Egypt, where we journeyed far up the Nile to Karnak, Aswan and Abu Simbel. On returning, I was invited to address the University of Cairo on the subject of ulcerative colitis and ileitis. It was 105° F. outside. The hall was not air-conditioned, there was no loud speaker, the drinking water in the carafe looked like Nile water and was obviously not potable. My city suit clung to me long before the end of the strenuous lecture. But the professor in charge took me aside and said that he was authorized to offer me a three-months’ professorship in Egypt. Considering my religion and nationality, this was quite an offer. It was declined! Some lectures are not scheduled but are thrust upon one by chance or serendipity. My wife and I were traveling in Spain in 1962 as part of a trip arranged by the Archives of American Art. We wandered away on our own to visit Salamanca, whose university was one of the oldest institutions of its kind, founded in the 12th century. It had one of the first medical schools of medieval Europe. We were walking down a street, somewhat lost in the city with its old Romanesque buildings, looking for the famous library. We asked directions of a young man who turned out to be a student at the university. He answered in perfect English. He turned out to be an American, a medical student at the college. Would I be interested in seeing the medical school? Was I a physician? On entering the quaint old building with its smell of formalin and disinfectants, we were introduced to the professor of anatomy. On seeing my visiting card, he hesitated for a moment, looked again quizzically at the name, and suggested that perhaps the professor of medicine would like to meet me. Apparently, he recognized my name; he extended a cordial invitation to address 111.


classes next morning. No plea of lack of preparation or lack of slides or illustrations was acceptable. Next morning at 10:30, a delegation of students called to escort me to the school. The smallish auditorium was crowded. The dean himself was present and introduced me, of course, in Spanish, only an occasional word of which I understood. For an hour, with only a piece of chalk and an eraser, in what was to them a foreign language, constantly interrupted by the interpreter, I tried to elucidate the subject of regional ileitis (Crohn’s disease). Apparently, the lecture was a success. The dean thanked me enthusiastically for my unexpected effort and said (according to my interpreter), “It was like Christopher Columbus returning from the New World.” In 1964, the International Congress of Gastroenterology met in Brussels, a wonderful city, the center of many centuries of history revolving around the Low Countries. I was invited to read a paper on granulomatous colitis, the most recent of the topics on colitis and possibly one of the most interesting. Here I learned what true Belgian hospitality was: not once was I allowed to pay for a meal nor for a taxi ride. When at the end of the session I attempted to pay my hotel bill, that, too, had been taken care of, anonymously. Montreal was the seat of a joint meeting of the American College of Physicians and the American Gastroenterological Association in 1965. As one of the panel of instructors at a joint post-graduate course, my topic again was granulomatous colitis, a subject that the British clinicians have so much emphasized and to which they have attached so much importance. The halls and corridors of the remarkable and interesting Queen Elizabeth Hotel teemed with persons of professional fame. The city itself, with its historic 112.


background, and particularly the Mount Royal with the old McGill University, embodied the aura of Osler and the Osler tradition at its best. Much of our August vacation in 1965 was spent in Buenos Aires and the Argentine on the invitation of my friend Dr. Norberto Stapler. Dr. Stapler had built himself a small modern, private clinic and surrounded himself with a group of enthusiastic scientists devoted to the specialty of clinical gastroenterology and related scientific studies. The graciousness of their hospitality more than compensated for the duties of my lectures which, although they covered less than one week, began at 10 p.m. and ran to midnight (with an intermission for tea) which was a bit unusual, at least for me. By far the most interesting experience was speaking at a joint session of the Gastroenterological Society of Australia and the Section of Proctology of the Royal Australian College of Surgeons in Canberra in October 1965. My respect for British clinicians and British-trained clinicians has been ingrained by frequent contacts, and Australia was a powerful magnet. Australian medicine was excellent, with some very significant research being carried on. Canberra, the capitol city, hosted the combined medical societies. The part I played was very minimal. Actually, all they wanted was to see me in the flesh. They requested the background and steps that led up to the discovery of regional ileitis and the granulomatous diseases. My name, the eponym, has been so much used and abused, particularly by British colleagues, that they seemed to relish the personal contact. The privilege and title of an honorary member of the Gastroenterological Society of Australia was bestowed upon me, for which I was very grateful. 113.


{V I } L’ ENVOI

A

S I L O O K B A CK O V ER T H E YE ARS, the contrast is striking

between the simplicity and primitiveness of the first decade of this century and the complexity of modern medicine. To have lived through the rapid advances of the past six decades has meant and means to us all constant application of new procedures, constant reading of medical journals, repeated attendance at world conferences and national and state meetings and unremitting time and effort to keep up with scientific advances. Medicine can be the mistress of all one’s leisure moments. Time for family, for friends, for music, for art, for travel, so essential to the well-rounded man, is difficult to find. A wife must often surrender her husband’s attention in the interest of Aesculapius and the Hippocratic standard of conduct for the conscientious physician.

On reflection, it is a source of satisfaction to feel that in a small way I and others of my generation have handed down some of the old and new traditions of clinical medicine. In my office the opportunity has presented itself to train young men in gastroenterology; these were aspiring practitioners who volunteered their services in return for the old preceptor method of learning by contact. Doctors Abraham Penner, Bernard Rosenak, Albert Yunich, Mike Shutkin, Harold Goulston, A. I. Friedman, Roger Steinhardt, 115.


Henry Janowitz and others all developed into recognized and successful specialists in this chosen field. I like to feel that Dr. Richard H. Marshak, a really brilliant radiologist, gained much from sharing offices and from the rich clinical material provided by my practice over many years. Just as I derived my inspiration from Dr. Emanuel Libman, I hope to have passed along much of my enthusiasm to these men. The graduate courses given by Columbia University at Mount Sinai meant contact with many receptive graduate students. In 1969, at the age of 85, hoping to devote full time to my Connecticut farm and to my beloved wife, Rosie, I sent out retirement notices, inspired by sentiments from Thomas Jefferson: The motion of my blood no longer keeps time with the tumult of the world. It leads me to seek for happiness in the lap and love of my family, in the society of my neighbors and my books, in the wholesome occupation of my farm and my affairs, in an interest or affection in every bud that opens, in every breath that blows around me, in an entire freedom of rest or motion, owing account to myself alone of my hours and actions. I had convinced myself that it was time to retire, but I failed to convince my patients and colleagues. I remained in practice for another five years. The practice of good medicine is its own reward. Let me quote Paul C. Hodges: “As has been said so many times by so many people in so many connections over so many centuries, if those who follow see further than their predecessors, it will be because they are standing on the shoulders of giants.�

116.


EPILOGUE

Ruth Dickler, Dr. Crohn’s daughter, read this on the occasion of her father’s 80th birthday, June 13, 1964. Dr. Crohn did not retire for another decade. He died of natural causes at 99.

With the exception of my brother, nobody here knows my father as a father. I would like to tell you about him as I came to know him in my youth. Some things you know already. That he is a man of tremendous physical energy. That he is physically probably the fittest of all of us, young and old—a man who digs up the earth, plants the seed and harvests the produce of a large garden. That he is a man of enormous mental energy, a man for whom there is no end to intellectual vistas, who is not only an expert in his field but an expert on the Civil War. A man who has become knowledgeable in many other things, as well—art, history, music, literature. I can remember coming home from parties and finding my father sitting up in bed, reading. I would tell him about my evening, and then he would say, “Listen to this,” and he would read to me from Macaulay’s history of England or Gibbon’s history of Rome, picking 117.


the lively passages that would appeal to a young girl, and so enthusiastic that it was impossible not to enjoy it with him. He was a superb teacher, and long before any of us thought about progressive education and motivation, my father instinctively taught my brother, Woodie [Dr. Edward B. Crohn] and me in a way that made learning a joy. He would take us Sunday afternoons on trips, and every trip became an expedition. If we were in hilly country, we were cold and starved in our covered wagons, barely making our way through the Donner Pass. When we crossed a river, we were Washington crossing the Delaware. Climbing the rocks in Central Park, we were the French and the Indians fighting the British and dying heroically in the great battle of Quebec. The warm interest and attention given me in my youth were only one evidence of Dad’s love of people, sympathy with their strivings and empathy for their woes. Young and old alike have responded to his affectionate engagement. What else can I tell you about my father? That he is brave? I learned early from him to bear physical pain gracefully. To conquer fears that had no basis in fact. To bear with discomfort. To overcome problems that seemed unconquerable. Dad mixed compassion with a zeal to right things. In a thoroughly nice way, he has always demonstrated the power of positive thinking. When I was quite young, in third or fourth grade, we had a teacher who had a passion for mental arithmetic. When you failed, which I often did, you were supposed to have your father sign your paper and return it to the teacher the next day. After a 118.


while I couldn’t bear being so stupid, and I practiced my father’s signature until I was an expert forger. And then I was caught. My father got home long after my supper. He came and sat on the edge of my bed and asked me why I had forged his name. I told him I couldn’t face him with a long series of failures. Naturally, I expected to be severely punished. Instead, he patiently explained why forging his signature was unproductive and suggested that the next time I ran into trouble with my work, I should come to him for help. When he was with us, sometimes we played guessing games. Was it the Seventh or Eighth Beethoven Symphony Pa was whistling? Was it Longfellow or Bryant he was reciting? The City of New York was boundless in its opportunities, and he used them all. What did we see? Trinity Church. The Sub-Treasury Building where Washington took the oath of office. The Staten Island Ferry and the tugboats docked near the Battery. The Aquarium, the Bowery, the Lower East Side, Chinatown, Little Italy. The Bronx Zoo and the Brooklyn Botanic Gardens. The Jumel Mansion. Dyckman House. You name it; we saw it. We visited the Metropolitan Museum, the Natural History Museum, the Museum of the American Indian and the Hispanic Museum way up on Broadway and 155th Street; the Brooklyn Museum, the Cloisters and all the others. And where didn’t we eat? In Chinese restaurants, in Sweet’s on the East River near the docks. In Katz’s on the Lower East Side. In French, Russian and Japanese restaurants all over the city. Was everything intellectual, then? Certainly not. 119.


There was Coney Island with hot dogs and sauerkraut and lots of ice cream. Movies. I remember “Ben Hur” and “The Freshman” and “The Jazz Singer.” The Hippodrome. And many, many Sunday afternoons in Van Cortland Park or Westchester’s open country, playing baseball or hide-and-seek or cops and robbers. And, of course, there were the long walks in the city, when we frequently met patients whose names Dad couldn’t remember. We developed a technique for that problem. He nudged me; I hung back and pretended I didn’t know him. Then if he knew the name, he called me over and introduced me. And there was his delightful flouting of minor rules. For instance, one night every week or two Dr. A. A. Berg, the famous surgeon, used to hold medical meetings at the Harmonie Club, and a wonderful cold supper was served afterwards. It was customary to pass out paper bags after everyone had had his fill, and each of the doctors was expected to take something home with him. My father would come home around midnight, long after I was asleep. He would wake me and sit on my bed and feed me the most wonderfully indigestible things and tell me about his day—what had happened that was special. And then he’d listen to what had happened to me. And all the while I’d be stuffing myself with pickles and fried chicken and streusel cake and other goodies any mother would have a fit about. But I justified his faith: I never got sick. They talk today in the columns for parents about how it isn’t the amount of time you spend with your children, but the quality of parental attention. Instinctively, my father knew this. He was out a great deal.

120.


Sometimes he would be gone by the time I woke up, but usually he would be around, and I would sit in the bathroom and watch him shave, and we would make plans or settle my problems. Sometimes he was out for dinner and the evening. Often he would be called out to see a sick patient. But somehow he made time for me. I often went along on house calls, lugging my book or my homework and waiting in a patient’s living room or the lobby of the hospital. He even took me to medical meetings, and I would listen fascinated and get to meet some of the great doctors. Often I was allowed to roam the lower depths of the hospital, watching technicians in the laboratories or playing with the animals used for experiments. Does this splendid man have no faults whatever? Certainly he has. What are they? I can’t think what they are at this moment. It will have to be the subject of my next paper—on his 85th birthday.


THE BURRILL B. CROHN RESEARCH FOUNDATION

Division of Gastroenterology, Mount Sinai Medical Center One Gustave L. Levy Place, New York NY 10029–6574

Evolution of a Medical Specialist  

Burrill B. Crohn, discoverer of Crohn's Disease, recounts his life, research and times.

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