Department of Pathology History
Written by Robert H. Heptinstall
Two previous index volumes of the publications of the Department of Pathology have included brief accounts of the Department's activities. The first dealt with the years 1885 to 1930, and the second with 1931 to 1963. Because these accounts - however short - provide the only composite history of the Department it seems sensible to continue this practice and the following report covers the years 1964 to 1988. While the two previous index volumes contained a roster of staff members the present volume does not. Those seeking such information are directed to the catalogues of the Medical School. It should be noted that the reprints of publications for certain years are incomplete, owing either to a failure of faculty members to submit reprints or to an imperfect job by those collecting the reprints.
As outlined in the index volume for 1931 to 1963, Ivan Bennett succeeded Arnold Rich in 1958 and brought about considerable changes in many of the functions of the Department. In 1966, however, he took a leave of absence to serve as Assistant Director in the Johnson Administration's Office of Science and Technology, and I was appointed to act in his stead on a temporary basis. Bennett never returned, for in his third year in Washington he accepted an administrative post at New York University. A search committee was appointed and in 1969 I was made Director of the Department and Pathologist in Chief, serving in these two capacities until 1988.
The years 1964 to 1988 saw consolidation and expansion of the changes initiated by Bennett and these will be described later in this account. Before proceeding, however, it is appropriate to describe a major change that took place. This was our assuming responsibility for clinical pathology. Up to this time the various diagnostic tests for the hospital-microbiology, chemistry, hematology, parasitology, blood banking and immunology had been carried out by the various divisions of the Department of Medicine. There was much dissatisfaction with this arrangement and in 1965 a report was drawn up on the organization of the Hospital's diagnostic laboratories which is attached as Appendix A. Acting on this report the Hospital formed a search committee to identify an individual to be Director of diagnostic laboratories. After an exhaustive search Dr. Rex Conn from the University of West Virginia was chosen for this position. Extensive deliberations the Medical School and Hospital led to the decision that the diagnostic laboratories would become an independent Hospital Department and a Subdepartment within the Department of Pathology for Medical School purposes. Dr. Conn chose the name Laboratory Medicine - rather than Clinical Pathology - for the new entity and in 1968 he was appointed Director. This double-headed arrangement meant that Laboratory Medicine had a seat on the Medical Board of the Hospital but was represented on the Advisory Board of the Medical School by the director of the Department of Pathology who was responsible for the academic welfare of the Subdepartment. Although not without frictions and irritations, this apparently cumbersome arrangement worked well over the years. More is said of Laboratory Medicine at other points in this account.
For ease of presentation the rest of the account is divided up as follows:Organizational structure +
The increase in size and complexity of the Department called for expansion of administrative staff and establishment of a better defined chain of command. Appendix B shows the organizational structure that had evolved by the early and mid 1980's. By 1988 a billing operation for professional fees in surgical pathology and cytopathology was developed as part of the Administrative Unit. As described in the previous section Laboratory Medicine has direct access to the Hospital Administration, a fact not brought out in Appendix B. The Department of Pathology at Francis Scott Key Medical Center (previously Baltimore City Hospitals) was an independent operation but since its professional staff members hold full-time Johns Hopkins faculty positions the appointment of staff-including the Chief Pathologist-was subject to the approval of the Director of Pathology at Johns Hopkins. The Director also had input into the appointment of the Chief Medical Examiner for the State of Maryland since he was a member of the Sate's Postmortem Commission which is the supervisory body for the Medical Examiner's Office.
The years under consideration saw the provision of new space to accommodate Laboratory Medicine but only a small increase for Anatomic Pathology. Extensive renovations, however, were carried out to provide better research laboratories and facilities for service work.
The following account summarizes these various changes on a floor by floor basis. The basement area was extensively remodeled in 1978-79 to provide a new autopsy facility including a special area for contaminated cases, storage space for old slides and records, and space for autopsy sign out. These adjustments were made possible by moving old autopsy blocks and tissue and old surgical pathology blocks and slides to various places outside the Department. Few changes were made in the electron microscopy suite apart from a continuous replacement of transmission electron microscopes by more up to date instruments and the purchase of a scanning electron microscope.
The first floor, which in 1964 accommodated the autopsy suite and lecture theater, saw several minor reshufflings, but in 1978 the encroachment on our territory by the Meyer Building in Phase II of the Hospital's rebuilding program necessitated removal of the autopsy suite to the basement and tearing down of the lecture theater. Lectures in the 2nd year Pathology course were transferred to the newly built Preclinical Teaching Building. The rest of the floor was extensively remodeled at this time by the creation of the Quantitative Cytopathology Laboratory with funds obtained by Dr. John K. Frost from the William Penn Foundation, and by constructing a large photography unit with money earned and carefully husbanded over the previous few years by its Director, Pete Lund. A department conference room and offices were provided at the same time.
The second floor was completely transformed during the 24-year period. The first alteration took place in the early 1960's when the old lecture room at the northwest end was converted into five research laboratories. Next, owing to an overall increase in the student body it became necessary in the early 1970's to provide space for a sixth group of students. This was effected by altering the student teaching laboratories which had been built during the early 1960's. The changes in the teaching laboratories, however, were short-lived, for with the opening of the Preclinical Teaching Building in 1981, our entire student teaching operation was moved to this new site. This move allowed us to dispense with the teaching laboratories, and in 1981-82 as part of the Phase II renovations the entire old teaching space was converted to research laboratories and offices. Veterinary Pathology was provided with a suite of offices as part of this reconstruction. We also acquired some 2500 sq. ft. of new research laboratories by expansion in to the Carnegie Building.
The third floor, originally occupied by poorly equipped research laboratories, had its first major renovation in 1974-75 when the north and northeast area was converted into an immunopathology suite and a common equipment room. Several years later the northwest corner was renovated as a general purpose research laboratory. Air-conditioning and some minor renovations were made to the old chemistry laboratory initially inhabited by George Gey on the east side.
The fourth floor saw many renovations and reshufflings. In 1966 the ceiling of the library was lowered to improve the lighting. Not only did this make the lighting worse but ruined the appearance of this beautiful room. Happily this error was corrected in the Phase II renovations in 1981-82 when the library was restored to its former glory and later named the Ella Oppenheimer Memorial Library. The Director's and administrative office were renovated in 1966 and accommodations provided for the photography unit. Cubicles for the house staff at the west end were constructed in 1964-65 and expanded and improved over the years. The photography unit expanded and underwent a major renovation in the early 1970's. It was finally relocated on the first floor as part of the Phase II reconstruction in 1982-83, at which time its vacated space on the fourth floor was converted to offices to house the expanding administrative operation.
Over the years 1964-1988 the fifth floor was completely changed. At the start of this period it comprised surgical pathology, gynecologic pathology, eye pathology and the autopsy histology laboratory, as well as sundry offices. In early 1969 surgical pathology and gynecologic pathology were physically-although not administratively-united in new premises on the seventh floor. Autopsy histology also moved to this new location and as a consequence a large amount of space became available on the fifth floor. In 1973 laboratories and offices were provided for Dr. Donald Price's neuropathology unit and over the ensuing years-particularly in Phase II-virtually the whole of the floor was renovated to accommodate this fast growing unit. Before all of this came to fruition part of the newly created Subdepartment of Laboratory Medicine was temporarily accommodated on the fifth floor. It later moved to its present quarters in the Meyer basement as part of Phase II in 1981. Eye pathology remained on the floor until 1971 when it moved to the Wilmer Institute.
The sixth floor was occupied by Cytopathology during the whole of the period 1964 to 1988. Renovations were constantly taking place on this floor to improve the facilities for service work, research and the training of cytotechnologists.
As outlined earlier a major reconstruction took place on the seventh floor in 1969 when surgical and gynecologic pathology were relocated there. Up to that time the floor was used for miscellaneous operations including a small neuropathology unit. Facilities provided were areas for reception and processing of specimens from surgical and gynecologic pathology, photography, sign-out of specimens, and offices for faculty and support personnel. The rationale for this move was to provide contiguity with the surgical operating area located on the seventh floor of the Carnegie Building. Autopsy histology was consolidated in the central tissue-processing laboratory. Further improvements were made in 1983 as part of the Phase II reconstruction plan and these included provision of a room for house staff and fellows, and offices for faculty and supportive staff. A small amount of faculty office space was obtained on the seventh floor of the newly constructed Meyer Building. These years also witnessed the introduction of multi-headed microscopes for teaching, computer modules for reporting and documentation, and replacement of the old hissing C02 microtomes by modern cryostats for frozen sections. One important innovation was the creation of the so-called immunoperoxidase (more correctly, immunohistology) laboratory to apply the burgeoning number of monoclonal antibodies to diagnostic pathology.
The eighth floor remained an area for housing laboratory animals. Minor improvements in the early 1960´s were overshadowed by a complete reconstruction as part of the Phase II alterations in 1981-82. The increasingly stringent government regulations on the welfare of laboratory animals during the 1970's saw the surrender of our control of this floor to the Division of Comparative Medicine.
Construction and renovations for Laboratory Medicine were considerably less complicated than for Anatomic Pathology.
Certain of the divisions of Laboratory Medicine were inherited the service laboratories previously operated by the Department of Medicine-mainly in the Carnegie Building-and initially these and space on the fifth floor of the Pathology Building housed the newly formed subdepartment. However in 1981 as part of the Phase II building program most of the divisions and Laboratory Medicine Administration were accommodated in the basement of the Meyer Building. Certain of the divisions, including the blood banking operation, clinical immunology and blood drawing laboratories, remained on various floors of the Carnegie Building. Shortage of research space was a constant problem that was never satisfactorily resolved.
Medical student teaching continued to be one of our most important tasks. Apart from the incorporation of new knowledge and concepts of pathology into the course, few major changes took place over the years being described. The course was given over the first two quarters of Year 2. Initially it shared this time with Microbiology but later with Clinical Skills, Clinical epidemiology and Human Pathophysiology. Microbiology was moved into Year 1. Time constraints necessitated the teaching of neuropathology as part of a Neurology course in the third quarter of Year 2. A series of formal lectures was introduced covering the general principles of pathology during the first few weeks and specific organ-system pathology for the remaining time. The schedule for 1987-88 is attached as Appendix C. Lectures were given daily between 9:00 and 10:00 a.m. following which the students split up into the traditional small groups for the rest of the morning for informal classroom teaching. Lectures were given by faculty members and the classroom sessions by faculty, residents, fellows and selected pathologists from community hospitals. Between 60 to 70 instructors (10 per group) were used for the classroom teaching (Appendix D). In this way the students received individual attention, and the instructors were afforded an opportunity to know the students well. Students were graded on the instructors´ assessment of their performance in the classroom and by three intragroup tests and a final classwide essay-type examination.
In 1981, our teaching activities were moved to the Preclinical Teaching Building which provided us with more spacious accommodations. It did, however, break a long tradition of teaching in our own building and deprive the students of a sense of identity with the Department. Clinicopathologic Conferences (CPCs) maintained their popularity in spite of a more egalitarian approach replacing Rich's virtuoso performances. As will be recorded later the declining autopsy rate and the introduction of more refined diagnostic techniques made it increasingly difficult to obtain suitable cases for discussion. Medical students were also offered a number of courses on an elective basis. These were organized by individual faculty members. (Appendix E)
The years covered in this account saw the admission to the medical school of increasing numbers of students from minority groups. At first many of these students required remedial instruction, but over the ensuing years the quality improved and extra coaching was less often required. The time honored summer prosectorship program - in which students performed autopsies in the fourth quarter-maintained its popularity and was still in existence in 1988. We continued to attract high quality students who were accommodated at Johns Hopkins, Francis Scott Key Medical Center, Sinai Hospital, and Union Memorial Hospital. Many of our residents developed their interest for a career in pathology after this experience.
The residency training program was radically changed following the creation of the Subdepartment of Laboratory Medicine. In 1970 for the first time, we were able to offer clinical pathology and provide residents with various alternative forms of training. Some, particularly those with an academic bent, chose three years exposure to anatomic pathology followed by training in research methods; others opted for a prolonged training in anatomic pathology with a year being spent at Memorial-Sloan Kettering Cancer Center; and still others chose a combined program of two or three years in anatomic pathology and two years in clinical pathology. The expanding use of needle biopsies of the liver and kidney, endoscopic biopsy of the gastrointestinal tract, and fine needle biopsy of many organs necessitated special rotations, and time had to be set aside for training in diagnostic electron microscopy, immunohistology and cytogenetics. The effects of the declining autopsy rate were largely offset by rotations at The Francis Scott Key Medical Center (formerly Baltimore City Hospitals, now known as Bayview Medical Center) and by the setting up of an "autopsy charge" system in which a second or third year resident was in constant attendance at the autopsies performed by the interns. In this way the resident´s personal exposure to autopsies was almost doubled. A typical schedule for residency training in anatomic pathology is attached as Appendix F. The schedule for clinical pathology was much less complicated. The first year of training consisted of three monthly rotations through the main divisions while in the second year the resident would work in on of the divisions on projects such as the development of new techniques. By the early 1970's, the housestaff had increased to 27, of which increasing numbers were women.
Research training up to 1976 was carried out under an NIH Training Grant in Pathology, but inappropriate use of training grant funds in several medical centers caused the NIH to discontinue the entire program. From this time on various sources of funding were utilized, and these included NIH Career Development Awards, NIH Individual Fellowships, NIH Teacher Investigator Awards, the Medical School's in-house Career Development Awards, the Clayton Fund, the Stetler Fund, and the Simpson fund, and in faculty members' research grants. In addition, both research trainees and junior faculty members were supported by the interest derived from the considerable sum bequeathed to the Department by Dr. W.G. MacCallum, the second Director of the Department. Research training in neuropathology was considerably enhanced by the award in 1980 to Dr. Donald Price of a neuropathology training grant.
Outstanding among our postgraduate teaching efforts were the Cytopathology Institutes presented by Dr. John K. Frost and his associates referred to in the report covering the years 1931 to 1963. This two week courses attended by up to 70 pathologists from all over the world celebrated its 25th birthday in 1984. Note should also be taken of the considerable contribution of the Department to the training of residents and fellows in other departments. This was effected by our support of large numbers of interdepartmental conferences, a list of which for 1983-4 is included as Appendix G.
The acquisition of clinical pathology (laboratory medicine) in 1968 resulted in a considerable increase in scope of our service activities. The organizational structure was described earlier and is displayed in Appendix B.
Anatomic Pathology: Autopsy Service
For virtually the whole of the period 1964 to 1988 this service was directed by Dr. Grover Hutchins. It continued to play an important role in the training of residents, in the teaching of medical students, and in providing research material. Unfortunately, there was a decline in the number of autopsies performed during the 1970's and 1980's owing to fewer permissions being obtained. This nationwide trend was mirrored in the decrease from 741 autopsies in 1964 to 396 in 1987. This disastrous fall with its potential effect on our residency program was partially offset by rotation of the residents to Francis Scott Key Medical Center where, for example, they preformed 137 autopsies in 1987. This provided an adequate training pool which, for example, was 533 autopsies for the year 1986-1987.
Postmortem examinations were carried out with the same attention to detail as in former years but increasing numbers were subjected to techniques such as electron microscopy, immunohistology, and in-situ hybridization. The retention of tissue, slides and paraffin blocks from every autopsy ever performed in the Department constitutes an unrivalled collection of material that can now be studied using modern technology. While the hoarding instincts of the early generation of pathologists have been amply justified it would have counted for little without the computerized cataloguing and retrieval system initiated in the 1970's by Drs. William Moore and Grover Hutchins.
The early 1980's were marked by the appearance of AIDS and, by 1988 almost 100 autopsies on this condition had been performed by the Department. This is mentioned not only as a historical fact but as a stark reminder of the dangers facing young pathologist. Every generation of pathologists has been exposed to such occupational hazards as streptococcal septicemia, syphilis and tuberculosis, but none except the present generation has been at risk of accidentally contracting a uniformly fatal disease. Observance of strict precautions has happily prevented any such contamination.
Surgical Pathology continued to expand and alterations made in the building to accommodate it were described earlier. The operation was headed until his departure for Charlotte, N.C., in 1970 by Dr. William Shelley, at which time Drs. Darryl Carter and Joseph Eggleston were appointed as joint heads. This arrangement continued until 1977 when Dr. Eggleston assumed sole charge; this continued until his untimely death in 1989. (Click here to watch the video for the tribute to Dr. Eggleston.)
The years under consideration saw an increase in the numbers of specimens handled from 16,572 in 1964 to 22,867 (including "medical" biopsies) in 1987, an increase of 38%. In addition there were 1,792 frozen sections in 1987. While the increase in specimens seems only modest it should be recorded that many of them were subjected to electron microscopy, immunohistology, etc., thereby requiring more time to be spent on them. The importance of immunohistology was early on appreciated by Dr. Eggleston who, in the late 1970's started a special laboratory to develop and utilize the various techniques needed. This laboratory flourished and is now an important departmental resource, not only for service commitments but for research and training.
The complexity of surgical pathology was greatly increased by the extended use of needle biopsy of the liver and kidney and endoscopic biopsy of the gastrointestinal tract, and by the introduction of non-surgical heart biopsy. Realizing that such biopsies (referred to as "medical" biopsies) required the attention of specialists these tissues were treated separately from conventional surgical biopsy specimens. Numerically, gastrointestinal biopsies headed the list and 3399 were examined in 1987. Dr. John Yardley had prime responsibility for this service and was assisted by Dr. Stanley Hamilton and a series of fellows enrolled in a two year training program in gastrointestinal pathology. Liver biopsies numbered 501 in 1987 and were interpreted by Dr. John Boitnott. Renal biopsies were fewer in number (280 in 1987) but involved proportionally more effort since each was subjected to immunofluorescence microscopy and many to electron microscopy. This service from 1964 onward was headed successively by Drs. Gerald Spear, Kim Solez and Jean Olson. Heart biopsies (Dr. Grover Hutchins) reached 532 in 1987 and had doubled in numbers from 1985.
The staff responsible for the general (conventional) surgical pathology service expanded from two in 1964 to five in 1988. At this latter date the personnel comprised Drs. Joseph Eggelston (chief), Risa Mann, Jonathan Epstein and Frank Kuhajda plus the chief resident who acted as a junior faculty member. Parenthetically it should be pointed out that each of the two departmental chief residents occupied the surgical pathology sign-out position for a six month period, the other six months being spent in an overall administrative and supervisory role for the rest of the housestaff's activities. Included among others who staffed the surgical pathology service from 1964 to 1988 were Drs. Hartmann, Sharon Weiss, Jerome Taxy, and Geoffrey Mendelsohn. Gynecologic specimens during this time frame were reported on by practicing gynecologists from the Department of Gynecology and Obstetrics.
The contentious issue of gynecologic pathology, which provided up to one-third of the number of specimens in surgical pathology, needs explaining. Historically gynecologic pathology was handled by the Department of Gynecology in separate premises. Residents in Pathology received no training in this important area. Although by 1964 all surgical and gynecologic specimens were accessioned, numbered and processed together, the sign-out of gynecologic specimens was still done by Dr. Donald Woodruff and other practicing gynecologists from the Department of Gynecology and Obstetrics. This nonsensical holdover from ancient times was rabidly defended by the old-time gynecologists and its perpetuation ensured by an ex-Head of the Department of Gynecology who made a considerable financial bequest to the Medical School with the stipulation that the status quo be maintained. Our protests to the Medical School over this surrender of principle to expediency went unheeded. However, over the ensuing years we were able to make considerable inroads into this atavistic system and by 1969 the pathology residents were allowed to "sit-in" at the sign out sessions although without responsibilities comparable to those of the residents in gynecology. By the early 1980's the pathology residents had assumed responsibilities comparable to those of residents from gynecology. Pathology faculty members increasingly took part in the signouts, and the frozen sections were interpreted by pathologists. In the mid 1980's a search was initiated for a new head of gynecologic pathology to replace Dr. Donald Woodruff but it took until 1989 for this to come about when Dr. Robert Kurman was selected with appointments in both the Departments of Pathology and of Gynecology and Obstetrics. In order to satisfy the conditions of the financial bequest referred to above, it was required that Dr. Kurman's primary appointment be initially in the Department of Gynecology and Obstetrics. Although this was not a perfect arrangement it was a reasonable compromise since Dr. Kurman is almost exclusively interested in pathology and is physically located in our department. I am also pleased to record that two graduates of our residency program (Drs. Kathleen Cho and Lora Hedrick) were later appointed to join Dr. Kurman and our residents now receive the same high quality training as in surgical pathology. I have described this rather sordid chapter in the history of the Department since it is a tale that is unlikely to be told anywhere else. It reflects little credit on the part of the School of Medicine, which abetted the efforts of a group of old men to hinder progress by placing financial gain over the welfare of one of its departments.
Surgical pathology was one of the cornerstones of our residency training program and also provided a great deal of our financial income. In 1983 we moved to an arrangement by which we charged for professional services and Dr. John Boitnott deserves much commendation for setting up the billing procedures for the computerization of our indexing, reporting and data retrieval.
Dr. John K. Frost was responsible for the inauguration of this operation in 1959. Since that time it has prospered and now makes a significant contribution to our service operation, to training of residents, post-graduate students and cytotechnologists, and to research.
At first the service aspect of the operation was predominantly gynecologic (vaginal smears) but over the years it expanded to include specimens from bronchi, pleural and peritoneal cavities, urine, cerebrospinal fluid, etc. The ration of non-gynecologic to gynecologic specimens therefore increased and in 1987 there were 5,697 of the former and 15,742 of the latter. Modern technology supplemented the traditional Papanicolou staining, and immunofluorescence, electron microscopic and in-situ hybridization techniques were increasingly used. In the 1980's the procedure of fine-needle aspiration was introduced and by 1987 this accounted for 1267 specimens. The service operation was carried out by Drs. Yener Erozan, David Hollander and Prabodh Gupta over the years in question.
Cytopathology also assumed greater importance in the residency training program and most of the housestaff spent three months on this rotation by 1988. As mentioned elsewhere Dr. Frost's Cytopathology Institute was the Department's major postgraduate teaching effort. A two year training program for cytotechnologists ensured a supply of superbly trained technicians.
This section would not be complete without mention of the splendid leadership shown by Dr. Frost. He developed what was undoubtedly the outstanding cytopathology program in the United States. In addition to what is described above, he initiated and supervised two large research projects on the early detection of lung cancer and on automated cytopathology. He was truly the doyen of American cytopathology. Regrettably, he died in 1990 just as he was preparing to enjoy his semi-retirement. (Click here to watch the Memorial Service for Dr. Frost, held in November 12, 1990.)
As detailed elsewhere this enormous service operation began in 1968 when the responsibilities previously assumed by the various Divisions of the Department of Medicine were transferred to the Hospital's Department of Laboratory Medicine, a subdepartment of the Department of Pathology. This transition was ably effected by Dr. Rex Conn and further developed by Dr. Robert Rock on Dr. Conn's departure for Emory University in 1976. By 1988 there were ten full-time faculty members and nine who were "part-time" (i.e. had primary appointments in other departments or in other hospital). Over 300 technicians and administrative personnel were employed.
Laboratory Medicine was divided into the following Divisions.
1. Laboratory Information Systems
This division developed mainly by Dr. Robert Miller centered round the laboratory computer which provided data collection, analysis, and reporting of test results for all the major laboratory divisions. Online monitoring of automated instrumentation was combined with manual entry of other procedures to link up with the JHH central computer for reporting results of tests direct to inpatient units and major clinic areas. Administrative data related to laboratory workload, economics of laboratory operations, and utilization of laboratory services were collected, analyzed and reported to JHMI central administration and major functional units.
2. Clinical Chemistry
This operation was pioneered by Dr. Robert Rock and taken over by Dr. Daniel Chan in 1977 when Dr. Rock assumed the directorship of Laboratory Medicine.
The Hematology Division, early on directed by Dr. Robert Baisden, was taken over in 1979 by Dr. Sam Charache. It dealt with general hematology, special hematology,described later being performed by one of the affiliated University laboratories. General hematology carried out automated blood counts, differential white cell counts and manual studies of blood-cell morphometry. It also performed automated assays of prothrombin and other coagulation defects; electrophoresis for abnormal hemoglobins, studies of hemoglobin derivatives and certain red-cell enzymes; and chemical test and microscopic examination of urine and other body fluids. In 1987, 626,539 tests were performed by this Division compared with approximately 225,000 in 1967.
For several years after the autonomy of Laboratory Medicine was established this division continued to be directed by Dr. E.E. Morse of the Department of Medicine. In 1970 Laboratory Medicine's own staff assumed control and successive directors were Drs. Alfred Grindon and Paul Ness. The Division had many responsibilities chief among which was the transfusion service. Tests were performed to establish safety or blood, packed cells, platelets, and protein concentrates for transfusion. A donor service arranged for blood collection, processing and storage to supplement the main supply from the regional Red Cross facility. Diagnostic tests for hepatitis and HIV infections became increasingly important procedures. A reference laboratory identified unusual antigens and antibodies on samples from JHMI patients and on samples referred from outside hospitals and physicians. Tests done by the diagnostic immunology section included immunoglobulins, antinuclear antibodies, T- and B-lymphocytes and subsets, and tumor antigens. The numbers of procedures performed in 1987 were: Blood Bank -230,044; Diagnositc Immunology -57, 177; and Diagnostic Immunohematology -24,384. Owing to organizational changes and different ways of reporting it is not possible to compare these figures with 1967.
Until 1972 Dr. Robert Baisden was in charge of this Division but following his departure in 1972 Dr. Patricia Charache assumed responsibility. Under her direction the following sections were created: Bacteriology; Mycobacteriology; Mycology (Dr. William Merz); Biochemical Microbiology (Dr. James Dick); Parasitology; and Virology. The functions of the Division were identification by morphologic, cultural and immunologic techniques of specific microorganisms; antimicrobial susceptibility testing; therapeutic drug monitoring of antibiotics; immunologic procedures for microbial antigens and specific antibodies; and biochemical testing for microbial cellular components or metabolites. Genetic recombinant technology for CMV, legionella, HIV, mycobacteria and salmonella was introduced in the 1980's. In 1987 the number of tests was 255,380 compared with approximately 115,000 in 1967.
In addition Laboratory Medicine covered various affiliated University Laboratories under its general institutional license. Whereas in 1968 there were a dozen of these units, by 1988 they had been more than halved. Those remaining were:
- Adult Special Hematology
- Pediatric Special Hematology
- Adult Endocrinology
- Pediatric Endocrinology
- Genetics and Metabolic Screening (Kennedy Institute)
These laboratories are holdovers from the 1960's at which time certain specific procedures were carried out by clinicians with special interests. Over the years 1968-1988, more and more of the tests carried out in these laboratories were incorporated into the various divisions of Laboratory Medicine so that by 1988 only five significant University Laboratories were in existence. It might well be asked why even these units had not been taken over by Laboratory Medicine. There were many reasons, chief among which were: the tests performed were often more appropriate to these special laboratories; harmonious relationships had been established with these units; and the loss of the laboratory would have had serious financial and intellectual consequences for those giving it up. So long as our residents had access to these laboratories for training purposes no strenuous efforts were made to take them over. The situation was similar to that in Anatomic Pathology, where Ophthalmic Pathology and Dermatopathology continued to be done in the respective clinical departments. Those University Laboratories that remained included:
- Adult Special Hematology and
- Pediatric Special Hematology, both of which performed examination of bone marrow morphology and coagulation assays for specific factor deficiencies.
- Adult Endocrinology and
- Pediatric Endocrinology which performed radioimmunoassay for steroids, pituitary hormones, and other specialized endocrine analyses.
- Genetics and Metabolic Screening in which such procedures as karyotyping and metabolic testing of children with inborn errors of metabolism were carried out.
Over the years covered by this report a great deal of research was performed by the Department and some idea of its scope and volume can be gleaned from the titles of the publications. An account of the Department's research from 1958 to 1987 is attached in Appendix H. This was written by me for Dr. A. McGee Harvey who was chronicling the research activities of each department of Johns Hopkins Medical Institutions for the Centennial celebration. Although substantial, the research efforts were hampered by a shortage of modern laboratories for apart from renovations in our own building the only additional laboratory space acquired was 2500 sq. ft. on the second floor of the Carnegie Building as part of the Phase II reconstruction. Such lack of modern laboratories made it difficult over the years to recruit faculty primarily interested in research, and this was at no time more apparent than over the years 1985 to 1988 when an unsuccessful search was made to find my successor. Ironically, this failure was not without benefit to the Department for it led to the provision of an extra 10,000 sq. ft. of space in the new Rutland Street Research Building.
Most of the research support came from the National Institutes of Health (NIH), mainly in the form of R01's although the largest single projects were an NIH contract from 1973 to 1985 to Dr. John Frost to determine the role of cytopathology in the early diagnosis of lung cancer, and Dr. Donald Price's NIH Center grant to study Alzheimer's disease. By 1985-6, the annual amount of sponsored research was $3,282,000 (exclusive of indirect costs). In addition, the Department contributed to sponsored research primarily located in other departments to the extent of $666,000 (direct costs) per year. A detailed list of the various projects is attached as Appendix I.
The single great success story of this period was Dr. Donald Price's neuropathology operation. In response to the needs of the newly formed Department of Neurology, Dr. Price was recruited in 1971. In very short order he developed what was probably the best neuropathology unit in the country with substantial research grant and training support. Apart from Dr. Price's significant contribution to the Department he has received many national accolades.
At this point it is useful to look back on patterns of research support and their impact on departments of pathology. The 1960's and early 1970's witnessed an increasing outlay of research funding by the NIH predominantly in the form of individual awards, the so-called R01's. It was relatively easy for a faculty member to obtain this type of award - which included salary support - even by devoting as little of 30 to 40 percent of his time to research. The effects were manifold, some good, and some bad. On the good side an increase in the size of the faculty was made possible since a source of salary was provided additional to the monies provided by the School of Medicine for teaching and by the Hospital for patient service work. Second, an incentive was provided for faculty to do research, thereby increasing their academic satisfaction and at the same time improving the intellectual tone of the department and encouraging young people to pursue investigative careers through such mechanisms as NIH Research Career Development Awards. On the bad side, departments became overly dependent on "soft" research grant money for faculty support which led to considerable uncertainty when the "lean" years arrived. Additionally, easy access to research funds attracted some with little investigative aptitude who were unable to maintain their grant support in ensuing more competitive times.
The halcyon years for R01's ended in the early 1970's which saw efforts on the part of the federal government to curtail the growth of the NIH's budget coupled with a shift of funds by the NIH to targeted research in the form of Cancer Centers, Heart Centers, Program Projects, etc. These enormously expensive projects drained money from the more critically assessed R01's which became increasingly difficult to obtain. For example, by the 1980's only approximately 1 in 5 of approved R01's were being funded. This intense competition virtually eliminated the type of investigator of the 1960's, namely those who were mixing research with service duties. Increasingly two populations began to emerge in departments of pathology, those spending virtually all of their time doing research and those doing predominantly service work. Admittedly the latter could still do investigative work but this was seldom of bench type. While it cannot be denied that top class research requires sustained effort and that diagnostic pathology requires constant practice, the increasing difficulty of combining the two has removed much of the fun of working in a pathology department and threatens to undermine pathology as a discipline. The present day trend in academic pathology departments to concentrate on research training at the expense of providing a solid background in human pathology since the products of such programs are tomorrow's leaders. It should be added that our departmental policy was to ensure that the residency program concentrated on providing a firm base in human pathology and that research training was regarded as an additional but separate exercise.
A 24-year span inevitably takes its toll. Arnold Rich died in 1968. Following his retirement in 1958 he maintained an office in the Department and shared his wisdom with yet another generation of pathologists in training until ill health in the mid sixties curtailed his visits. Tributes by Ivan Bennett and Ella Oppenheimer are attached as Appendices J and K. His enormous contributions were recognized by the creation of the Arnold Rice Rich Fund to be used to support young pathologists.
Ella Oppenheimer died at the age of 83 in 1981, and was working in the Department until the day before her sudden death. It is impossible to find the right superlative for her services to the Department, and eloquent tributes were paid to her at a memorial service at the School of Medicine. In her memory the departmental library was named The Ella Oppenheimer Memorial Library.
Abou Pollack died in 1971 after many years of service as Chief Pathologist at Baltimore City Hospital. He initiated and fostered the participation by the staff of Baltimore City Hospitals (now Bayview Medical Center) in medical student teaching. As described earlier in the report this teaching effort had been extended over the past several years to our residency training program.
Walter Sheldon also died during the years of this report and I should like to express my gratitude to him for the yeoman service he gave to the Department and for the invaluable help he gave to me, particularly when I was new to the job. As described in the previous index volume this remarkable man came to the Department from Emory University at Bennett's invitation in 1960 and rapidly put his stamp on all of the Department's activities. He was a superb human pathologist, probably the best I have ever met, a great teacher, an excellent research worker on infectious diseases, and an experienced administrator. He retired in 1976 and continued to come in each day until his terminal illness in 1988.
Another faculty member who died during this period was Bill Shelley whose big contribution was to establish a strong surgical pathology division. Shelley left in 1970 to become head of pathology at Charlotte Memorial Hospital but within four years he was fatally injured in a commercial airplane crash while returning to Charlotte from Charleston, South Carolina. In his memory and in appreciation of his services to the Department a fund was established which each year brings to the Department a surgical pathologist of renown who spends two days discussing cases with the resident staff in addition to delivering the William M. Shelley Memorial Lecture.
A death of particular sadness to me was that of Fred Germuth who trained in the Department under Rich and was a faculty member from 1954 to 1958. Fred and I worked together in 1954-1955 when I was a British Medical Council Fellow in the Department. He was the first to suggest that the glomerulonephritis produced in the rabbit by the injection of foreign protein was the result of deposition of soluble antigen-antibody complexes in the glomerular capillaries. His elegant experiments provided evidence for this concept which was rapidly expanded by him and others to explain human glomerulonephritis. His further studies on the size and location of immune complexes in relation the histologic picture provided for the first time a rational explanation for focal and mesangial proliferative forms of glomerulonephritis. Although appointed Chairman of Pathology at St. Louis University he never received the recognition his brilliantly conceived ideas and experiments deserved. Others who died during these years where Sumner Wood, a noted cancer research worker, Bruce Konigsmark in neuropathology, Rafael Garcia who succeeded Abou Pollack as Chief Pathologist at Baltimore City Hospitals, and from a previous generation, Richard Follis, a world authority on deficiency disease who drowned in Amsterdam. As recorded earlier in the account, Joseph Eggleston died in 1989 andJohn K. Frost in 1990.
Four faithful and longtime members of the technical staff also died during this period. These were Ed Walker, the chief technician in surgical pathology, Eva Hildebrandt, chief technician in gynecologic pathology, Cecil Myers, a man of all trades, and Wesley Brown who organized the teaching material.
To conclude this section, Ivan Bennett died in Tokyo in 1990 while on a visit to receive an award from the Japanese government. Bennett's contributions to the Department were enormous, but clearly the most important was his planning and presiding over its entry in the modern era.
It seems wrong to conclude this account on such a depressing note as obituaries and I shall end it in a happier vein. I had the privilege of being acting or permanent Director for 22 of the 24 years covered and received wonderful help and cooperation from both past and present members of the Department. Two of our departmental alumni, Gordon Hennigar and Morgan Berthrong gave considerable support over these years and it is a pleasure to record that both of them, along with Ivan Bennett, were elected to The Johns Hopkins Society of Scholars. It is also gratifying to note the success of previous members of the Department and over this 24-year period the following were appointed chairmen of academic departments: Morgan Berthrong; Larry Clowry; Larry Dee; Robert Faulconer; Fred Germuth; William Hartmann; Gordon Hennigar; Kim Solez; William Willoughby; and Jack Yardley. Others received national and international honors and awards, but lack of space prevents me from listing them.
Finally, I should like to thank our Administrator, Mabel Smith, for the wonderful work she has done for all of us and for me in particular. I can pay her no greater compliment than to say that she was truly the only indispensable member of the Department.
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