B Leonard Holman
Sally Ann Edwards
Fortunately for American radiology, the x-ray was one of Harvey Cushing's passions. Within days of the New York Times announcement of Roentgen's discovery of the x-ray, Harvey Cushing wrote to his mother, "Everyone is much excited over this new photographic discovery. Professor Roentgen may have discovered something with his rays which will revolutionize diagnosis. Imagine taking photographs of gallstones in situ, stones in the bladder, foreign bodies everywhere, fractures and so on." On May 10, 1896, he wrote, "We have at last succeeded in having an x-ray machine put in." At the time, he was an intern at the Massachusetts General Hospital: "It is great sport, very useful in the outpatient to locate needles. We could look through the chest readily this morning, count the ribs, see the heart beat, the edge of the liver. It is positively uncanny. I will send you some photographs" (1).
Within a few months, Cushing went to Johns Hopkins Medical School where he stayed until he was lured back to Boston to be Chief of Surgery at the new Peter Bent Brigham Hospital, which opened to patients in 1913. Despite his interest in the x-ray, Harvey Cushing felt that the proposed Peter Bent Brigham Hospital had no need for a full-time radiologist. After a succession of part-time, short term roentgenologists, none of whom lasted more than a year or two, Lawrence E. Reynold was appointed the first full-time roentgenologist in 1919 (2). After 3 years, he joined several friends in private practice in Detroit, and Cushing cast an eye in the direction of the Massachusetts General Hospital. Merrill C. Sosman was on leave from the military as a trainee with George Holmes. Cushing saw to his recruitment and to his early discharge from the Army, and on March 22, 1922, Merrill C. Sosman was appointed roentgenologist to the Peter Bent Brigham Hospital.
Sosman enjoyed what he did and the department reflected his humor. In later years, the pillar near the middle of the x-ray viewing room displayed the word lux in gold paint with an arrow pointing to the left. Just beyond, was another pillar inscribed veritas with an arrow pointing to the right -- words from the Yale motto, light and truth. Sosman explained, "The resident reads the films over there. There they find light. But over here the Professor does his work. Here you find truth." And, just inside the door to the viewing room, was a case exhibiting the metal and rubber parts of an old stethoscope with the typed legend beneath: "Rare and unusually well preserved fragments of an instrument known as the stethoscope formerly in common use in the diagnosis of pulmonary and heart disease. This contraption was actually in general use until the Roentgen era" (3).
On October 30, 1944 the Administrative Board of Harvard Medical School voted to establish Roentgenology as a separate department. This was approved by the Corporation on April 2, 1945 and the title was officially changed from "Roentgenology" to "Radiology." Sosman, who had been appointed clinical professor of roentgenology in 1940, was named head of the new department, and his appointment was changed to clinical professor of radiology.
1947: The great majority of Americans, including the physicians, erroneously think that progress is measured by growth in size. They feel that only a big hospital with big and numerous special services can do the best work. The cry has been for more beds, for more surgeons, for subspecialties, more buildings and more equipment, forgetting that efficiency often deteriorates with excessive growth. The original Chiefs of the two services, Cushing and Christian, when faced with the pressure to enlarge the Hospital, wisely decided to keep it small, preferring a small number of patients, carefully selected and very thoroughly studied, to a larger and more heterogeneous hospital population without the integration between services and departments which would be lost by doubling or tripling the bed capacity (8).
1948: The calibre of men seems to improve steadily and we try to take more of them each year, remembering that they are with us primarily for training and not to do routine tasks as is expected of them in too many hospitals. In order to learn properly and well, free time must be available to each of us -- "time to think" as Walter Cannon wrote. There should be, in an academic institution devoted largely to teaching and research, at least three men to do two men's work, so that the spare man can have time and opportunity to pursue his investigations, prepare his lectures and clinics and make greater contributions while still caring for the larger daily clinic load (9).
1954: A happening of considerable importance as well as interest was a formal affiliation of our department with the Robert Breck Brigham Hospital. On their request, due to the retirement of their radiologist, Dr. Sidney Morrison, our group investigated the possibility of accepting responsibility for the radiologic work in their hospital. After several conferences and with the approval of our executive committee and trustees we agreed to take charge of the X-ray department and be responsible at all times for proper conduct of the work. This ties us in even closer with our sister hospital on Parker Hill and adds a further diversification to our work and to training of technicians, students and residents (10).
1954: Dr. Philip Cook, a radiologist practicing in Worcester, died in April, 1954 leaving his considerable estate to Harvard Medical School, to endow a chair of Radiology, something not yet accomplished in any of the medical schools as far as I know (10). As Jim Dealy described it,
During an era in which the field of roentgenology was on trial as an entity worthy of recognition apart from departments of medicine and surgery, Dr. Sosman relentlessly exploited the x-ray method as an aid to more precise and accurate clinical diagnosis. His bibliography does not contain lengthy reviews of vernier observations on the x-ray findings in any given disease, although he made them. Rather it contains brief reports of new observations -- often no more than experiences with a handful of cases, because his observations were that certain and that important. His classic descriptions of intracardiac calcification brought him no less prestige than did his writings on the x-ray treatment of pituitary tumors; both loaned stature and dignity to his chosen field (11).
Sosman also pioneered the systematic evaluation of this new diagnostic technology as it evolved over three decades. His Shattuck lecture, which he presented to the Massachusetts Medical Society, became a benchmark for defining the diagnostic accuracy of radiographic imaging. "X-ray films are not all black and white. Some parts may be black and others white, but there are many shades of gray in between. Similarly, the diagnoses from roentgenographic examinations are not all yes or no propositions. There are many shades of certainty in opinions and many degrees of reliability based on deductions" (12).
In 1949, Sosman was finally allowed to appoint one associate radiologist. In 1951, Milton Elkin became his associate and in 1953 James B. Dealy, Jr., became the first junior associate. In 1957, upon Sosman's retirement, Dealy became the Brigham's second Radiologist-in-Chief. Dealy had done his residency training at the Brigham with interval assignments at Children's and The Pondville Cancer Hospitals in Massachusetts and the Memorial Hospital in New York.
Early in that program, Sosman asked him to go over to the Massachusetts General Hospital and work with radioactive isotopes. Soon he became involved in the early transplant efforts at the Brigham. "With rabbits after radiation we were able to get bone marrow and skin transplant takes for over one month in approximately 65% of the cases. For all of us the many years of work led up to John Riteris [the first patient to survive a nonidentical human kidney transplant]." In 1959, with Nobelist Joseph Murray and Surgeon-in-Chief Francis Moore, Dealy became part of the team that carried out the historic procedure, the first kidney ever transplanted successfully between non-identical human twins.
Perhaps the most far-reaching accomplishment of the Dealy era was the quality of its trainees, who now number among the leaders in academic radiology, including Robert N. Berk, editor-in-chief of the AJR, Charles A. Gooding, executive vice-chairman of UCSF, H.J. Burhenne, chairman at the University of British Columbia, and E. James Potchen, chairman at Michigan State University.
In September of 1967 Dr. Herbert L. Abrams became the first Philip H. Cook Professor and Chairman of Radiology at Harvard and Radiologist-in-Chief at the Peter Bent Brigham Hospital. Before coming to Boston, Abrams was Professor of Radiology and Director of Diagnostic Radiology at Stanford University School of Medicine. During the decade of the fifties, he had participated in the analysis of radiologic abnormalities in many forms of heart disease, and in 1961, wrote what has become the first definitive text on radiology of the vascular bed -- Abrams Angiography. Abrams wrote about his decision to come to Boston:
One of the many attractions was the creative energy that characterized biology and medicine in the Boston area, the incomparable depth and breath of expertise and interest that are matched in no other city in the world. I found it full of excitement though it meant leaving our new medical school in Palo Alto designed by Edward Durrell Stone and coming to a Peter Bent Brigham Hospital that was old the day it opened. It had long since needed replacement. Long on tradition and intellect and with great strength in medicine and surgery, it was incredibly short on resources with an impoverished radiology department and a physical structure that must have made the fire marshall shudder.
In the beginning during that fateful year of 1967 there was a faculty of six and one resident. The department was a catastrophe: 3 x 4 cubicles as office for the staff, equipment that belonged in the Smithsonian Institute, separate areas for clinic and private patients, and little sense that angiography and neuroradiology were developing fields of radiology that required not only enormous professional skills but the kind of hardware and physiologic recording equipment that gave each examination a high likelihood of resolving the patient's problem. Within a few short years the number of examinations had increased markedly, the faculty had doubled and we had a full complement of superbly qualified residents (13).
Abrams directed the expansion of the hospital department and appointed specialists to head the divisions of diagnostic radiology, radiation therapy, nuclear medicine, and physiologic research.
Shortly after I came to Boston, Harry Z. Mellins was appointed Director of the Diagnostic Division. For the previous 12 years he had been the Chairman of the Department of Radiology at Downstate Medical Center in New York City and there he had structured one of the great training in programs in the nation. As the Director of one of the largest departments in country, Dr. Mellins was able to bring order out of chaos and to provide a quality of teaching in patient care unsurpassed in any other county hospital in the nation (13).
An authority on the radiology of the gastrointestinal and genitourinary tracks, he has attracted a large number of students to the discipline. An extraordinarily bright, penetrating individual, he is one of the outstanding teachers on the national scene in radiology whether at the student level, the resident level, or the post-residency level. More than 100 residents in the last 25 years have benefited not only from his wealth of knowledge but also from his capacity to convey that knowledge in a stimulating and disquisitive way.
At about the same time the problem of radiation therapy loomed large and, because it was a division of my department, I chaired the Search Committee. Although there were numerous candidates of greater maturity and experience, one candidate, Sam Hellman, stood out as a potential leader in the field and I finally determined to invite him. I was insistent that he have a tenured Associate Professorship in spite of his youth and relatively few publications because, without that kind of security, he would not have been able to operate efficiently in the five hospitals of the Joint Center that we were establishing. Over the objections of Sidney Farber but with the support of the Dean and the rest of the committee it was agreed that the risk should be taken and Hellman came as a tenured Associate Professor. In 1972 with the support of the dean, I initiated the process whereby Radiation Therapy would become a separate department with its own access to the dean and to the hospital directors [Hellman went on to create the Harvard Joint Program for Radiation Therapy, an amalgamation of the radiation therapy -- now radiation oncology -- departments at the Brigham and Women's Hospital, Dana-Farber Cancer Institute, Children's Hospital, New England Deaconess Hospital, and Beth Israel Hospital]. The gamble on Hellman had paid off.
The nuclear medicine search came next:
During one week in the Spring of 1966, I was in Boston, still a member of the Stanford faculty but getting ready to join Harvard the following July, in order to interview candidates for the Position of Chief of Nuclear Medicine in the Department. At noon I would have a candidate meet at lunch with George Thorn and members of the Department of Medicine interested in radionuclide studies. At 4:00 p.m. we would meet with a similar group in Frannie Moore's Department of Surgery. Each day at noon I came across an interesting fellow by the name of Jim Adelstein, whose role at the luncheon was mysterious to me. As it turned out he was a member of the Department of Anatomy teaching Anatomy to medical students. I inquired as to the reason for his presence and George Thorn informed me that he was head of the isotope committee at the Brigham. As the story unfolded he had been through M.I.T., Harvard Medical School, a residency in Medicine at the Brigham and a Ph.D. in Biochemistry under Burt Vallee and had ultimately become Chief Resident in medicine at the Brigham with subsequent training in radiation chemistry at Cambridge University. With that background, what would be more natural than for him to end up in the Department of Anatomy? It soon became clear that Jim Adelstein was as familiar with the intricacies of nuclear medicine as the eminent candidates I have brought to interview. I resolved to ask him whether he was interested in running a clinical division. Subsequently our letters crossed in the mail expressing mutual interest. We arranged for Jim to spend a period of time with Henry Wagner of Johns Hopkins and on his return he took over nuclear medicine (13).
In 1971, Adelstein established the Joint Program in Nuclear Medicine at Harvard Medical School, an umbrella institution which includes Brigham and Women's Hospital, Children's Hospital, the Dana-Farber Cancer Institute, the Beth Israel Hospital, and the West Roxbury VA Medical Center, and has established itself as a leader in research and education in nuclear medicine.
The field of modern clinical pharmacoangiography had been initiated in the early sixties by Abrams' studies on the effect of norepinephrine on the renal circulation and his investigations on the differences in reactivity of normal vessels and the neovascular beds of renal carcinoma.
Our interest in the circulatory bed and in particular in the renal circulation was complemented by that of Dr. Norman Hollenberg in the nephrology section of medicine and the collaboration was warm and fruitful. Ultimately with Hollenberg's background and Ph.D. in pharmacology reflecting a further converging interest with our own, it seemed reasonable to ask him to join the department on a full-time basis but with an appointment in Medicine as well. He became the Director of our Physiology Laboratories and his function in that role remains a critically important part of the department (13).
One of the most important factors in my decision to come to Harvard was the existence of the Shields Warren Radiation Laboratory, a building that owed its very existence to the perspicuity of Dr. Henry Kohn, Professor of Radiation Biology, and to Dr. Shields Warren's interest in the effects of radiation. It was virtually empty except for one area occupied by Dr. Kohn that was available for research in the radiation sciences. It was agreed that the second and third floors would be made into research laboratories for diagnostic radiology and for radiation therapy respectively and that the fourth floor would be divided between nuclear medicine and radiation biology under Dr. Kohn. I brought some of my own NIH grants with me and served as the principal investigator for a Diagnostic Radiology Research Center at Harvard and the Brigham. The Center at that time was the only one of its kind in the nation, beginning in 1970 and, for many years, had one of the largest and best organized academic radiology training programs funded by the NIH. Out of it emerged a group of splendid individuals who are populating a number of academic departments around the country.
Merging with the Robert Breck Brigham and the Boston Hospital for Women (Lying-In and Parkway Divisions) in 1980, the Peter Bent Brigham Hospital changed its name to Brigham and Women's Hospital (BWH) in time for its move into a new four-tower hospital complex. This expanded institution provided 726 beds just down Francis Street from the original hospital. As Abrams described it:
1984: In 1967 when I arrived, the department had 8,000 square feet of space with about five radiographic rooms; we now have 50,000 net square feet including 38 rooms over and above 14,000 net square feet of research space. The Department budget has gone from about 1 million dollars a year to well over 16 million and beyond the 95 physicians and Ph.D.s there are an additional 217 personnel for a total of over 300 employees. There are active research programs in applied physiology with particular reference to the regional circulation; pharmacology; nuclear magnetic resonance; digital imaging; radiopharmaceutical development and tissue specific monochronal antibodies; cost-effectiveness and technology assessment; computer science; physics, ultrasound, nuclear medicine, digital radiography and computed tomography; and numerous other areas of clinical and laboratory investigation (13).
Following Abrams' retirement in 1984, David C. Levin took the reigns as Acting Chairman until 1986 when he was called to the chairmanship at Thomas Jefferson Medical School. After a year and a half as Acting Chairman of the Department of Radiology, B. Leonard Holman, M.D., became the Department's fourth Radiologist-in-Chief and the second Philip H. Cook Professor of Radiology at Harvard Medical School. Dr. Holman is certified in diagnostic radiology and nuclear medicine, and his research has focused on cardiac and neuronuclear medicine.
The common thread throughout the 80 year history of the Brigham has been the education of new physicians in order to perserve the vitality and to assure evolution of the academic specialty, to see to the expansion of radiological research to new territories in order to redefine the meaning of what is radiological, and in the process, to maintain the centrality of the patient as the primary purpose of the radiologist's being.
While many of our newer technologies have changed the very nature of our specialty, profoundly affecting the scope and purpose of academic radiology departments, it is the individuals who pose the important questions and who go ahead and answer them who must be found, nurtured and supported (14).
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