Q: On the topic of microscopy, in 1976 you wrote an article in the JAMA on "The Role of the Laboratory in Diagnosis."

Wallerstein: Yes.

Q: Can you tell me why you felt it was important to...?

Wallerstein: This was an invited article. [Lundberg], who was then the head of the--I think he still is--chief editor for the AMA, JAMA. Had read some of my stuff. I'd met him. He may have listened to some of my talks. I'd done a pretty nice set of talks on diagnosis of anemia, which I gave to second-year students and residents on the lecture circuit. It was a talk that I thought was damn good, was very practical, it was from the consumer's point of view rather than from the teacher's point of view. In other words, I tried to deal with problems as they appeared to the bedside clinician rather than the instructor, who can categorize all those things.

And Lundberg must have heard me or talked to somebody who had heard me and asked me to do just that. That was the origin of this article. I put microscopy front and center on this, because I felt this really sort of helps you decide where you are. And I made a list of useful tests and when to use them, categorized anemias, and I felt it was a very useful exercise. I still think it was a nice article. My son has written a similar article since then in the Western Journal of Medicine, which is perhaps much better, much more up-to-date, but when I wrote mine, that was the way to do it.

Also people congratulated me on still being up there with a highly sophisticated--although I had to admit I hadn't written it. My son is Ralph, Jr. That's why the confusion is obvious.

Nevertheless I was pleased with the article. I think it reflected the state of the art at that time and I think it was very user friendly, and there was an enormous request for reprints, which I was very happy about.

Q: When you say consumer's point of view--?

Wallerstein: The doctor. I meant the doctor. I meant the general internist. When faced with anemia, how should he or she think about anemia problems. This was at that time a useful guide. And also paying some attention to having a working concept of medical probabilities that went into it, rather than being all that complete. And I enjoyed writing it and I was pleased with the response to it.

But that was the origin of it and reflected my years in practice. How I saw problems, how I had to explain problems to people who referred patients to me, and to patients.

Q: You mentioned yesterday to me that you really looked at blood microscopy as an extension of the physical examination. Is that a widely held point of view in medicine?

Wallerstein: I don't think so, because there are not a whole lot of doctors who look through a microscope. They haven't got the time. If you don't do it every day, you lose some sharpness. I use the scope virtually every day, even though I'm doing other things now. Because I'm here all day at the hospital. And if I haven't looked through the scope for a couple of weeks, I'm not quite as quick, I'm not quite as firm. No, I think you have to do it all the time, otherwise it doesn't mean much. And I'm afraid that our recent trainees rely more on quantitative non-subjective measurements rather than on microscopy. I wouldn't want to force it on anybody.

Q: Mostly on measurements done elsewhere?

Wallerstein: In the laboratory, yes.

END OF SIDE TWO, TAPE TWO; BEGINNING OF SIDE ONE, TAPE THREE:

Q: I was wondering what sorts of techniques--have the staining techniques changed much?

Wallerstein: Not the basic staining things. The new staining techniques I'm not that much of an expert on.

Q: Just to step back to your early work at the Thorndike Memorial Lab for a moment. Can you talk about the relationship between Thorndike and its role within Boston City Hospital?

Wallerstein: It was a very intimate relationship with the Harvard Service. As you know, there were fellow services at the Boston City and the relationship was pretty much confined to the Harvard Service. Most of the people at the Thorndike, the teachers taught on the wards. Some of them taught general medicine as well as their sub-specialty medicine. We constantly had people rotate for some of their training--some of the residents, I think some of the students--through the Thorndike. It was physically right there. Highly accessible. And highly integrated with the wards.

The research was very clinical really. Some very sophisticated measurements were done. They all dealt with clinical problems. They were not basic research. It was just an intimate arm of the Harvard Medical Service. Castle was a Professor of Medicine at Harvard. So was Dr. Max Finland, Dr. Davis, and everybody else, on the full-time faculty of the university.

Q: That was not true of the entire staff of City Hospital? They weren't all members of the Harvard faculty?

Wallerstein: No. It was mostly Harvard; Boston University, and Tufts were the others. But the people at the Thorndike were all full-time members of the Harvard faculty, at the Boston City Hospital. The Thorndike really was just one building and it was the City Hospital complex.

Q: How was it determined that patients from some other service should be members or should become part of the Thorndike research?

Wallerstein: Dependent on what diseases we were looking for. Patients with certain diseases would be transferred to Thorndike. Believe it or not, we had in-patients with pernicious anemia. My God, that really dates me. In-patients with pernicious anemia. Yes, when somebody had a certain disease that was being studied, then they were simply transferred to the Thorndike. It was sort of--but nowadays it's a metabolic ward. And this really was to have easy access to them.

Q: What sorts of arrangements would be made with those patients?

Wallerstein: Well, the reason they came over was--I think perhaps diet was a major part of this, because they had to be on a special diet. They gave them something to eat that didn't contain this or that. They had to be at Thorndike. So we called some patients from the open wards, but if we wanted to study somebody seriously, if we wanted to treat the pernicious anemia with intravenous gastric juice and I was told it was my job, then we damn well better have them at the Thorndike ward, where we could see them and monitor them very closely. The same was true for the other sub-specialties. I don't quite remember all that much. There were not that many patients that were there, but the ones we studied either had to be followed extremely closely or were on a very special diet, usually missing some key ingredient on purpose.

Q: Well, it's generally thought in the history of medicine that pernicious anemia was effectively treated by liver extract. Why did you still have in-patients with pernicious anemia?

Wallerstein: So we could study something or other on them. That's why I say it was bizarre having in-patients when you come to think of it. No, we looked for patients with pernicious anemia and put them on some sort of protocol that we were doing. We wanted to observe their daily reticulocyte response. For that you need to have--it seems like a different era. I mean, not only DRG's, informed consent, nevertheless this was before those restrictions.

Q: I'm just wondering, how did you convince the patient that it would be in their interest to participate?

Wallerstein: Our patients did what they were told. Also we were very nice to them and they enjoyed our company. Some of them were in Boston City Hospital--as a city hospital, we had a lot of indigents. They were probably better off in the hospital than not. But this may be a paternalistic view. Basically they did as they were told. This is only thirty years ago, forty years ago. Seems hard to believe that those things prevailed then. God! We had a little study group--this was out-patient--where instead of getting Vitamin B-12, they got saline. This was one of Dr. Castle's and we used to see how quickly they'd relapse into pernicious anemia. God! This, of course, was the sort of thing that would be absolutely inconceivable nowadays. Nevertheless, the results were interesting. Some of them didn't relapse for the longest time, over a year. Nowadays, when we treat someone for pernicious anemia, if some of them are a week late for their therapy, they get terribly nervous. They know better, but--anyway, so that was medicine then.

Q: You actually saw patients for a year at a time?

Wallerstein: In the clinic. Yes, I was there two years. So some of the people we'd see twelve to twenty-four times. Then we had an out-patient department. Some even come to the out-patient clinic, where there'd been liver or Vitamin B-12 shots since Minot's days. You know Minot won the Nobel Prize for pernicious anemia.

Q: Is there any other issues that we haven't touched on, that we might have left out, that we have not given a full feature of your career?

Wallerstein: One of the most important things is that I met my wife at Thorndike. Dr. Max Finland always said that Betty was a fringe benefit and should not be counted in evaluating my training at Thorndike, but it was important.

Q: She was...?

Wallerstein: She had graduated from Wellesley and she was thinking of a medical career. In the meantime she decided she wanted to work as a technician. She came to work in our laboratory. This was at the start of my second year and we got married after that year. But that was probably more important than anything else I did at Thorndike.

Q: Were those lots of college graduates working as technicians?

Wallerstein: There were several. John Harris married his technician, and I gather this had been going on for years. She had just graduated from Smith, I'm not quite sure. Any one of the women's colleges. No, this was not unheard of. There were college graduates working there for slave labor wages.

Q: But this was conceivably a route to medical school?

Wallerstein: Yes.

Q: Did many of them go on to medical school?

Wallerstein: I don't think so. This was well before medicine was a major field for women. That didn't come until later. It was still unusual for women to be in medicine. In my class there were about six out of seventy-two.

Q: I was talking to Dr. [Helen] Ranney and interestingly that was also her past. She worked as a technician at Babies Hospital in New York before she went to medical school.

Wallerstein: Some technician! I met at Thorndike many of the people that preceded or followed me as president of the American Society of Hematology. Well, yes, one thing I should mention in hematology, the Aggeler lecture. Did I mention that to you? When Paul died, we established a lectureship in his honor. They went to all his friends and some people in industry. We collected a fair amount of money to make a decent annual stipend and expenses at the University of California, San Francisco General Hospital, where we both worked. And we've had a really prestigious group of people lecture every year. At least half of them either have been or most of them were about to become president of the American Society of Hematology. So when you look at the C.V. of the people you interview, a good many of them have been Aggeler lecturers. For the first ten or fifteen years they all knew Paul personally and could say something about him. At first we restricted the topics to coagulation and knowing Paul. Sam Rapaport was the first speaker. And Ratnoff was an Aggeler lecturer. Lockhard Conley was a lecturer. Don [E. Donnall] Thomas, the only Nobel Prize winner we have in the lecture series. Phil Majerus was a lecturer. A lot of people--Jane Desforges, [Ernest] Beutler. Myself. I was lecturer last year. I was extremely pleased to be asked. Y. W. Kan has been a lecturer. So that is something I'm still involved in, in determining who's going to be a lecturer. I attend the functions that go with this. This has meant a great deal to me, because I'm very grateful to Paul as my mentor and a sort of conscience of the University of California here. This has been a nice way to honor him, this prestigious lectureship. And we all attend it.

That's the main thing I left out, I think.

Q: Well, thank you very much.

Wallerstein: Thank you.

END OF SESSION

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