ASH Oral History: Louis K. Diamond (2/7)
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Q: Could you continue with your discussion on Blackfan, please?
Diamond: Dr. Griffitts, the pediatrician, at Cincinnati -- Professor of Pediatrics at the Cincinnati Medical School--had under his care the children of a businessman named Proctor, in Cincinnati. He was the Proctor of Proctor and Gamble. To show his gratitude to Griffitts, Proctor said he'd give him money to set up some research at the children's hospital. He not only gave his own money, he gave stock in his company, Proctor and Gamble. It was interesting that the Children's Hospital directors, businessmen, said "This is valuable stock. Sell it! We need the money." Griffitts said, "Don't sell Proctor and Gamble stock. It'll be worth more later on." He persuaded them to hold on to Proctor and Gamble stock. In fact, Proctor gave Griffitt more stocks -- or the family gave them to him. Eventually, they had quite a bit of stock. Anyway, the Children's Hospital Research Foundation, in Cincinnati, turned out to be one of the wealthiest and the best research units in pediatrics.
Q: What sort of research was carried out?
Diamond: Everything: They had research in biochemistry, pathology. I know some of the men that went there were good biochemists, hematologists, nutritionists. The Cincinnati Children's Hospital Research Foundation is still one of the larger well-endowed and active research foundations in pediatrics.
Q: About when was the research foundation actually established?
Diamond: I can't tell you the exact year, but it must have been some time around 1919, 1920, the early 1920's.
Q: Would this have been one of the first places where there was a real push to have experimental science linked to--
Diamond: I think it was one of the first. That and Hopkins. And Pennsylvania had had some. Saint Louis, of course, when they got the new medical school. Cincinnati was looking for a Chief of Pediatrics. But when Cincinnati wanted a full-time Chief of Pediatrics, which they hadn't had, they asked Howland who to get, and he pushed Blackfan. Blackfan went there, 1921, as Chief of Pediatrics at Cincinnati Children's Hospital. Then when Edsall was Dean at Harvard, they had had only a part-time Chief of Pediatrics, at Harvard in the Children's Hospital, an old-timer named John Leavitt Morse. M-O-R-S-E. Famous pediatrician in Boston. Edsall wanted a full-time chief, and they invited Schloss -- Oscar Schloss from New York, who was professor of pediatrics at Cornell -- to come to Harvard as the first full-time professor at pediatrics at Harvard. Schloss was a very fine experimentalist with an interest in allergy. He'd really established allergy as a specialty.
Q: Did he work with Coca?
Diamond: I don't know. They had a relationship in New York anyway. Schloss was a wonderful teacher. Schloss came to Boston and made the mistake of bringing his staff with him. Not a whole staff--he brought four or five men with him. And put them in as heads of various subdivisions at the Children's Hospital. Demanded, I guess, and got the resignation of 3 of the men who had been at the Children's, who were practitioners. They had no full-time staff. You can imagine what that did to the pediatricians in Boston, which was a center of pediatric practice under Morse. Incidentally, it was two separate hospitals. The Infant's Hospital and the Children's Hospital. Different directorships, although some joint staff. Of course John Leavitt Morse, who had retired or was out as head, never forgave Schloss for bringing his own men. Schloss had had a big, wealthy practice in New York. He had been hoping, and had been told, that he'd get a large consultation practice in Boston. But John Leavitt Morse and his men who were put out made sure that they didn't get any consultation practice to speak of. So this promise of a consultation practice, which Schloss needed because full-time professors got very little salary then, just didn't materialize when he got to Boston.
Q: Could you recall the names of some of the families that--
Diamond: Not me. They would. I'm sure they would remember him. He just had a big consultation, and family practice. That's where most of his income came from. I think a full-time professor at Cornell, as at Harvard, probably got in the neighborhood of eight or ten thousand dollars at the most. So Schloss, bringing his own men, and doing a good job at the Children's, reorganized everything, made it much more of a scientific place, could not stand more than two years at this. Then he was offered a better position to return to Cornell, went back to Cornell.
Q: When you say that it was made much more of a scientific place, can you be more specific about--
Diamond: Well, he set up research in biochemistry, in nutrition. He set up research in bacteriology, taking care of infectious diseases. He organized a very good outpatient department, which hadn't been quite as well thought out before him. He brought his own men to run the outpatient department. They forced the resignation of the practitioners of pediatrics in Boston. They couldn't even admit patients at Children's Hospital without going through a resident. You can imagine how they took that. At any rate, Schloss left Boston. Dean Edsall invited Blackfan to come as Chief of Pediatrics at Harvard, and head of Pediatrics at the Children's Hospital. Blackfan was a small man, only about five foot three. Very quiet, a diplomat, an excellent physician, and a good diagnostician. Took good care of the children. When he came to Boston, he only brought two or three men with him, and re-appointed, I understand--I can't vouch for this--some of the old practitioners in Boston to bring their patients in. In the next couple of years, he rebuilt the Children's Hospital reputation. Fit it in well with the practitioners. He, himself, was asked out as a consultant. That was permissible at the Harvard system -- even the full-time men are allowed to have consultation practices. Blackfan rebuilt the Children's outpatient department clinical service. Had good, young men coming as interns. Made it a graduate appointment only. You couldn't get an appointment as a resident at the Children's and Infant's Hospital--they were combined -- until you'd had at least one year general medicine or its equivalent. Got outstanding men. As I say, he brought with him two or three good men. One of them was a doctor named McKhann. Dr. McKhann's still alive. He came as Dr. Blackfan's assistant from Cincinnati, where he had been a resident. He also brought with him George Guest. G-U-E-S-T. Now dead. But put him in charge of bacteriology and infectious disease.
Q: What was McKhann's role in this? What did McKhann do?
Diamond: McKhann was Blackfan's assistant. He was associate, assistant professor and associate. I bring him in because he was a strong influence on me. I'll bring that up. So Blackfan established this very good service. Was a very good teacher, a slow, careful speaker, and an excellent clinician. He taught clinical medicine the way Osler did. Just talking to the patient, quizzing the patient, making the patient feel that he was being cared for. Dr. Blackfan gave a few lectures at the end of the second year of medical school, to medical students, on how to examine the infant and child, and some other feeding problems and clinical problems in pediatrics. I think he gave a series of six clinics, maybe more. They were fascinating. That, too, made me feel sure pediatrics was my specialty. During the summer after my second year, I had to deliver babies, of course. I delivered them at the New York Lying-In Hospital down on the east side--Second Avenue and Fifteenth Street. Boy, was that a breeding ground.
Q: Could you describe it some?
Diamond: PJ, it dealt with poor patients. It was an old hospital. They took patients from all over the east side. They also did some research on anesthesia as I remember. They had an outpatient service where they delivered many patients in their homes. That's where in the summer after my third year, I went and went out on district and delivered patients -- delivered my six. We had to have 12 deliveries. Anyway, during that summer, also, I made contact with a very well-known pediatric specialist in New York, who was professor of clinical pediatrics at the Baby's Hospital of Columbia University P&S. His name was Fred Bartlett. He was one of the leading pediatricians, a wonderful clinician. Loved by everybody. A gentle person. Fred Bartlett was just -- there was a new hospital on upper Fifth Avenue called the Fifth Avenue Hospital. Right beyond Mount Sinai. I think it was therefore about 105th Street and Fifth
Avenue. It's still there--it's New York Medical College.
Q: Right. That's where the New York Medical Library is.
Diamond: That's right. Anyway, that hospital had just been built, and he was asked to take over the pediatric service at that hospital. Toward the end of the summer when I was through delivering really, the middle of August--
Q: Which summer was this?
Diamond: This was the summer after my second year, so that was the summer of 1925. Fred Bartlett said, "Look. You're interested in pediatrics. Why don't you come down and help me at this new clinic I just opened up?" I said "Fine," and I went down there. I spent the next four or five weeks working at the clinic with him every day. Every morning and some of the afternoon. Apparently I satisfied him. He praised my work. When I went hack to Harvard in the third year we had a regular course in pediatrics, given by Dr. Blackfan, working in the outpatient department. Fred Bartlett was a friend of Blackfan's. He wrote a letter telling Blackfan that I had worked with him, and he thought I'd done a very good job. He hoped to persuade me to go in to pediatrics. So, when I took the course the third year at Harvard, I went up and told Dr. Blackfan, "Bartlett sends his regards." He said, "Yes," he had a letter from Bartlett telling him what a good job I had done. He therefore knew me better than some of the other third year students. Toward the end of my third year at Harvard I volunteered as a student research man in pediatrics, to work in a laboratory and work with Dr. McKhann, who was then studying the biochemistry of nutrition and had a laboratory in the Children's Hospital, a little research building there.
Q: If I could ask a question at this point. The number of times you've referred to the close connection between biochemistry and nutritional studies. That type of connection is not always that apparent today.
Diamond: The reason for the close connection was that when Blackfan came to Harvard from Cincinnati he had had with him in Baltimore a Professor James L. Gamble. Gamble was a biochemist. He had graduated Harvard, took an internship at the Mass. General. Was one of those quiet, hard working fellows who had always been interested in biochemistry. He had been at Hopkins, in the Harriet Lane Home, doing biochemistry and nutrition. Particularly body fluids -- sodium, potassium, fluoride, so on. He really stabilized that whole area in pediatrics, countrywide. Blackfan invited Gamble to come up and do his research at the Children's and Harvard Medical School. Gamble came and had laboratories set up in the laboratory research building. His laboratory was right next to where Dr. McKhann was set up--that's how I got to know Gamble very well. He was one of the Proctor and Gambles.
Q: So Proctor and Gamble enter into this story a number of different times.
Diamond: Right. Dr. James L. Gamble was at Harvard, then, as Professor of pediatrics and biochemistry at the Children's. I worked with Dr. McKhann two afternoons a week, and weekends. I did Kjeldahl, the basic routine for analyzing urine and so on -- the protein constituents.
Q: How do you spell that?
Diamond: Oh! I was afraid you'd ask! [laughs] Leave it out. Just say biochemistry of urines. It's Swedish.
At any rate, I spent a fair amount of time with Dr. McKhann. Dr. McKhann had been trained by Dr. Blackfan in Cincinnati, and then at Harvard. He was without doubt the keenest clinician I have ever known, next to Dr. Blackfan in some respects he was even greater than Dr. Blackfan as a diagnostician and caretaker. That's how I got to know Dr. McKhann. So, Dr. McKhann influenced me a great deal as a great clinician. He taught clinical medicine in pediatrics. He made some real contributions. He was the first one to develop gamma globulin as useful in measles and hepatitis -- prevent or modify measles and hepatitis.
Q: When was this worked on?
Diamond: Oh, his measles work was back in the 1930s, 1940s. The hepatitis was in the 1940s, when it began to he recognized. I think it's hepatitis B, the kind that you get from food. But McKhann developed gamma globulin which had been synthesized and purified by E. J. [Edwin] Cohn, a great biochemist.
Q: Did you make contact with Edwin Cohn during this period?
Diamond: Very much, I'll tell you more about that. I worked under him.
Q: Before we go on, do you think that we could generalize about the relationship between biochemistry and nutrition, or is this a specific interlapping area of interest for people such as Gamble? There are other people who are starting to push for a discipline of biochemistry who also came out of a nutritional background.
Diamond: Oh sure. That became, of course, the hot subject for research in infant feeding. I can't recall all the names that were so important, there. But there were a whole series of investigators who influenced the choice of formula, helped make up formula that are now part of routine artificial feeding for children both in Canada -- Toronto, Canada -- and Montreal. Toronto mostly, because that was where Connaught laboratories had a lot of research going on. Part of the University of Toronto. That's where they developed insulin, of course. But I can't recall all the pioneers in infant feeding that were in Boston, New York, Hopkins, and Marriott in Saint Louis. He followed Dr. Howland.
Q: How do you spell Marriott?
Diamond: M-A-R-R-I-O-T-T. He was a great influence in infant feeding.
Q: Would you have any notions about why at certain times there is greater interest in questions such as the biochemistry of infant feeding, and other times the interest recedes?
Diamond: Infant feeding became so important when it was recognized that a high percentage of the mortality of infants occurred in the first eighteen months, or the first year of life from bad feeding, contaminated food. In fact the Children's Hospital, even before Blackfan's day, recognized that lack of sterility, lack of precautions against contamination, was the chief cause of high mortality. Particularly in the summertime, the hot weather, in Boston. Boston, through a group of ladies, had organized what they call a "floating hospital." They bought, or hired, a boat, and in hot weather they fitted it with beds and wards and doctors, pediatricians, and they would take infants out every day who were suffering from diarrheal disease, or who were from poor families, and take them out in to Boston Harbor -- that's why they called it a floating hospital. Where it was much cooler, and also where they could use better sterile precautions, and thereby saved a lot of lives. This went on, probably, for half a dozen summers. Hospital -- floating hospital. It was actually part of Tufts University.
Q: Do you know who was behind the program?
Diamond: One man at the time I was there was a Dr. Barron. B-A-R-R-O-N. But several pediatricians were involved in this. A floating hospital actually became--the ship burnt down a couple of times during the winter, and they had to get a new ship. They had a fair amount of money they collected and it became a branch of Tufts University and the Infants' Hospital at Tufts University. It was called the Floating Hospital, On-Shore Division. But infection, and summer diarrhea-cholera infantum--was the chief cause of mortality in big cities during the hot summertime. The pediatricians became interested, of course, in stabilizing formuli. There was a period when they had acidified milk.
Diamond: Acidophilous -- milk. Marriott out in Saint Louis was one of the backers of that, I believe, and some others in New York too. Isaac Abt from Chicago, was a famous pediatrician. He was interested in feeding children in Chicago. Real formuli were then developed. But Boston under Dr. John Morse had developed what they called percentage feeding. They take two percent butterfat -- cream -- and 40 percent water, and six percent sugar. They measured everything exactly. In fact, they'd make up formuli exactly for each child -- pediatricians who were in practice would make up percentage formuli. There was Walker Gordon Laboratories, a commercial organization -- milk company, that the pediatrician would call up and tell them to make up a formula of so much maltose, so much butterfat, so much water, so much salt particularly for the child.
Well Blackfan and Gamble very quickly showed that this was not necessary. That if you just took diluted milk and added some extra maltose, or even just ordinary sugar, you could make up a formuli that the children would do just as well and the mother could learn to do. Then of course they went in for canned, sterile, pasteurized, formuli -- sterilized formuli -- that they could just open the can and dilute it once and feed the child. Simplify feeding a great deal.
Q: Did Walker Gordon labs put up any resistance to the arguments of--
Diamond: No -- they were still busy enough. I don't know when they finally folded. They became part of the Hood Milk Company.
Q: The claim was that this was more scientific?
Diamond: Anyway, infant feeding was greatly influenced by Blackfan and Gamble, and other New York and Baltimore nutritionists. Down in Baltimore, a famous pediatrician Dr. Edwards Park. P-A-R-K. He had been trained by Howland. Blackfan, Powers, Park, and several other pediatricians were residents under Howland. They became chiefs of services.
Anyway, Gamble was of course the center light of biochemistry and of fluid therapy -- parental(?) therapy to treat children with diarrheal disease.
Q: Was there a very high mortality rate from the diarrheal disease?
Q: Until when did that continue, about, as a major problem?
Diamond: Until they learned to sterilize Torruli make them up fairly simply, and of course learn to protect children from the extreme heat of the Boston summers. For sick children we even had early on at the Children's and Infants Hospital some air-conditioned rooms. We were right next to the Harvard School of Public Health. There were some engineers there originally developed air conditioning.
Q: The air conditioning units were originally developed at the Harvard School?
Diamond: That was one place, yes, by men at the Harvard School of Public Health, and actually used at the Children's and Infants' Hospital. The first air-conditioned nurseries for premature babies were established at the Infants Hospital when I was there, under Dr. Blackfan around 1926,1927, 1928.
Q: The rationale for developing these units?
Diamond: Premature children have to be kept at a stable temperature. They couldn't go up and down the way full-term infants did. You couldn't keep them warm just by wrapping them in blankets. So we had two air-conditioned rooms. One of them at one temperature for infants, premies under three pounds, another one between three and four and a half pounds, and then they could go out on the ward. By that time they could stabilize their own temperature. But this was an important part of the reduction of morality of premature infants. Dr. Blackfan showed that you could reduce the mortality almost to the same as for ordinary full term infants by this air-conditioning and sterile precautions, and so on.
Q: There was an interest at that time in birth weight?
Diamond: Oh yes. We developed an air conditioned nursery at the Boston Lying-in. Children's Hospital pediatric department was in charge of the newborns at the Boston Lying-in across the street. That is true of other cities, too. They took over the care of premies. Dr. Blackfan wrote one of the first books on the care of premature babies. In terms of the actual research into the question of birth weight, that birth weight has something to do with survival rates. That was a question that was looked in to at that time and it'd be pasteurized and then used for infant feeding. That was quite an advance for the feeding of premature babies.
Q: Was there any biochemical interest, or interest by scientists in the biochemistry of breast milk during this period?
Diamond: Oh yes. I can't remember names of that, but again Dr. Gamble and his group, Dr. Marriott and his group I guess, Park and Powers -- all of these people. Powers, who was professor at Yale, was very much interested in infant feeding.
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Q: Dr. Diamond, would you care to elaborate on further experiences at Harvard, the Medical School, and perhaps talk about some of the other personalities that you came in to contact with?
Diamond: Yes. In my fourth year, as I began to plan to go into pediatrics, I wanted to intern at the Children's Hospital in Boston. Knowing that it was necessary to have a one year general medical appointment, I applied for medical internships for appointments after I graduated. Amongst them I had an application to the New York Hospital, which was the Cornell Medical teaching service. I was fortunate enough to be given an appointment there. But, in those days appointments to internships were usually staggered, like every three months, so that a new man came on and would be broken in by the man ahead of him. Therefore a one year appointment had one man starting July, next man October, third one February or January, and the fourth one in April. I received the appointment for April 1928. In other words, I'd have to wait awhile before I could start. I had approached Dr. Blackfan to put my name on the waiting list for an internship at the Children's after I finished the New York appointment, which would have been 1929. Dr. Blackfan said he would put me on the list, but of course he had dozens of applicants, and there was no certainty that I would make it. But in my fourth year as a medical student, I was on the Children's Hospital ward when we happened to have a few interesting hematologic cases -- blood diseases in children. Our consultant in hematology was Dr. George Minot. He came over to see the children with blood diseases. One of them was the second child in a family with big spleens and severe anemia. The cause of the anemia was obviously destruction of blood because the child was jaundiced. But it wasn't typical of what we call familial jaundice with anemia, or spherocytosis. Dr. Minot called this child an atypical hemolytic anemia, cause unknown. As a medical student I became interested enough to follow this case as well as others I'd had on the ward. In the fourth year we spent a month on the ward taking care of children, admitting them, working them up and so on with the interns in residence. Dr. Minot asked me to report to him about this child later on. That was my contact with Dr. Minot, who at that time had already begun working -- this is in 1926, 1927 -- with liver as a treatment for pernicious anemia. Recognized pernicious anemia as being a nutritional deficiency, and lacking in some important nutritional factor. So, reporting to him on this other child a few times, I went over to see him at the Huntington Memorial Hospital, a small hospital right next to Harvard Medical School on Huntington Avenue, endowed by the Huntington family. That's where Dr. Minot kept his pernicious anemia experimental patients. I did go over there, and got to see some of his patients, and made ward rounds with him. So, that was my contact with Dr. Minot. Also, as a fourth year medical student on the C.H. wards there was a three-year-old child admitted one night (when I was on service) with enlarged lymph glands, enlarged spleen, fever, and peculiar looking white blood. I worked him up. He'd been diagnosed as having Hodgkin disease on the basis of having a biopsy of the lymph gland done in his local hospital in Connecticut and had been sent to us as a case of infantile Hodgkin with a piece of the lymph gland. The professor of Pathology at H.M.S., and the head of pathology at the Children's, was Dr. Wolbach. He studied the lymph gland and said "it didn't look like Hodgkin disease. Maybe the child had something else." Dr. Blackfan came on ward rounds, and I was lucky. I'd taken the history, and I presented the case to him. I said "it had a peculiar blood, a peculiar lymph gland which was not typical of Hodgkin, that Dr. Wolbach thought it wasn't. We wondered whether it really was malignant Hodgkin disease in this little two-year-old," who looked pretty sick. Dr. Blackfan said, "I vaguely remember that there was an epidemic of fever and swollen lymph glands which they called "glandular fever," in a boy's school down near Johns Hopkins. It was described by the pathologist and the clinician, Drs. Sprunt and Evans. They also said there were peculiar cells in the blood. Maybe this child has glandular fever. Why don't you go look up what glandular fever is, get Sprunt and Evans' write-up."
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