Title: Leighton Cluff
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UFHC 44
Interviewee: Dr. Leighton Cluff
Interviewer: Nina Stoyan-Rosenzweig
Date: September 14, 2001


S: This is an interview with Leighton Cluff, by Nina Stoyan-Rosenzweig, the date is
September 14, 2001. I will start, Dr. Cluff, asking you when and where you were
born?

C: I was born in Salt Lake City, Utah, in 1923.

S: Can you give me just a little background about what it was like growing up there?

C: The Second World War was on when I came east to go to medical school, and I
have not returned since that time except to visit family. I have no more family in
Salt Lake City, [which] was a wonderful town to grow up in. I went to elementary
school, junior high school, high school there, and graduated from the University
of Utah and left there to go to medical school in the east two weeks after I got
married. The Second World War was on at that time. I had initially volunteered
for the Navy in 1941 shortly after the war started, after Pearl Harbor. I joined the
Navy V-12 program, was transferred to the University of Colorado to complete
my pre-medical training, but because of a chronic ear infection I was discharged.
[I] went back to finish school, went to medical school and subsequently, of
course, I was drafted again and served in the United States Public Health
Service [and was] attached to the Navy. I came from Salt Lake City, [and] that is
where my wife came from as well.

S: Did you meet her there?

C: Yes, she was in one high school, I was in another, and we met through a mutual
friend.

S: You went to school at the University of Utah, or at least you started there.

C: I graduated from [Utah] in 1944.

S: You said you had a little bit of a detour due to the war?

C: Not really, because being in the V-12 program, I was deferred from active military
duty and continued in college during that period of time. That was a program
during the Second World War which allowed certain individuals who were
pursuing degrees like medicine to remain in school while being attached to the
military service. The V-12 program was a Navy program which I had enrolled in
and served in, and when I was transferred to the University of Colorado, that was
the program I was in at that time.









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S: Could you tell me just a little bit about what you did in the Public Health Service?

C: Yes, I joined the Public Health Service in 1955, and at that time I was an
assistant professor of medicine at the Johns Hopkins Medical School. The
Korean War was on and the possibility of my being drafted was [likely], so I
joined the Public Health Service. Because of my expertise in infectious diseases
at that time, I was attached to the Navy program at the Fort Detrick Biological
Research Center [officially the Biological Defense Research Laboratories at Fort
Detrick, Frederick, Maryland]. That was the principal center of the United States
for the study of biological warfare. I was attached to that program for two years
and served as medical consultant to the Department of Defense on biological
warfare [for ten years].

S: What were they considering in terms of biological warfare?

C: The diseases I dealt with were botulism, anthrax, most of the equine
encephalitides, brucellosis, tularemia, [and] influenza. Those were the principal
ones being investigated at that particular time.

S: I remember from looking at your publication list you have written some papers on
brucellosis.

C: I did those papers on brucellosis while I was attached to the Navy at the
Frederick, Maryland Biological Warfare Center.

S: What were your feelings about being involved in that sort of program?

C: You must remember that we were in a Cold War at that time. Russia, the
U.S.S.R. at that time, [was] well-known [to be] very much involved in the
development of biological-warfare weapons. One other organism was Pasteurella
pestis, [source of the bubonic] plague. The Chinese accused the United States of
having released plague in China during the Korean War. We were in the midst
of a Cold War, and it was clear that biological warfare was a potential threat to
the United States and to the military services as they were serving abroad. I felt
like I was honoring my duty to the nation.

S: Was this mostly defensive?

C: I was involved exclusively in the defensive aspects of biological warfare.

S: What were some of the defensive programs or things that they were considering?
How did they plan to defend against biological agents?

C: That was an area I got very actively involved in because the principle mechanism









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for the dissemination of biological weapons at that time was airborne [means].
One of the other agents that was under consideration then was Q fever. The[re
were] elaborate facilities at Fort Detrick for the experimentation of aerosolized
microorganisms. Often times, [they were] using volunteers to examine the whole
issue about what particle size was required for the aerosolization of a
microorganism to, in essence, induce infection, and what was the load that was
required to produce infection, and there were also studies being done in the field.
The principal field testing ground program was at Dugway, Utah, which is right in
the Salt Lake Desert. I had opportunities to serve] as a consultant to the
Department of Defense [while in CPHS, and] all the time I was at Hopkins. I
went to Dugway proving grounds on one occasion with the director of the
National Institutes of Health, James Shannon [1955-1968], with Walsh
McDermott, who had been very much involved with the control of tuberculosis
and Tommy Francis, who was responsible for the polio [Jonas] Salk vaccine
[national study]. [We went] to investigate the program at the Dugway proving
ground, [because] they were aerosolizing, at that time, Q fever organisms. The
reason I was asked to go out there and consult was because there had been a
claim made by some sheep herders in that general vicinity that their sheep had
become infected with Q fever and had died. Our job was to go out there and
investigate the nature of the experimentation that was being done by the
aerosoliziation of organisms. There they were looking at the whole issue, what
air patterns, what wind patterns were involved in determining how an organism
disseminated into the air was likely to be disseminated. There were also studies
going on in the northwest using the Bacillus globegii, which is a non-pathogen,
does not produce disease in man, but is easily detectable. By airplane,
organisms were released into the atmosphere in the northwest and the pattern of
dissemination was examined throughout the northwestern states. As far south
as Utah, California, Montana, Idaho. All of this was done to try and get an idea
as to how air currents and the flow of air had an impact on the dissemination of
microorganisms. That was clearly an effort to try to get at the issue of offensive
weapons as well.

S: What did they learn about the possibilities of disseminating this from the air?

C: Yes, as a matter of fact, Walsh McDermott and I published a review on the whole
issue of airborne infection based on the work being done on biological agents.
[It was] published in Bacteriological Reviews, that must have been about 1957 -
1958, which was a definitive evaluation of the whole issue of how organisms can
be disseminated into the air, what particle sizes are required, because if a
particle size is too large, it will get held up in the upper respiratory tract, which is
not where you want them to be. You have to determine what particle size was
necessary to get the organism into the lung. We published a very extensive
review which was under the auspices of the National Academy of Sciences, and
we had representatives from the Department of Defense and experts in the field









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participated [as well]. That publication, I think, opened up the whole field of
airborne infection, because there had been very little work done on that before.
Moreover, there were studies being done as a result of that to try to determine
how do you protect against airborne infection in terms of immunization, use of
masks, what kind of masks are required, how does one protect against the
dissemination of organisms, [and] availability of stockpiled anti-microbial drugs all
of those things were covered in that publication. I think that publication had a
significant impact on the dissemination of interest in the whole issue of airborne
infection.

S: It sounds like most of the potential diseases they are considering were bacterial?

C: Bacterial and virus and rickettsial.

S: So there was a wide range?

C: Yes, and bacterial toxins as well.

S: Did they ever decide on something as being ideal?

C: I do not think so, not at that particular time. Everything was in consideration
because those were the organisms that were recognized for being studied by the
U.S.S.R.

S: I would like to go back and at least talk briefly about medical school. You went
to George Washington University?

C: Correct.

S: How did you choose that particular medical school?

C: At the time I was getting ready to go to medical school, the University of Utah
only had a two-year medical school. I was very much dependent on the advice
and counsel of physicians known to me in that area and it was interesting indeed,
even though I was not a Mormon, the bishop of the Mormon Church in
Washington D.C. was the professor of anatomy at George Washington
University. For that reason, I am sure a very large number of young people from
Salt Lake City went to George Washington University's medical school. I would
venture to say that a third of my class were from Utah. I went there in large part
for that [reason]; I was also admitted to the University of Pennsylvania but having
grown up in Salt Lake City, Utah not knowing an awful lot about the eastern
United States at that time, it was an obvious reason for me to go to George
Washington University.









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S: To go back even further, were you always interested in medicine? Was that
something you started as an undergraduate?

C: I became a pre-medical student when I went to college. What was responsible
for and what was the nature of the origin of my interest in medicine, that is a
question that is about as difficult to answer as possible. When I was a faculty
member at Hopkins and when I was here as chairman of the department of
medicine, interviewing medical students for internships or for admission to
medical school, I would frequently ask them that question. I found very few of
them who could answer it definitively. Often times if their father was a
physician that was easy, [they would say,] well, my father was a physician and
my father wanted me to go to medical school. The only person in my family that
was a physician was an uncle, but I do not think he had much influence on my
going to medical school. However, while in the University of Utah as an
undergrad student, I did a lot of work in the summer and on weekends for the
laboratories of the hospitals in Salt Lake City. I served as a lab technician in one
of the major hospitals in the city. Subsequently, [I] became the laboratory
technician of the Salt Lake General Hospital, which became the principal
teaching hospital at the University of Utah, where I happened to meet Dr.
Maxwell Wintrube, who [then] was the most distinguished hematologist in the
world. He had just moved to Utah to become chairman of the department of
medicine there. Obviously those associations had a significant influence on me,
but it was an evolutionary thing. I do not think there was a point in time when I
decided I wanted to be a doctor.

S: There was not a single defining moment or anything?

C: No, I do not think there ever really is. People may think there is, but there really
never is.

S: That is just what they might remember as being the defining moment. In
medical school, obviously you specialized in medicine and in infectious disease.
We have just been talking about how you make choices, when did you choose
that as your specialty?

C: I do not know that either. I was in medical school while the Second World War
was on and at the end of my sophomore year we were on an accelerated
program where medical schools were graduating students in three years, not
four. We went to school twelve months of the year. At the end of my sophomore
year the war ended, so all medical schools in the United States had a prolonged
vacation. I had a six-month break before I had to start my junior year. That
six-month period I spent as a Research Fellow in the department of pathology in
the medical school. [I] was doing a lot of autopsies and working under the
tutorship of the chairman of the department, as well as one of the faculty









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members. I wrote a paper on a patient that I had done an autopsy on, a young
seventeen- year-old boy who had disseminated tuberculosis. I published a
paper on that, [and] a couple other papers I published as well. [I] became very
much involved in the study of the important effect of radioactive materials,
particularly thoriam dioxide on human tissue, and published a paper on that as
well during that six-month period. At the end of that six-month period, I was
found to have developed tuberculosis. Mind you, at that time there was no
treatment for tuberculosis except bed rest. So I spent the next year away from
medical school in the sanatorium in upstate New York, at Saranac, the Trudeau
Sanatorium. That sanatorium was largely in a place for medical students and
other physicians with tuberculosis [who] often times went for treatment. There
were a number of other medical students there whom I got to know and have
been life-long friends. My having tuberculosis may have had an influence on my
interest in infectious diseases, I cannot say that for certain, but I suspect it did in
its own way. My subsequent interest in research and infectious disease really
began when I finished my internship at Hopkins and went to Duke Medical
Center for one year to work with Gene Stead and Sam Martin. At that time a
colleague, Ivan Bennett, and I wanted to do some research on fever, so we
worked in Sam Martin's laboratory at the medical center and during that year we
published three papers on fever. It was just a natural sequence of events from
that point on for me to move progressively into the area of research on the
various aspects of immunology and infection. After I finished my second year of
residency at Hopkins, I went to the Rockefeller Institute for Medical Research in
New York for two years where I did nothing but research. I got very much
involved with the study of rheumatic fever and streptococcal infections. I
returned to Hopkins at the invitation to become the chief resident physician for
the hospital, and after that I joined the faculty.

S: Let me just ask you as an aside about tuberculosis and physicians, was it fairly
common for physicians to contract tuberculosis?

C: When I entered medical school, ten percent of the class had a positive tuberculin
test, at the time of graduation ninety percent of them had a positive tuberculin
test. Not all of them developed active tuberculosis. In my own class of
seventy-five students, two of us ended up in the sanatorium. It was an
occupational disease for medical students.

S: Was that from patients, or from doing autopsies as well?

C: From patients, there were a lot of patients with tuberculosis [then]. [It was] often
times undetected and it was a very common infection, not only in medical
students, but in the public at large.

S: When you went through that treatment, which was just allowing nature to heal...









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C: I spent twenty-four hours a day in bed except when I had to go to the [toilet], it
was a cottage arrangement for the patients and it was in upper New York state, I
slept at night outdoors all the time, except when I went into the shower or went to
the toilet. When the temperature got below eighteen degrees Fahrenheit, [I had]
to wear a ski mask [so that my] face did not freeze and [I] had to have an electric
blanket. It was good food and rest and good medical care, and a lot of caring by
nurses and social workers and others.

S: When you went through the cure, would you then still test positive for
tuberculosis?

C: Yes, I am sure I am still positive for tuberculin tests, but I have not had one for a
long time.

S: I guess a large portion of the population always has tuberculosis but never
develops the symptoms.

C: Well, not now, not today.

S: That was the case back then.

C: Yes, the disease now is particularly common amongst two groups in our
population. Patients with AIDS [acquired immune deficiency syndrome] and the
homeless population, that is where the disease is most prevalent at the present
time.

S: That is also the population that is hardest to treat as far as making sure they take
their drugs regularly. At least the homeless, not so much the AIDS patients.

C: One thing that is interesting was [that] I had been married two years when I had
developed tuberculosis, and left Washington to go to upstate New York to be
treated [at the] sanatorium. My wife was a school teacher, she remained in
Washington that whole time. I only saw her twice over a twelve-month period of
time.

S: Did she ever develop tuberculosis?

C: No, she was tested, of course, by my physician, but she never developed a
positive tuberculin test.

S: Again, as an aside, I just found a book in the library from the early 1920s where
someone is making the argument that with an infection with tuberculosis, there is
a period where you have a lot of energy even though you are sick. According to









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the claim, a lot of geniuses who had tuberculosis actually became geniuses
because of their infection.

C: That has been written, but I do not think there is a shred of truth to it.
Historically you can find that written, [but] one has to be careful with that,
because genius or not, tuberculosis was very prevalent [in the past]. There were
a lot of non-geniuses who had tuberculosis as well. I think it would be very hard
to prove that tuberculosis generated geniuses.

S: That is pretty much what I thought as well, but it seemed like an amusing idea at
least.

C: There is a very famous book, which is still a classic, written by Thomas Mann
called The Magic Mountain, which anyone who has ever had tuberculosis will
certainly have read and it is a monumental novel about a person having
tuberculosis in a sanatorium in Switzerland. It is a classic and everyone [should]
read that book who has ever had an interest in tuberculosis or has not.
Obviously, I read it and it had a lot of influence. One thing that was interesting
about tuberculosis for me was that it was the one period in my life, up to [then],
when I had the leisure to read and I did a great deal of reading in both medicine
and literature. A lot of literature, [I] read all of the classics and I actually wrote a
paper during that period of time and published it. By the time I graduated from
medical school I published three scientific papers, but it was a time for reflection,
a time for thinking, a time for reading. I did a lot of reading.

S: As far as medical school is concerned, what was the medical school curriculum
like then?

C: Very much like it is today, it does not differ very much from what it is today.

S: In terms of the amount of memorization, the types of courses that you take?

C: Yes.

S: Clinical rotations?

C: Almost identical, the content has changed, obviously, but the program itself
remains very much the same. Two years of basic sciences, the last part of the
second year is physical diagnosis and introduction to clinical medicine. There is
obviously a little bit of introduction to clinical medicine in the beginning too. Then
you enter the clinical years, spend time in the clinics and spend time on the
wards. The one difference perhaps is that there was a great deal more
attention, at that time, paid to home care. When I was a medical student, every
medical student had to do home visits.









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S: Did people just not stay in hospitals as long then?

C: They stayed longer, patients were in the hospital a long time then. That was the
case up until a few years ago when the control of healthcare costs reduced
hospital stay. There was no hurry to get a patient out of the hospital then. A lot
of social factors had to be taken into consideration to determine how long a
patient stayed in the hospital. I can remember vividly when I was on the faculty
at Hopkins, a young black woman [with tuberculosis] being admitted to the
hospital who had four children at home. [I remember] spending a lot of time
dealing with social problems, making sure that her children at home had care and
reassuring her. We kept her in the hospital until we were confident that she was
no longer likely to infect her children, so she was in the hospital at least a couple
of months. They don't do that today.

S: In regard to home care, was that just visiting patients at home and making house
calls?

C: It was particularly during the course in obstetrics where the students were
actively involved in delivering patients and indeed they were obliged to make
home visits on mothers after they had returned home. This was a charity
hospital, so the patients were all indigent, but we were obliged, as students, to
make home visits on the patients whom we had delivered. [We had] to see
them in their home, advise them on the care of their baby, see what the
circumstances were, make sure that the babies were receiving adequate care
and that the mother was receiving appropriate care. We had an opportunity to
visit people in very poor neighborhoods. I can remember on one occasion
walking up four flights of stairs in a very dark, black hallway in a crummy area of
the city, walking into a room that was immaculate with the mother clean and the
baby dressed in pink clothing, exceedingly well-cared for, with a gas stove in the
corner where they got heat. One can gain a very deep appreciation for how
people [who] were poor and black nevertheless led very honorable [lives]. It's a
powerful experience which medical students today don't have.

S: They really don't see the patient in the community.

C: They don't even see them as people.

S: Well, that's something that I know you've written about and I want to talk about
that more later. You mentioned your internship at Johns Hopkins, how did you
choose Johns Hopkins?

C: The professor of medicine at George Washington University at that time had
been a faculty member at Johns Hopkins Medical School. I was first in my class









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and he befriended me and indicated that's where I should do my internship.
However, I was also advised to apply to the Massachusetts General Hospital,
Boston City Hospital, Brigham and Women's Hospital [in] Boston. And because
of another faculty member who was a close personal friend, I was invited to apply
at the Mount Sinai Hospital in New York. I was accepted in all of those places,
but my wife was working in Washington and we didn't have much money. It was
going to be much more convenient if she kept her job in Washington while I did
my internship in Baltimore.

S: It was really more or less within commuting distance.

C: She came to see me on Wednesday afternoons and we'd have dinner together.
Then she'd come over on Sundays and we'd have lunch together. That's all I saw
[of] her for a whole year.

S: That's amazing as well. How were you funding your internship?

C: At that time I wasn't paid anything. [For] my internship at Hopkins, I received no
compensation. I received my uniforms, laundry, and a room where I could sleep,
and I was given meals. That's what I received. I was obliged to be in the
hospital twenty-four hours a day, so I lived there. My wife was supporting
herself [with] her job, and what pocket money I needed she'd let me have.

S: What was she doing then?

C: She was teaching.

S: When you were an intern, were you working mostly in medicine at that point?

C: Yes, entirely in medicine.

S: Was this an infectious-disease internship?

C: No, it was general medical service.

S: Did you have contacts with anybody at that point who had a particular influence
on you or your interests?

C: It is very intense, but the chief resident that year was Dr. Robert Austrian and
[he] became a very close personal friend. Dr. Austrian was trained in infectious
diseases and microbiology. I got to know him quite well and I suspect he had an
influence on me. My year was an intense year in caring [for] patients with a
variety of medical problems.









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S: This was in Baltimore?
C: Yes, it was on the general public medical service known as the Osler medical
service at the Johns Hopkins Hospital.

S: Were you seeing a lot of urban medical problems, poverty?

C: Yes, mostly urban, because it was a charity service. At that time there was no
medical-insurance program like we have today. The county did provide some
compensation for the care of indigent patients, but the hospital operated largely
on benevolent, charitable contributions and funds derived from the care of private
patients. I didn't work on the private service, I was working on the public
service and got to love my patients and learned an awful lot.

S: With longer hospital stays, did you really have a lot of contact with them?

C: I had an opportunity to get to know them as individuals, yes.

S: After your internship, what did you do?

C: I went to Duke for a year and I did that largely because Dr. Eugene Stead had
just moved to Duke Medical Center from Emory as professor of medicine and he
was recognized as one the most outstanding teachers of medicine in the country
and had developed an outstanding department. Ivan Bennett and I both decided
we'd like to go work in his department for a year. We applied to Duke for a
year's residency and went to Duke for that year. After that year, Dr. Harvey, the
chairman of medicine at Hopkins, called and asked if I would come back. I said
yes, so I went back to Hopkins for my second year of residency. Duke was a
very formative year for me because I got to know Dr. Stead, who became a very
significant mentor in my life subsequently. [I] learned an awful lot about
medicine there and I also did a fair amount of research as well in my spare time
and published three scientific papers while I was there.

S: In whose lab were you doing the research?

C: Samuel Martin, who subsequently came here as chairman of medicine, and
subsequently [became] vice-president for health affairs.

S: As a resident, what salary did you receive?

C: At Duke I think I made $25 a month. I was provided with room and board, but, in
contrast to Hopkins, I wasn't obliged to sleep in the hospital [five] nights a week.
My wife moved with me to Durham, North Carolina, and we got an apartment. I
lived at [the hospital], except on the nights when I [was free]. Obviously I stayed
in the hospital a lot. During that year my wife initially worked as a retail clerk at









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a store in town, then subsequently worked in the medical school library, [and]
supported me the whole time.

S: Did you go back to Hopkins after that?

C: [I] went back to Hopkins for my second year of assistant residency; I think I was
paid $35 that year. Because I was obliged to be within walking distance of the
hospital, my wife and I rented a row house just a block from the hospital where
most of the house staff lived. We lived there for a year and she worked in the
Welch Medical Library during that year. As you can see, my wife supported me
for years.

S: I guess so. It also sounds like there were several years where the two of you
were apart.

C: Correct, [that's] probably why we've been married fifty-seven years. My
daughter not long ago asked my wife, mother, how have you stood living with
dad for fifty-seven years? She said, it was not difficult, he was away a lot.
[Laughter]

S: After your second residency, did you stay at Hopkins for a year?

C: No, I went to New York. I went to New York to the Rockefeller Institute for
Medical Research. I was advised to do that by Dr. Thomas Turner, who
subsequently became the dean of the medical school at Hopkins and at that time
was the professor of microbiology and immunology in the school of public health,
a very distinguished person. He recommended that during that year I needed to
have more grounding in immunology. While I was a second-year resident, I took
the course in immunochemistry in the School of Hygenie and Public Health. [I]
graduated first in that class, and I also worked in Dr. Arnold Rich's pathology
laboratory that year and published three papers from his laboratory. How I ever
did that and served as an assistant resident too, I really don't understand, but I
did [it] successfully.

S: Looking back on it, it seems impossible?

C: I don't know how I did it. The course in immunochemistry started at eight in the
morning. I would go into the wards at seven o'clock and make rounds with the
interns. Then I would rush over to the School of Hygiene to go to the class, then
I'd rush back to the ward to make rounds with the attending physician. The
laboratory course was in the afternoon from 2:00 to 4:00, so I'd rush over there
three afternoons of the week to take that course for two hours and that was for
three months. My duties as an assistant resident didn't falter at all. At the
same time, I was spending my evenings and weekends at the department of









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pathology research lab doing work on leukocyte function and from that I
published the three papers that year. How I ever did it, I don't know.
S: It is remarkable. You went to New York to the Rockefeller Institute for Medical
Research. Were you working on infantile paralysis and polio?

C: No, I went there to continue the research I had been doing at Hopkins, so I went
there and I was primarily interested in bacterial pyrogens. They were an
important cause of fever and because I had been trained now in
immunochemistry, I did a lot of immunological work on bacterial pyrogens. The
whole field of immunology was just beginning to emerge at that time and one of
the first papers that I reviewed while I was there was on the first report of
agammaglobulinemia, which we now call acquired immune deficiency. So I did
a fair amount of work in the field of immunology, primarily looking at the issue of
immunologic tolerance, but I was working in perhaps the most distinguished
laboratory in the country dealing with rheumatic fever. As an assistant physician
to the [Rockefeller] hospital, I had a major role to play in the care of patients
admitted to that hospital for research purposes with rheumatic fever. I learned a
lot about rheumatic fever and streptococcal infections that year. Except for
going over to Cornell Medical School occasionally and sitting in on infectious
diseases conferences, that's about all I did. That was largely [time] spent fully in
research. That was two years, I spent two years there.

S: Rheumatic fever seems to be one of those diseases that was very common at
one time and then more or less vanished.

C: It was, and there's still some dispute as to why it disappeared, but I think the
general perception of the present is that penicillin became very actively used in
children in the treatment of the common cold and a variety of other respiratory
infections and also for treatment of wound infections. It is generally thought that
the introduction of penicillin and its widespread use had a lot to do with the
elimination of rheumatic fever. There are some parts of the country where it's
reemerging and that may be attributable to the appearance of resistant
streptococci.

S: I had a question that I drew from the title of some of your papers. What is the
Schwartzman reaction?

C: That's an interesting reaction, it's attributable to bacterial pyrogens. It's the
substance of every gram-negative organism which, when injected into the skin
and then is followed by an injection in the blood, produces an enormous
gangrenous lesion at the site of the initial [skin] injection in the animal. Gregory
Schwartzman was the one who initially described the reaction. I became
interested and subsequently did some work, because one of the important
causes of death in meningococcal disease is what's associated with adrenal









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hemorrhage. The meningococcus is a gram-negative organism which has [a
pyrogen] (endotoxin), [and I began to look at] whether or not sensitization of the
adrenal gland by endotoxin and bacteremia was the thing that resulted in the
Waterhouse-Friderichsen Syndrome, which is an adrenal hemorrhage in [some]
people with meningococcal infection. I published, I think, the most definitive
paper on the pathogenesis of that syndrome as a result of that [research].
That's the area during that period of time [where] my work was concentrated.

S: Are endotoxins always in the cell wall of the bacteria?

C: Yes.

S: So they're never free-floating?

C: Yes, they can become free-floating. As the organisms are disintegrated, the
endotoxin becomes free-floating.

S: I was curious about cholera, since I talk about that a lot.

C: Cholera is attributable to an entirely different toxin. There's a specific cholera
toxin. I subsequently had a lot of experience with that too. That is not an
endotoxin.

S: Is that something the cell releases?

C: Yes, it actually is released in the gut. The cholera organism doesn't invade the
body at all. It just manufactures the toxin in the gut and the toxin is then
absorbed and that's what produces the disease.

S: That was my understanding and I was just curious because it seemed like that
response was so dramatic that you didn't necessarily need all of the bacterial
cells to be in contact with the intestinal wall to get that response.

C: It takes a lot of organisms, you can't induce cholera just by swallowing a few
bugs. There have been a lot of studies on that, it takes an enormous dose of
cholera to produce cholera. In addition to that, one probably has to have some
predisposing factor either some other form of gastrointestinal disease,
coincident viral infection or something of that sort. A big dose is the important
factor. Drinking the water in the Ganges [River] is an important source of
cholera.

S: I know that Max von Pettenkofer [German hygienist, biochemist] in the nineteenth
century didn't believe that cholera the bacteria caused the disease and drank a
glass of fluid containing the organism.









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C: Yes, that would never cause a problem. It takes an awful lot of cholera toxin to
produce any kind of a problem.

S: You actually became a professor of medicine at Hopkins?

C: Correct. I became an assistant professor after my chief residency, then I was
made an associate professor and subsequently a professor.

S: Did you have a research program going when you were chief resident? Were
you able to continue publishing?

C: The principle study I did while I was chief resident was on pneumococcal
pneumonia. We studied 120 patients in the hospital that year with
pneumococcal pneumonia, and I published one other paper that year. I
remember participating in the study on pneumococcal pneumonia largely in the
relationship to the treatment of the pneumoccal pneumonia with tetracycline and
penicillin doing a comparative study. [End Side 1, Tape A]

S: You were just talking about comparing the tetracycline and the penicillin, so you
were really involved in the period when they first started introducing the
antibiotics. It must have been exciting.

C: It was. My first experience with an antimicrobial drug, however, was when I was
an undergraduate student at the University of Utah. I was a laboratory
technician in St. Vincent's Hospital at Salt Lake, working on weekends and
nights. I did all kinds of work, a lot of microbiological work. There was a patient
admitted to the hospital, a middle-aged woman with subacute bacterial
endocarditis, which, up to that time, was uniformly a fatal disease. I had isolated
the Streptococcus viridans from her blood in the laboratory and she was the first
patient in Utah to have her bacterial endocarditis treated with penicillin. She was
the first patient in Utah with subacute bacterial endocarditis to ever be cured of
the infection. That was a dramatic experience. When I entered medical school,
the only other antimicrobial drug that became available while I was in medical
school was tetracycline. Then subsequently others were introduced as well. I
never really studied antibiotics as a subject as some other people in infectious
diseases did. I was much more interested in the pathogenesis of infection and
the manifestations of infection. For example, you mentioned brucellosis before.
I did publish a paper on brucellosis as a disease and characterizing it. I became
very interested in the issue of why some people with brucellosis remained ill for
so long and others seemed to get well so quickly. We did a study on patients
with brucellosis and demonstrated that indeed there were significant differences
between those who got well quickly and those who had persistent symptoms. It
was not attributable to anything we could identify as an organic or physical









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problem with them. Nor was there any evidence of persistence of their infection,
but those with persistent so-called chronic, disabling brucellosis oftentimes [had]
a depression propensity and had been through some traumatic experiences in
their life. The only thing we could really relate their continued symptoms to was
their psychological status. That was a retrospective study, to a very large extent
done in 1956 or 1957, when there was a major pandemic of influenza in the
United States and there was no effective vaccine available. I studied about 600
people at Fort Detrick, because that was the place where I knew I could get data.
They all had to receive their care in one clinic, [and] were not immunized against
influenza, so we just followed them. Anybody who got sick with influenza, we
isolated the virus, demonstrated a rise in serum antibody titer and followed them
in terms of how quickly they got well, because there was nothing you could do for
them. Indeed they fell nicely into two different groups. There were those who
were still symptomatic at the end of two weeks or three weeks, and there were
others who were well within seven days. Because we had done studies on them,
both physically, biochemically, before they ever got sick. We [did] similar studies
after they got sick. None of them developed any significant complications of
their influenza, but those who had delayed convalescence had the same pattern
of psychological characteristics, sociological characteristics, and economic
characteristics as the patients with chronic brucellosis. It was the first study ever
done to try to examine the issues of what factors [are] responsible [for] delayed
symptomatic recovery from acute illness. There have been many subsequent
studies done, both in the military and elsewhere.

S: How did people take that research and apply it to treatment?

C: Not much has ever been done on that. I left Hopkins at about that time to come
here, so I was unable to continue those studies. It was my view that there were
two things that needed to be done. One [was] that there needed to be some
neuromuscular studies done on those patients because most of their symptoms
were neuromuscular to find out whether or not they had any persistent
neuromuscular abnormality. That's never been done. I also thought because
there was a depressive propensity in this population, that one might be able to
abort the problem by treating them with antidepressants. That study has never
been done either. There was an enormous interest in that work initially. I
received a lot of wide national recognition and publicity. One of the things that
became an interest to hospital administrators as a matter of fact, Dr. Martin,
when he was provost here, asked me to make a presentation at one time to
some of the students and the hospital administration. [I] had demonstrated that
not only were these people who had delayed convalescence more depressed,
but they were also more frequent users of clinic services. They were more likely
to go to the doctor because of a complaint. We even did some definitive studies
on that. We gave them smallpox vaccine so that we were able to study
objectively the size of their lesion and then we followed them to determine how









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many of them continued to complain about the smallpox vaccination. They again
fell into the two groups. It's the most definitive study ever done on the whole
issue of recovery from [acute] infections.

S: What role do you think stress plays?

C: A lot.

S: Does it change the body chemistry?

C: I don't know, those were studies that needed to be done when I left Hopkins and
I was never in the position to continue. The military did pick up and do some
additional studies, but, to my knowledge, they never looked at the neuromuscular
abnormalities, which I still think are probably there.

S: It seems like there is some relationship between stress and cancer as well.

C: That I can't speak to, because I don't know anything about that subject.

S: Not even speculative knowledge?

C: No.

S: You were at Hopkins as an assistant professor, an associate professor [and then
professor of medicine].

C: [A] professor for fourteen years.

S: Were you teaching at that point? Obviously, you had research labs.

C: Yes, I was doing a lot of teaching. About half of my time I spent teaching. About
half of my time, or maybe less, was spent in research and consulting work I was
doing outside. I got very much involved in doing work for the World Health
Organization in 1960, six years before I came here. I was very interested in the
development of a program in international health. [In] association with the School
of Hygiene and Public Health, I served as the representative of the medical
school and established [a] center for research and training in Calcutta, India.
That's why I know so much about cholera, because cholera was a major cause of
death in Calcutta at that time. The young man I sent over there to work in that
unit, Charles Carpenter, did the most definitive studies ever done on cholera and
was able to demonstrate that the disease could be cured if you just gave the
[patients] proper fluid-material. The substance they finally ended up giving them
was very much like Gatorade. In essence, that virtually eliminated the death
rate from cholera and a lot of work has been done on the cholera toxin. Cholera









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toxin vaccine been produced and that's how I happen to know so much about
cholera. That experience in India was very important [to me]. I served on the
National Institutes of Health Advisory Committee on International Health
programs. [I] went around the world three times for the National Institutes of
Health visiting their various research laboratories around the world. We can
come to that later, regarding my career, but that was an area I was going to
pursue when I left here.

S: Were you doing bedside teaching?

C: Yes, doing a lot of bedside teaching and doing some consulting on the private
medical service and doing a lot of attending on the public service.

S: Did you have private patients?

C: Yes, I did. I did a lot of consulting on private patients, but I had very few private
patients of my own. One private patient will always stand out in my mind Dr.
Stanhope Bayne Jones, who had been dean of the Yale medical school and was
in Washington after the war, writing the history of preventative medicine in the
Second World War. I had gotten to know a lot of these people and he called me
on the phone one day and said, Leigh, I've got a chronic fever, everybody over
here doesn't seem to know what the hell is wrong with me. Could I come over
and [would] you see me? I brought him over and admitted him to the hospital,
he happened to have subacute bacterial endocarditis and I cured him. I got to
know him exceedingly well, and that's one private patient I remember very well.
My care for private patients and other patients had a significant influence on the
direction of my research. I was very much interested in what you might call
clinical investigation. I saw a patient in consultation the private service one
time [who] had an infection in his knee and I couldn't understand why he had
developed an infection in his knee. It was a staphylococcus and I was very
much interested in staphylococcal infections at that time. In talking to him about
it, I found out that he had a boil on his neck at about the same time that he fell
and traumatized his right knee. I thought, now, isn't that interesting. Is it
possible the trauma to his knee [which was] producing acute inflammation in his
knee [is] associated with bacteremia from this boil resulting [in] the infection
localizing in his knee? So I got very much interested in the whole issue of the
localization of infection and a fellow and I published a few papers in experimental
animals where we would traumatize their knees, inject them at periods of time
afterwards with organisms and demonstrated quite nicely the localization of
infection at the site of injury. I've been an opportunist in research work. That's
how I got very much actively involved, subsequently, in the whole epidemiology
of staphylococcal infections. Staphylococcal infections in the hospital were a
nemesis during that period of time, they still are to a certain extent. There
wasn't very much known about the epidemiology of the disease, so I began some









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of the most intensive epidemiological studies on staphylococcal infections in the
hospital that have ever been done. I don't know how many papers I published
on that issue, fifteen or twenty. [It] really paved the road for much of what
subsequently became known about epidemiology of staphylococcal infections in
the hospital. About that time I was still doing a lot of laboratory research and
had a very close friend I got to know at the Rockefeller Institute, James Hirsch,
who subsequently became a very distinguished scientist. He and I were serving
as members of the Armed Forces Epidemiological Board and we were meeting in
San Antonio, Texas, at the Air Force base and one night he and I went to bowl
and I said, Jim, I can compete with you at every level with your research, but I
have to teach and I have patients to take care of. You can spend full-time [in
research at] the Rockefeller Institute, I can't do that at Hopkins. He said
something to me very important. He said, you know, Leigh, you [have]
something I don't have. I said, what's that? He said, you've got a hospital full
of patients to study. From that point I redirected all of my research out of the
laboratory and into clinical investigation. That's when I got involved in the
epidemiology of staphylococcal infections and that's how I subsequently got
involved in the study of adverse drug reactions, which then consumed nineteen
to twenty years of my life.

S: When you started as assistant professor at Hopkins, you had a lab, and your
research at that point was on endotoxins?

C: Yes.

S: Did your research involve the use of animals?

C: Yes.

S: Did you switch over from lab work after that?

C: I couldn't compete with a colleague who was spending full time in [laboratory]
research because I wanted to see patients and I wanted to teach. I had to take
advantage of the opportunity I had, which was to study patients and not rabbits,
dogs, and mice.

S: How many people did you have in your lab at any one time?

C: I guess the most we had at any one time was seven or eight [assistants]. We
had seven or eight Fellows all the time, and had an equal number of faculty. We
had a faculty member for every Fellow.


S: These faculty were all working on your research projects?









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C: Yes, they were working under me. I was the chief and they were basically
working under me. Some of them have subsequently become very
distinguished people. They obviously were doing their own research to a very
large extent under my supervision.

S: Did you have graduate students as well?

C: Medical students are graduate students, and I had a number of medical students
working in the laboratory with us. No students working towards Ph.D.s. When I
was at Hopkins, Ph.D. programs for physicians were not common. They
became much more prevalent during my latter years there and then [they
developed the] M.D.-Ph.D. program. Ph.D. programs for physicians were not
common at that time.

S: Once they had an M.D., would most of the medical students who worked in the
lab go on to be research physicians at universities or would they go into private
practice?

C: You've got some of them here, whom I recruited. Dr. Richard Conti, who was
the director of cardiology here, worked with me at Hopkins as a medical student.
He and I published a paper which was published in the Journal of Experimental
Medicine, [which] at that time was one of the most distinguished scientific
journals in medicine. I had hoped that he would go into infectious diseases, but
he got very much interested in physiology and became a cardiologist. I recruited
him here as chief of cardiology. Richard Reynolds worked in my laboratory as a
fellow, [and] I recruited him here and he became chief of the division of
community health, which is family medicine, then became dean of Rutgers
Medical School and is now back here, retired. Robert Petersdorf, was working
with me as a fellow and then a faculty member and he became professor of
medicine at University of Washington, then dean of the [University of California at
San Diego] medical school, president of the Brigham Women's Hospital in
Boston, then president of the Association of American Medical Colleges. Ed
Hook, who was with me as a Fellow as well as a faculty member, became
chairman of the department of medicine at the University of Virginia Medical
School. Dr. Paul Hoperich became professor of medicine at the University of
Utah and chief of infectious diseases there. Another young man, [John]
Robson, was from Canada, went back to McGill in Montreal and became chief of
infectious diseases there. I one time counted thirty-six young men [and women]
who worked with me at one time or another. I think five of them became deans
of medical schools, or vice-presidents for health affairs, seven of them became
chairmen of departments of medicine, one a chairman of department of
microbiology. It was a pretty good group.


S: It sounds like an exciting group.









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C: It was the premier group in the country in the field.

S: Were they creative in their research interests?

C: Yes, some extraordinarily important contributions [were] made by all of them.

S: What sort?

C: Dr. Petersdorg did some of the most definitive studies on meningitis, the
localization of infection in meninges. He did some of the most definitive studies
on why bacteria settle on the heart valves, and develop subacute bacterial
endocarditis and what are the most effective means of preventing that. Dr.
Hoperich wrote the first textbook on infectious diseases in the United States. Dr.
Hook became an expert in a variety of areas in infectious diseases, but one of his
most definitive pieces of work was on the localization of infection in [the spleens
of] patients with sickle-cell disease. Dr. Reynolds did some of the most definitive
studies in Maryland on histoplasmosis. Dr. James Allen did some of the most
early work on the definition and characterization of the immune globulins. Dr.
Robert Wagner did some of the most definitive studies on influenza. That gives
you a general feeling for things.

S: It does sound like a fantastic group.

C: It was.

S: Did you ever consider private practice, or has research always been more
important?

C: When I was at the Rockefeller Institute for Medical Research, my wife asked me
what we [were] going to do after that year, we've been moving around a lot. She
had been supporting me for eight years, [and] when I went to the Rockefeller
Institute for Medical Research, I was paid $3,600 a year, so she quit work and we
had our first child after having been married for eight years. She asked, what do
you think we're going to do next? I said I think it's going to go one of two ways, I
want to be an academician, I want to be a professor of medicine, but it depends
on what opportunities I have. If they don't arrive, we'll go back to Utah and I'll go
into practice. It hadn't been long after that the chairman of the department of
medicine at Hopkins came to see me in New York and asked me to come back to
Hopkins, so that was the beginning of my academic career.

S: When you were at Hopkins, you published a few things that were less
research-focused and more focused on the social side of medicine, or the
practice of medicine, such as the physician-patient relationship.









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C: Yes, those were sort of little asides. One of the young men who worked with me
as a Fellow was the chief resident physician at Hopkins and he was a very good
friend. He came to see me in my office one day. He said, Leigh, I don't know
what I'm going to do. I've got patients on the ward with serious cardiovascular
problems and I can't get anybody from the cardiovascular division to come to see
them. They're so tied up studying dogs that they don't have time to come to the
wards to see patients. I got very concerned that the extreme emphasis upon
research and research accomplishments in the publishment of papers was
diverting faculty in medical schools away from teaching medical students and
patient care. I did write a few papers on that issue.

S: Was that particularly the case at Hopkins?

C: That was true all over the country.

S: What were the publishing expectations at Hopkins?

C: They were the same as everywhere else. Scholarship was the theme.
Scholarship could be defined in a variety of different ways, but the institution was
built on the excellence in scholarship, so everyone was expected to be an
excellent scholar in one way or another, whatever field [one] might have been in.
During that period of time, obviously, biomedical research and clinical research
were the dominant themes.

S: How did you support your research?

C: Entirely by grants. I think during the entire time I was at Hopkins, the most
money I ever received from the medical school was $3,000 a year and that was
provided to me to help support a secretary. I never received a dollar in salary
from the medical school or the hospital. In my whole division, my five or seven
faculty people, all of my technicians, all of my Fellows were supported by grants
and they came from a variety of different sources. They came from private
contributions, mostly from the NIH [National Institutes of Health], a good bit of it
from the Department of Defense, because after I had left the public health
service, I still served as a consultant in the Department of Defense. They were
very anxious for studies on the pathogenesis of infection to be continued, as I
had been doing while I was with them. All the time that I was at Hopkins, they
continued to support my laboratory. I was looking at the issues related to the
pathogenesis of infection and I had large grants from the National Institutes of
Health, and then some of my faculty acquired their own grants.

S: You were an assistant professor, then an associate, and then a professor, and
then you became the head of the division of infectious disease?









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C: I became the head before I became a full professor.

S: You had your faculty members then for quite some time?

C: Yes, one didn't get to be appointed at full professor at Hopkins during those days
very easily.

S: They really waited until you had shown yourself.

C: Correct.

S: As the head of the division, what was your day like? How much of your time
would be spent teaching or on administration or on research?

C: I always had good administrative assistants so I left a lot of the administrative
details to the administrative assistant. I had to deal with budgets, and dealing
with grants was a recurring issue. I think I probably spent twenty percent of my
time in administration, thirty percent of my time in research, and fifty percent of
my time in teaching.

S: So teaching remained important to you?

C: Very much so, yes. An aside you might be interested in is that I had the most
heavily research-supported program in the medical school. I remember being
called by the dean of the medical school one day to come to his office, he wanted
to see me. One usually didn't get invited to the dean's office unless there was a
problem and I didn't know what the problem was. I got there one morning and I
knew his secretary very well, so I sat in her office and we chatted for awhile and I
said, do you have any idea what Dr. Turner wants to see me about? She said,
no. A moment later Dr. Turner invited me into his office and offered me a cup of
coffee and we sat down and began to chat. I said, Dr. Turner, was there
something you wanted to particularly talk to me about? [He said,] oh yes, Leigh,
the thing I wanted to ask you was that my administrator tells me that you're now
operating on a budget of one million dollars a year and I was wondering, is
everything going all right? And I said, yes, everything's going just fine. He said,
I'm glad about that; thank you very much for coming over. A million-dollar
budget at that time was a lot of money.

S: In fact you did have a million-dollar budget.

C: Yes.

S: How many research projects were you funding with that much money?









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C: Every Fellow had a research project and every faculty member had a research
project, so there were usually at least ten or twelve research projects going on at
one time.

S: You were involved in international health. Were many of your people doing
things overseas?

C: It depends on how you define that. Yes, I had some faculty members that I
recruited to go to Calcutta and some of them have become very distinguished
too. Bradley Sack is now director of the international health program at the
Hopkins School of Hygiene and Public Health and has continued to work on
cholera.

S: How many were involved in overseas research?

C: There were people whom I had responsibility for who I had assigned to work in
Calcutta for a period of time, so, yes. I had actually worked with medical
students and arranged for them to go over and spend some time there as well.
That was a very interesting experience, I learned a lot about medical students
being sent abroad. As far as the rest of my faculty are concerned, they got
involved in international health only because I had developed an exchange
program or developed a relationship with the University of Edinburgh. Some of
my faculty did actually spend some time at Edinburgh. One particular faculty
member became involved and very active with the University of Edinburgh in
Scotland. But that was about all at that time. Most of my international work
was in Calcutta. When I became involved in the study of drug utilization and
adverse drug reactions I became chairman of the World Health Organization
committee on drug utilization and adverse drug reactions and served as
chairman of that committee for about eight years. I was doing a lot of work for
the World Health Organization during that time, because there was a great
growing international concern about the issue of adverse drug reactions and drug
utilization.

S: What was the time period for that?

C: That began before I left Hopkins and then continued all the time I was here.

S: What did you learn about medical students overseas?

C: I sent a lot of medical students over to spend three months, usually during the
summer, but not always in the summer. They were able to go over at other
times of the year too. A lot of students wanted to go and I would interview all of
them and was very selective, because I could only send a certain number. I did









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this over a period of six years, until I left. It was possible for me to evaluate their
contribution, what did they learn, and why did they go. What I found out [was
that] students fell into three categories. There were a significant number of them
who went over largely as a lark, [as] a good way to travel and see a different part
of the world and have a good time. There was another group who went over to
learn. They went over without any [expectations] except they just wanted to go
over and learn whatever was going on there. That was fine, they were good.
Then there was a third group who went over there because they had a specific
job they wanted to do. They were interested in the research going on over there
in cholera and they had some specific research projects they wanted to get
involved in. I learned that there's absolutely no purpose whatsoever in sending
medical students over who are primarily going over just for the hell of it. But you
have to interview them all to be able to identify those who are going to fall in that
category. If you're careful about selecting the ones who go, it could be a very
productive experience for them, but it's a terrible drain financially, and it's a
terrible drain on the faculty who are there to supervise.

S: You have to keep training and retraining faculty, so you want to send them over
there long enough to make the training worthwhile.

C: To make a contribution in three months is hardly enough time. There are some
who went over there and did some really fine work. There was one [student] I
remember who went over. There was a particular cardiovascular problem that
was common in India that he had learned about and he wanted to do a study on
that cardiovascular problem and he did. He published a lovely paper on it.

S: You said you went around the world a few times while you were at Hopkins.
What countries did you visit?

C: I did it while I was here too. I've spent a lot of time in India, Pakistan,
Bangladesh, particularly in Dhaka. I've spent a fair amount of time in Malaysia,
particularly in Kuala Lumpur, Taiwan, a lot of time in Japan, Poland, the UK-
both England and Scotland. I've spent a fair amount of time in Jamaica,
primarily because when I was here I developed a program in Jamaica. I spent
some time in Egypt, France. [I have] never been to Australia or the Phillippines.

S: It was more of an Asian focus?

C: Asian and European, European. Otherwise, mostly Asia.

S: Was that specific diseases or health problems or health conditions?

C: When I went for the NIH that was clearly related to what the NIH's laboratories
were involved with. The one in Pakistan, for example, was very actively involved









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in the study of malaria, so I spent a lot of time in Pakistan looking at malaria. In
Malaysia there was a very active program in leprosy, so I spent a fair amount of
time looking at the problem of leprosy. When I made visits to India, Bombay, for
example, there was a lot of interest at that time in the transmission of smallpox to
chickenpox, and I got very actively involved with that. When I was in Calcutta as
a consultant, not with my own program there, there was a lot of interest in
infection as a precipitating cause of karashiokor, it's a major nutritional disease,
as you know. In essence, it depended an awful lot upon the purpose for which I
went. For some eight or more years, I also served as a United States delegate
to the U.S.-Japan Cooperative Medical Science Mission. I was one of six United
States delegates and I was in and out of Japan every other year for over eight
years and the Japanese delegation was here alternate years. There the
diseases that we paid attention to were largely those of Asia and southeast Asia
particularly. There I got very actively involved in other kinds of infectious
diseases. My experience there with international health, except for the program
I established in Calcutta, was very much associated with my serving as a
consultant.

S: Was it a response to people's needs and interests?

C: To institutional needs, yes. One [was] the United States [State] Department,
and the other is the National Institutes of Health, and also with the World Health
Organization dealing with drug utilization and adverse drug reactions.

S: How did you get involved with the World Heath Organization? Did you seek
them out or did they seek you out?

C: No, you never seek them out. They first approached me because of my
expertise in infectious diseases and particularly in bacterial infections and so I
was appointed a member of their board on bacterial infections. Then I was
appointed [as] the chairman of the international committee on adverse drug
reaction and drug utilization at their request because I was one of the few people
in the world at that time doing any definitive work in the area. [End side 2 tape A]

S: When you came to Florida in 1966, were you hired by Sam Martin?



C: No, my coming to Florida was interesting because it started long before 1966.
Dr. Martin had been a very close personal friend since I worked in his laboratory
at Duke in 1950 to 1951. I was a member of the Association of American
Physicians and the American Society of Clinical Investigation, which had their
annual meetings regularly, at that time, in Atlantic City. I would usually see Dr.
Martin at those meetings and he had left Duke at that time and come here as the









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first professor in medicine, I think he was the first full faculty member appointed
by Dr. George Harrell. Sam and I would meet in Atlantic City and he waxed
enthusiastic about the new medical school, what kind of buildings they were
designing, what they were doing to plan arrangements for the students. I sat
and listened to him and heard him wax enthusiastically about this new medical
school, so I learned about this medical school initially through him. Then I
realized after awhile that indeed a number of my friends had come here as
faculty members. Dr. Harry Prystowsky had come here as chairman of the
department of OB/GYN. Harry had been the chief resident of OB/GYN at
Hopkins when I was the chief resident physician and I had taken care of him one
time as a patient when he was at Hopkins, and I knew him and his wife very well.
Dick Smith came here as a chairman of pediatrics [from] Minnesota, and Dick
Smith and I had served on the Armed Forces epidemiological board together and
he was interested in infectious diseases and we crossed paths over and over
again. Tom Maren was here as chairman of the department of pharmacology
and he had graduated from Hopkins and he was a medical student when I was a
faculty member. There were others here too, but that's enough. Anyhow, I
knew people here. Dr. Maren invited me here about 1962. The school was
relatively new at that time. It was about 1962, I guess, because the first
graduating class I think was in 1957. Tom Marin invited me here to conduct a
seminar for the students in his course in clinical pharmacology, therapeutics, I
think he called it. I came here to talk about drug utilization and adverse drug
reactions on one occasion and I talked about antibiotic therapy on another. I
had been here and I had seen the medical school and I knew Tom Maren.
Usually when I came, I'd go visit Dick Smith and Harry Prystowsky and Sam
Martin. In 1963, George Harrell called and asked if I would be willing to consider
the possibility of becoming chairman of medicine here, because Sam Martin had
moved out of the chairmanship and had become Provost or Vice-President for
Health Affairs. I told George I'd be willing to consider the possibility, because I
had been at Hopkins then about twelve years and I was ready to move on. I had
been offered jobs at a lot of other places and this was a new medical school, I
knew the people here and it looked like an opportunity I might look at. So
George Harrell invited me to come down in 1963 to look at the chairmanship and
the department of medicine. The job was vacant. So I came to Gainesville,
flew into Jacksonville and George picked me up at the airport and [we] stopped
on the way and had a beer and talked. [I] came over here and went through the
usual interviews. It became clear to me during that visit there was an enormous
antagonism between the dean, George Harrell, and Sam Martin, the
Vice-President for Health Affairs. There was an enormous conflict there, and I
didn't want to become a part of that, so I turned the job down. That was when
Dick Schmidt, who was the chief of neurology, was appointed chairman of
medicine. Sam had invited me down here to give a seminar for the students in
health administration and I had done that because of my study on convalescence
from infection and the use of outpatient services, so I continued to have









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interaction. Dick Smith was coming to Hopkins to give a lecture and he and I
would always see each other. In 1966, Dr. Suter was now the dean, Sam was
still the provost and he called on the phone and asked if I'd be willing to consider
the chairmanship again. I said, yes, but I need to learn a little bit more about the
situation, so Dr. Suter came to Baltimore and stayed with me in my house and
we talked and walked a lot and I realized that the conflict that had existed
between George Harrell, [who] had now left and gone to Hershey, and Sam was
no longer a problem. So I said, I'll come down and look at the job, so I came
down again and looked at the job. Sam was here, and was a very dear personal
friend, so when I came here and met the faculty, many of whom I had already
known and knew very well, I went home and talked to my wife and we decided
we'd come and look at it another time. I still hadn't made up my mind, though, at
that time, I was very comfortable at Hopkins; I had a lot of money, good faculty,
good Fellows, and the chairman of the department, Mac Harvey, told me, Leigh,
don't leave, you've got the best job in the world right here. I sought out some
counseling as to what I should do. I had been a Markle scholar, and that may
not mean anything to you, but in my younger days to be a Markle scholar was
basically the entry point to a significant career in academic medicine. There
were very few of us Sam Martin had been a Markle scholar. I called John
Russell, who was the president of the Markle Foundation, who knew virtually
every medical school in the United States and visited them all. I said, John, I've
been offered this job at Florida, but I've never really lived in the South. I spent a
year at Durham, my wife didn't like it at all and I don't know if we're going to be
comfortable living in the deep South. John Russell said to me, Leigh, you're
farther south in Baltimore than you'll ever be in Gainesville, Florida, [for] the
simple reason that most people in Gainesville come from elsewhere; they're
largely from the northeast. That was one comforting thing. I went to see Gene
Stead at Duke, who I had mentioned before had become a significant mentor,
and I told Gene about the opportunity. He knew Sam and he knew this school,
and he knew me very well. And he said, Leigh, let me just give you one piece of
advice. It would be a great job for you, but if you take it, you've got to find some
way to make the faculty work because it's a wonderful place to live, it's a very
comfortable life, a lot of things that you can do all year-round outdoors, and it's
going to be tough to get a faculty down there who will really work. I knew the
people here and I knew they worked pretty well so that didn't bother me too
much. At that time I was sitting as chairman of the clinical education program
committee for the Hopkins medical school, and it was a committee composed of
very distinguished faculty members of the clinic departments. I remember
vividly one day during this period of time having a meeting in my office one day
and I raised a question, I said, don't you think it's about time, as we think about
the curriculum for our medical students, that we ought to provide some
opportunities for them outside the four walls of the Johns Hopkins Hospital? The
almost uniform response from them was, I don't know why we ought to do that,
we've been great for seventy-five years, why in God's name would we want to









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change? I realized at that time that indeed my interests had now extended
outside Hopkins and I was interested in a place where I could do something new,
something innovative. That I think was the coup de grace. Also that summer,
in 1965, when the negotiations were going on, I took a sabbatical for three
months and went to the University of Edinburgh to finish the editing of the
textbook of medicine, which was coming out at Hopkins at that time. I was one
of five editors. I went back to Baltimore after that and I said, Beth, we love
Baltimore, we're happy there, and I don't think we're going to leave. I think
we're going to stay here the rest of our lives. I think the turning point was Dr.
Suter's visit, so I brought Beth back and we looked at the job and decided to take
it. That was the beginning of my entry to the University of Florida. I came here
for a very special reason, this was a new medical school in a rural area where
there was not very much health care. I thought that would be a wonderful
opportunity to build a program outside the medical school where I could train
[and] rotate my residents and my students and give them an experience in the
real life of health care outside of the medical center. That was my primary
reason for coming.

S: Were you able to do that?

C: Yes, the first year I was here I sent my chief resident in his car around north
Florida. I said, I want you to scout the area and find me an area where there's
no health care, where there's a reasonably decent health-care facility that's not
being used and where there might be an interest in the possibility the department
has in building a health-care program. He came back and he said the county of
Lafayette and the city of Mayo that's the place to go. I met that year with all
the resident staff to find out if they would be interested in spending some time up
there usually a three-month rotation during their second and third year as
residents and I found great interest in doing that. I couldn't do it myself because
I had to run a hospital, medical school and everything else. I needed somebody
who I knew who was going to be able to do that. A young man who had trained
with me at Hopkins had gone into practice in Frederick, Maryland, and I knew
him and knew of his experience in providing care in rural Maryland. I asked him
to come here as a consultant, to advise me as to how we should proceed and he
got so enthusiastic when he went back, I called him on the telephone and asked
him, look, rather than consulting, why don't you leave your practice and come
down here and build this program for me. After a little bit of negotiation and
time, he agreed to do so. So he came here and he and I and a few other faculty
developed a health-care program in Mayo, Florida. We made a commitment to
the community that we would be there permanently, we would never leave, that
we would have somebody there twenty-four hours a day taking care of them and
making the service available to them. That program was developed in 1967, a
year after I arrived here and continued up till the time I left nine years later.









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S: What was the name of the person you hired?

C: Richard Reynolds, whom I've mentioned before, had come here and he was in
my department initially and I made him chief of the division of community
medicine and he developed the program for me. He and I served as the
attending physicians in Mayo, sixty miles away. I would drive up there at least
once or twice a week and make rounds, see patients, and had a resident there all
the time. The city provided housing for them in a mobile trailer, opening up the
nursing school to send nursing students up, and I spent one summer up there
myself as a student, because if I was sending students and residents up there, I
ought to go up and work myself as a resident and student one time. [I]
published a paper on that about my experiences with rural health care, so I did
it. What I came here to do, I had done in one year and then I needed money for
it. I remember that very well, because I went to the clinical science board at that
time, the executive committee of the medical school and told them what I wanted
to do. Everybody's reaction was, you're out of your cotton-pickin' mind, Cluff.
You don't want to do that, that's the worst idea in the world. I [said,] I'm going to
do it anyhow. Well, you go ahead and do it if you want to, but by God don't use
any of my space and don't take any of my money. I had to use departmental
funds to get it started, but then I called a good friend, who [was] the president of
the Commonwealth Fund, Colin McCleod, told him what I was doing and asked
him if he could help me at least for a year. He sent me a check which basically
carried the program for a year. [Subsequently I obtained a large grant for our
program from the Carnegie Fund.] My good friend Dave Rogers had become
president of the Robert Wood Johnson Foundation, so I called him on the phone
and we got a huge grant from the Robert Wood Johnson Foundation [which]
supported the program the rest of the time I was here.

S: You were here as the chairman of the department of medicine?

C: Correct.

S: How many faculty members did you have?

C: When I came here, I think there were twelve but I won't swear to that, maybe
sixteen. When I left there were sixty-five.

S: That's amazing.

C: My wife says she was going to take a sabbatical from entertainment when we
left, because we entertained every prospective faculty person. For every person
recruited, it was usually three to five people we had come in. Plus, we were
having dinner parties at our house on a regular basis.









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S: That's remarkable. Was this part of the growth of the medical school in general
or were you able to raise more money for the department and really get things
going?

C: [We] raised a fair amount of money from the medical school, of course, the
medical school itself was growing. The faculty got much more busy and I
budgeted the faculty in such a way that I put them more and more on their
research grants rather than supporting them entirely on state lines. With the
dean's office and help from there, I was able to split lines. The thing that really
made it possible was the opening of the VA [Veteran's Administration] Hospital.
The VA Hospital opened the year I arrived. I had the opportunity to build a
program at the VA which made the program at the VA an integral part of the
department of medicine. That still exists today the faculty at the VA and the
department of medicine are the same faculty that work over here. There's no
difference made between any of them. [The] same house-staff rotate between
both places, and it became a model of its kind, [and] it still is a model of its kind in
the nation.

S: Your department was four or five times larger by the time you left than it was
when you started. Were you teaching and doing any research?

C: I was continuing to do research, I was continuing my work on drug utilization and
adverse drug reactions. I was very fortunate, in that regard, to be able to get a
person out of the college of pharmacy, Ronald Stewart and a couple of other
people in the college of pharmacy, to work with me. Then I got a biostatistician,
and we developed a computerized capacity to handle data and basically
developed a clinical pharmacy program through them. It was largely through
them and George Carenasos, who was a member of the faculty and [who] had
been one of my chief residents who was involved. Over the period of
subsequent years, we were heavily supported by the Food and Drug
Administration, because we were the only real site in the country doing work of
that kind. I was certainly doing a fair amount of consulting work for them. That
provided a fair amount of funds, but only to support that program. I continued
that research, but we published a lot of papers, two or three books, but that was
largely with the assistance and cooperation of others. I made attending rounds
regularly, I held teaching sessions with the students every Wednesday, I worked
very closely with all of the house-staff, held a morning report every day, and for
the first year I also served as chief of medicine at the VA as well as over here. I
was spending half of my time over there and [half] here. I did that largely to
ensure that the program at the VA and over here would in terms of salary of
faculty, function of program house-staff and so on would be identical. That it
would operate as one department, not two.


S: There wouldn't be a sense of competition or anything like that.









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C: I did a lot of teaching, first there was the administrative duties, [and] because of
my involvement in international health, I got appointed to the university's program
[in] Latin American studies. I developed an exchange program with the University
of the West Indies in Jamaica, which unfortunately was not a terribly good
success, but at least we got a start. [We] developed an exchange program at that
time with the University of Edinburgh, in Scotland, because I had a lot of contacts
there [and] sent a number of faculty people to Edinburgh for three months. They
sent faculty over here for three months, so we had a really nice exchange
program. We picked up the expenses for those people coming here and they
picked up the expenses for our people going there. That was a great program, a
number of people, some of whom are still here, were on that program.

S: Was the Jamaican program to be an exchange of faculty or students?

C: Faculty, residents, and students, but it never really materialized. I got that
started largely because of Robert Cruikshank, who had gone there [as] an
advisor to the school and had been a professor of microbiology at the University
of Edinburgh, whom I had known quite well, but we were never able to get funds
to really support it.

S: You talked about how at Hopkins they really focused on research.

C: That's called scholarship.

S: Was that the case here as well?

C: Yes, I think so. Much more so in the beginning. Virtually all of the faculty had
research grants and were actively involved in research. The change towards
increased clinical involvement began shortly after I arrived here in 1967 with the
passage of the Medicare-Medicaid legislation. All of a sudden [it] provided an
influx of additional monies into the department which it never had before,
because prior to that we never got paid for the care of the elderly or the poor.
Money began to be a generating factor and that gradually began to change the
whole character of the program. Generation of income from patient care
became a much more dominant part of the activity and therefore faculty
involvement in patient care became much more intense. That will compromise
their time. Patient-care activities to generate money and research began to
dominate education, which it still does today.

S: Did the dean of the College of Medicine have any impact on the focus of the
program? My understanding is that Suter's focus was more on education.

C: Yes, his interest was almost entirely on education. He formed a special









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education program committee, which I served on with Parker Small and a few
other people, and I chaired the clinical education program committee, composed
of other department chairmen. I insisted that the committee be composed of
clinical department chairmen. That turned out to be an unfortunate thing,
because Dr. Prystowsky insisted that the amount of time students spend in
OB/GYN be identical to that which they spend in medicine, which is an absurdity.
We had a committee that was split largely by Dr. Prystowsky, so ultimately I
threw the problem in Dr. Suter's lap and he refused to take a position, which was
unfortunate. Dr. Suter's big problem was [that] he didn't understand clinical
medicine. He was very interested in education, particularly at the basic science
level. But he really didn't understand clinical education, and if he had one major
weakness, that was it. He did not understand patient care or clinical medicine,
and for that reason he became a weak dean in that arena.

S: Did he have more background in scholarship?

C: Yes, he came here from Harvard, [and], I think, from the Rockefeller Institute,
and he was chairman of microbiology when he became dean. He had no
experience in clinical medicine, none at all.

S: What was the cost in terms of the clinical side of teaching?

C: It hurt the department of pediatrics and the department of medicine badly. Dr.
Scheibler had become the chairman of the department of pediatrics while I was
here. We were carrying the bulk of the teaching load, not only in the clinical
departments, but in the basic sciences too. He and I kept a log on the amount
of time our faculty was spending teaching in the basic sciences as well as in the
clinical arena. [We then] presented this data to the dean and indicated that the
dean's office needed to pay more attention to the allocation of funds to support
the educational enterprise rather then distributing funds equally amongst all
departments. Dr. Suter never did anything about that, and generally favored the
basic science departments with the allocation of funds. So in the building of the
clinical department, it became increasingly dependent upon the generation of
funds for research and patient care, and the school did very little.

S: What were the facilities like here? When you came it was still relatively new.

C: They were good facilities, there were no complaints about the facilities. The
hospital was perfectly satisfactory. Over a period of time intensive-care units
became an important part of our activity. We had to do a lot of remodeling to
build a medical intensive-care unit on the fourth floor of the hospital. The
facilities were fine, there was basically nothing wrong with the facilities. We
didn't have enough beds and there was a lot of dispute over a program that Dr.
Harrell had put in place, [which] was sort of an intermediate hospital-care setting









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which we ultimately had to abandon because it was soaking up services,
patients, and beds that we needed.

S: Was that in a different location?

C: The emphasis began to change under Dr. Suter. For example, the department
of ophthalmology and anaesthesiology were making an awful lot of money.
Herb Kaufman, who was the chairman of the department of ophthalmology, was
able to build his own little palace on the campus from his patient revenue.
Anaesthesiology was able to expand its program enormously with faculty
numbers, Fellows and residents, largely because they were generating a lot of
money. The Department of Medicine never generated that kind of money, we
generated a lot more money than we had before Medicare and Medicaid, but not
that kind of money. Money began to become an increasingly driving force in the
medical school and that had an enormous influence on Dr. Suter and the school
as well.

S: Did he tend to be swayed by money?

C: What could he do about it? They had the money and could pay for it themselves
what was he supposed to do, say no?

S: What was the comparative size in terms of faculty for each department?

C: I don't remember that. They were relatively small in comparison to medicine
and pediatrics [was] relatively small. Medicine and surgery have always been
the largest departments. There was a period of very rapid change in medicine,
you must understand, cardiac catheterization was just coming on board and I can
remember real disputes about whether we were going to treat that as a research
project or [whether] doing cardiac catheterization was going to be a service
[activity]. Intensive-care units had become a prominent part of medical care,
coronary-care units began to emerge. The whole character of medicine began
to change, a whole new armamentarium of medications, a whole new
armamentarium of interventional work. The rapidity of change during that time
and since has been so dramatic it's very hard to describe it, except to say that it
was a process of great change.

S: I guess it [would] be hard to separate changes in the field from whatever internal
changes went on.

C: Yes.

S: What is your feeling about how that changed medicine in general?









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C: I think it changed it dramatically and I think it's still changing. Medical schools
still have their real purpose. They are instruments of society, they were formed
by society to serve a particular social need and that was to [train] physicians,
nurses and other health-care providers, but particularly physicians. Their job
therefore was dominantly oriented in that direction. With the growth of the
National Institutes of Health from ninety-five million dollars in 1957 to nine or ten
billion dollars this year gives you some appreciation of the impact that research
had upon the growth of the academic medical center. I could illustrate that,
when I first joined the faculty at Hopkins, there were six full-time faculty members
in the department, when I left in 1966 there were 350. I went to the chairman of
the department of medicine and I said, Mac, how many full-time faculty do you
have in the department? He said, I don't know. I said, I just counted them and
you have 350. He said, you know, I don't even know half of them. The
research began to change the character of the medical school because it
became a dominant force within the institution. Now, it did some good things, it
brought some very bright people into research and it brought a lot of bright
people into the academic setting, but it also diverted the medical school away
from its primary mission, which was to train physicians. Applicants to medical
school, if they were interested in research, got favorable treatment. If they
indicated [a] primary interest in medical care, they didn't get the same kind of
treatment, at least at Hopkins. The students began to change even in the
application for residency positions. A medical student who applied for an
internship who had research experience always get a more favorable
consideration than the one who did not. You recruited faculty who were able to
get good big research grants, not necessarily because they were distinguished
clinicians or physicians or teachers, but because they were able to get big
research grants. That began to have a significant influence on the medical
school and its purpose. That all began to change in 1966 with the passage of
the Medicare and Medicaid legislation, as I mentioned. The generation of
revenue from patient care began to accelerate and that has continued to
accelerate ever since. I can remember on one occasion at an executive
committee meeting in the medical school with Dick Smith, who was at that time
chairman of the department of pathology and running the clinical laboratory. [He]
said that, under the current Medicare regulations, he could set a fee for doing a
stool examination, and he'd get a fee for doing a hemoglobin, and he'd get a
professional fee for doing a urinalysis. Before, that was just a straight charge for
a uranalysis or stool or whatever it was, but now the procedure can be done and
his director of the clinical laboratory [can] get a professional fee for that, because
he was overseeing the activity. So you've got to charge five dollars for every
urinalysis for a professional fee, in addition to the charge for the procedure itself.
There were a lot of arguments over that but ultimately it was done, it was an
accepted charge by Medicare at that time and third-party payers. Money from
most sources became an exaggerated force within the medical school. At about
that time, probably around 1972 or 1973, the Medicare and health-care finance









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administration became very concerned about how bills were being submitted and
they investigated this institution, among many others, as they also have done
more recently here. They investigated here and did a random-search sample of
hospital records and found that there were procedures that were being done for
which an attending physician had not signed the record. That was particularly
true for electrocardiograms, [which] was predominantly a Department of Medicine
activity. After the survey had been completed, they submitted a report to the
medical school indicating that the Department of Medicine owed the health-care
finance administrations a quarter of a million dollars for charges that were
unjustified charges. I had to generate funds through departmental funds to pay
back the $250,000. Subsequently, the medical school has gone through a
whole new [investigation] on that regard. I remember a meeting I had [with] the
faculty during that period of time, the attending physician [was required to] sign
all orders, [or] co-sign. I remember Jape Taylor, who was a member of the
department, spoke up and said, we ought to look upon this positively, not
negatively. He said, it might very well make our faculty pay more attention to
what's being done and provide better supervision of our house-staff, so let's not
look upon this negatively, let's look upon this positively. That was the attitude
we adopted while I was here, I don't know what it became after I left. The
house- staff grew. When I came here, it was impossible for the Department of
Medicine to fill its house[-staff positions] at that time, but two years after I came
here, we had more applicants than we could ever accept from all over the
country. I understand now they're very much more narrowly sequestered, but I
made the Department of Medicine a nationally-recognized department. I think it
probably remained that way.

S: You were here until 1976, did you continue to do your research the whole time?

C: Yes, until I left and it was continued after I left by Ron Stewart in the College of
Pharmacy and by George Caranasos in the Department of Medicine.

S: What drugs were you looking at?

C: Everything, we weren't looking at any particular class or group of drug. We did
do some specific studies on antimicrobial drugs, but we were looking at all drugs
prescribed by the pharmacy.

S: Did you continue your work on international health-care the whole time?

C: While I was here, the whole time, I did it. I did it even after I left.

S: What caused you to leave?

C: I had been here ten years. I never had a sabbatical [or] a vacation. I don't









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believe I ever had a vacation during the ten years I was here as chairman, and
my wife will testify to that. We'd sometimes take a weekend and go to the
beach, but that was about it. I had been here ten years and I had been told
when I came here, by a mentor, that I ought to be able to accomplish pretty much
what I wanted to accomplish as chairman within five years and then it would
probably take me five years to embellish [those accomplishments]. It was now
approaching the end of the tenth year and I had pretty much accomplished what I
wanted to do here and I was looking for new things to do. I really was interested
in going into international health, so I made an application to the Henry [J.] Kaiser
Family Foundation Bob Glaser, a good friend, was the president there at that
time for funds to take a sabbatical year and spend it at the Institute for
Behavioral and Social Science in Palo Alto California, [which is] affiliated with
Stanford University. [It] is a place where many academic physicians have gone
for a sabbatical, and I was going to write a book. I wanted to explore getting
involved in international health, but I was quite sure I'd get a job at the World
Health Organization in Geneva or with the Pan-American Health Association here
in the United States. Those were my plans and I worked that all out in the
spring of 1975. I was chairing a committee for the National Research Council
in the National Academy of Science [then], looking at research programs in the
Veteran's Affair's Hospitals. I had a very distinguished committee and we were
doing a site visit in Hartford, Connecticut. I remember very vividly [that] I
received an announcement that I had a telephone call, so I went up to the bar
and picked up the telephone and it was my good friend Dave Rogers, who had
just gone to the Robert Wood Johnson Foundation as president. I said, David,
it's great for you to call. It was the tenth of June and I said, it's nice of you to call
and wish me a happy birthday, because today is my birthday. He said, that isn't
really why I called. The chairman of the board wants me to bring somebody up
here who can help manage this place and work with the staff, and he's very
anxious to know if you'd be willing to come up and look at the job. I said, look,
Dave, Beth and I haven't had a vacation in a long time. If you'll invite us up to
Princeton in August for a few days and you and I could play some tennis, we can
talk about it. I already made arrangements to go to Palo Alto, so this was just a
lark. Beth and I went up to Princeton, and Dave and I [played tennis] and sat up
late at night drinking and talking about old times. [He] told me a little bit about the
job, I had an opportunity to meet the chairman of the board and the treasurer,
who are the principal officers of the foundation. I guess I met a couple of other
people at that time too. They [had] rather inadequate facilities at Princeton.
[Then we returned to Gainesville and I] said, Beth, it might be fun working with
Dave Rogers again. I've never worked for a foundation but I've gotten a lot of
money from them, I think probably I'll do that. I called Dave on the phone the
following Monday and I said, Dave, I'll take the job, not really knowing what the
job was. He said, before you get it, you've got to come up and meet with the
board of trustees and if you can come up, we'll meet at the Nassau Club at
Princeton with the board and they can interview you. I flew up and drove to









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Page 38

Princeton, met them at the Nassau Club for dinner and I was feeling pretty loose,
because this was not really something I'd been planning on anyway. I found
some real colleagues on that board, even though they were all businessmen, so I
went home and the chairman of the board called me on the phone and offered
me the position of executive vice-president. I said, fine. I came back here and
announced that I was going to be leaving, made the arrangements to leave, and I
left.
[End of Interview.]




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