DOE Shield DOE Openness: Human Radiation Experiments: Roadmap to the Project
Oral Histories
Roadmap to the Project
HomeRoadmapWhat's NewMultimediaRelated SitesFeedback
Oral Histories

Radiologist Earl R. Miller, M.D.


Short Biography

Part I (August 9, 1994)

Wartime Work on Radiation Exposure

Remembrances of Joseph Hamilton

Neutron Therapy Research

Relations Between UC Berkeley and UC San Francisco

Working for the Manhattan Project and UC Medical Center

Process for Obtaining Radioactive Isotopes

Human Applications Committee and Informed Consent

Textbox: About Consent Forms (April 11, 1995)

Work With Soley to Diagnose and Treat Thyroid Disease With Iodine-131

Patient Consent; Contradicting Perceptions

Wartime Plutonium Injections

Hamilton's Research on Effects of Cyclotron-Produced Radioisotopes

Textbox: Dr. Joe Hamilton (April 21, 1995)

Research With Patients From Laguna Honda Home

Radioactive Iodine Uptake in Schizophrenia Patients

Recalling Dr. Joseph Hamilton

Invention of a Baby Holder (1951)

Technique to Produce Infinite Laminograms

Introduction of Stereoscopy to X-ray Film Making

Postwar Preference for Unclassified Research

Zirconium and Plutonium Injections

Research With Healthy Volunteers

Tracing the Records of Patient Consent

A Career in Research

Professional Contribution

Textbox: Recollections of Research Activities (April 11, 1995)

Remembrances of Personalities

Tension Between John Lawrence and Stone

Textbox: Robert Spencer Stone, M.D., L.L.D. (March 10, 1967)

Part II (August 17, 1994)

Use of Tomography to Diagnose Tuberculosis Patients

Textbox: History of Radiology, University of California at San Francisco, as Seen by Earl R. Miller, M.D. in the Mid 1980's

Working in the Radiological Research Laboratory

Investigating How Radiologists See Images

Establishment of the UCSF Radiation Laboratory

Remembrances of University Presidents Sproul and Kerr

Early Career

Work Through the AMA to Improve Radiology Training

Rise of Radiology Specialization

Study of Pediatric Patients With Congenital Heart Disease

Physiologic Studies


Brief History, Earl R. Miller, MD

E.R. Miller's Residency and Career at UC

Recollections of an Old Crock (March 16, 1978)

Activities of Earl R. Miller as Indicated by Published Material (April 22, 1995)

Chronological Bibliography

Investigating How Radiologists See Images

MILLER: I was concerned with, and interested in, interpreting the data from the 13th-floor lab. We would run the movies over and over again and interpret the information on the lower urinary tract and the speech path. I was particularly interested in how a radiologist saw things.

To "see" has two definitions. One is "to perceive" and the other is "to understand." My interest in this grew out of a study in error interpretation: "What is it that got in your way?"

In the process of this, we set up a television arrangement looking at x rays or any kind of image. We were able to isolate a single line of this information [on an oscilloscope]. Ed McCurry did the engineering work. You could see what line was being studied. This showed the density across this line. Not only that, but [we] were able to differentiate the rate of change. For example, one of the things that I beat my head about forever was the realization that the contrast gradient83 was most important.

Also, [I sought to investigate,] "What do you mean by 'an image of something'?" An image of something has to have an edge, and you have to understand what you mean by an edge, in order to be able to talk about an object. An edge can be sharp or not sharp.

Suppose, for instance, you're looking at an infinite[ly wide] wall, and to the left it's bright and to the right it's actually black and it's uniformly changing. There's contrast there, but no edge. This is due to the fact that the contrast gradient across the image remained constant; therefore, no edge. An edge appears when the rate of change of illumination differs from that of the surround. The sharpness of the edge is defined by the rate of change of luminescence per unit distance in the scene and ultimately, in the eye.

The Zones of Confusion of all parts of an image-producing system have a profound effect of the sharpness of edges and the ability to define an object. Defocusing images enlarges the Zones of Confusion and has a profound effect on [the radiologist's] ability to define an object. Viewing distance plays an equally important part in scene interpretation.

These studies were the life of the lab.84

I don't know if there's anything more to say.
BERGE: I was just trying to look at what years. That must have been the 1950s, is that right?
MILLER: Actually it was the last years until I retired [in 1974]. A lot of this stuff was never published, because I felt that either I could understand it all or I couldn't understand any of it. I may still write some of this stuff.

We can look at a thing that's in the reprints. What I talked about at a postgraduate course is the most important. It has more information about what the whole thing was about, more than any published paper. What I just told you about the second derivative—that is, the rate of change per unit distance across an image, across an edge—was, I think, new. At least, I had never heard anybody talk about it. Nor had they considered this idea of this huge image that doesn't have any edges.

Another aspect of this was particularly interesting. One of the people that worked in the lab had a poster with two pictures on it. The pictures were identical. The text was in English on one and in Russian on the other. Now the images of the pictures and of the text were identical in sharpness. The fact that I didn't understand the Russian meant that I could never understand the picture. This illustrates that even though you have an excellent, sharp picture, you may not know what it means.

The latter is what a layman does [when] looking at an x ray. It's all there, and he can "see" it with his eyes, but he can't "see" it with his brain. That's what separates the layman from the expert in any field at all. It turns out that this rate of change that I was talking about applies to all senses—touch, taste, smell, sight, and hearing. Maybe [it applies as well to] ESP85 for all I know. I don't know what else to say about it. I'll show you the one thing on there.
BERGE:Are you okay?
BERGE:Thanks. (sips from a drink Miller has provided her)
MILLER: Is that good?

Establishment of the UCSF Radiation Laboratory

BERGE: Yes. Question: You mention here that the University of California San Francisco Hospital started out as a clinical facility, and somehow it gravitated towards research. I was wondering if you could say more about that. It's very sketchy here [in the transcript of your video].
MILLER: Originally, before 1940, UCSF was a proprietary medical school with unpaid volunteer teachers. With the coming of a full-time paid staff, research grew. Personally, I guess all my life I was interested in research. I was characterized by a curiosity. In other words I wanted to know how and why a thing worked. When I was given an office I got some radioiodine. I turned it into a lab, and then I tell the story of how I happened to get the lab.

Every young going guy was offered chairmanships of Departments of Radiology all over the country. I don't know how many I was offered; it doesn't matter. Finally Columbia [University], in New York came through. They offered me a three-story research building. I have lived in New York and also I had been chairman of the department. I didn't want either one again.

Through Dr. Stone, I had lunch with the president of the university and I said I wouldn't take that offer if I could get a research lab [elsewhere]. I wasn't going to take any offer [at Columbia] anyway. At any rate, they thought I was worthy of having around. Dr. Sproul said, "I'll get you a lab." Later he said, "We've got money for a lab, design it." I had a ball trying to design that.

Anything else?
BERGE: What kinds of considerations were you looking at when you designed the lab?
MILLER: I wanted a first-class shop, because we needed to make things. I needed an electronics lab, x-ray room, dark room, conference room, and office [space]. I needed good TV equipment and a complete electronics shop. The conference room was used to interpret data from the 13th-floor lab. The shop was used to make instruments and gadgets. The electronic lab was used with the TV and electronics to study the characteristics of images and edges and the effects of defocusing of the ability to identify an object.

The basement lab developed the equipment for use in the 13th-floor lab. I had the support of Ed McCurry, electrical engineer, and Bernie Hruska, super tech[nician], without whose dedicated help these studies would never have been made.

Remembrances of University Presidents Sproul and Kerr

BERGE: You mentioned that you were able to sit down with President Sproul. Was [the University] small enough in those days that you could set up an appointment and speak with him, or did you have a prior appointment?
MILLER: Dr. Robert Gordon Sproul was probably the most amazing person that anybody ever met. He never forgot anything. He knew intimate details of people in the San Francisco campus that he almost never visited. He knew things about it.

It was through Dr. Stone that I was able to have lunch with Dr. Sproul. Because Dr. Stone apparently would like to have me around, and there was a chance that I might leave, I needed to talk with somebody that had enough power to get enough money to set up the lab I wanted. It was through Dr. Stone and the dean that I got the appointment with President Sproul.BR>
I remember that Leon Goldman—that's Dianne Feinstein's86 father—needed an electric typewriter. Those were the days when people were poor. Dr. Sproul got him an electric typewriter. And one day they met somehow and [Sproul] said, "Did you get your typewriter?" He said, "Yes." An amazing guy.

Did you ever know of Clark Kerr, who was also president of the University after Sproul?
BERGE:I don't know much about him.
MILLER: Maybe this is off the subject.
BERGE:If you want me to keep it on, I don't mind.
MILLER: This has to do with Clark Kerr. We went down to a UC conference and seminar. It was an open session: faculty were allowed to ask any question. Some guy got up and was going to embarrass Clark Kerr. He gave him something like a thirteen-part question. Kerr listened, and this guy sat down with a smirk on his face, and Clark Kerr repeated each of his questions and gave the answer right down the line! There was a standing ovation. We couldn't believe it.

Early Career

BERGE: That was lovely.

I thought you might talk a little bit about some of the people you've mentioned in here that you are grateful to. For example, let's start off with Stone, because he's earlier, and then maybe move on to Dr. Margulis.
MILLER: I remember when he gave me the job.
BERGE: He must have thought you were worthy of keeping around if he went to President Sproul for you. Why do you think that is?
MILLER: When I came to UC, I had just finished my instructorship under [Hugh] Wilson at Yale. I had just passed the boards and I was an AOA.
MILLER: Alpha Omega Alpha, an honor society composed of the top ten percent of medical school classes. And Dr. Stone needed an instructor. He knew I had been over at Stanford with Dr. Newell, so he offered me this job.

In those days I was hot. When you're just out of your residency, you know more than you ever do again in your life. I had a good time. I did a lot of work on developing a teaching file, and a lot of work doing teaching, after the usual workday, from 5:00 to 7:00 every night. He pushed me, as far as promotions, very hard. He gave me an office. Nobody else had an office. Whatever it was, we got along well.
BERGE: I noticed you mention, later on [in your video transcript], Dr. Margulis. Can you talk a little bit about him? I know nothing about him, by the way.
MILLER: I met Dr. Margulis one time when I was a part of the residency review committee of the AMA.87 It was in St. Louis. When Stone was going to retire, consideration was given to a lot of people. There were some that had made me shake in my boots. When Margulis's name came up, I remember Maurice Sokoloff called me and said, "What do you think about this guy?" I said, "You can't get a better one."

Then, I described in this thing, too, how he developed the department. I think there's little doubt about the fact that it was due to Dr. Margulis that he developed a residency program, a postgraduate program, a postdoctoral program that was as good as any in the world, and I think maybe better than many of them in the world. Tremendous guy.

We disagreed on some things; that is, I thought things ought to be done this way and he thought they ought to be done his way. He was right in every case. He made a few mistakes. They were beauties! But he made very few of them.

I learned one thing about him. One thing to do is to make a decision, go ahead with it, [and] if it's wrong, change it. And he did that. He was a master at that. I don't know what his IQ was but I think it was over 1,000 [sic].88
BERGE:What was his specialty?
MILLER: He was a diagnostic radiologist with particular interest in the gastrointestinal tract. He did fluoroscopy89 one day a week.

Work Through the AMA to Improve Radiology Training

BERGE: You make a statement here, let me read it to you: "Many residencies in Radiology were established in private hospitals and in private practices of radiology. A number were used as slave pens for the trainees." I wonder if you could talk a little bit about that.
MILLER: That was a common thing. You got a resident in Radiology, like an apprenticeship. He would take all of the night calls; he would take all of the weekend calls, and they would use him as a "gofer." With that, he had a chance to watch the master at work. In watching the master at work he became "a radiologist." Then he took his boards, and then he did the same thing to the next person.
BERGE: What were some of the common places they did their residencies?
MILLER: There wasn't any place that didn't have them. Many of them were in the private hospitals, just all over the country.

There were only two aspects of service to the NIH,90 to the AMA, and to the College of Radiology that interested me. One was research and one was teaching and education.

I got involved with this matter of the evaluation of [Radiology] residency programs across the country. In the process of this, we, as a committee, visited almost every residency program in the country. We did just what the Flexner Report did with the medical school program. It revolutionized medical practice and teaching. We did exactly the same thing with the residency program. We would write up an evaluation.

That's where I met Dr. Margulis. We would write up an evaluation, and either it was approved or it wasn't approved. If they lost their accreditation it was a very severe blow. We were the power that could get a Radiology department upgraded in a way that the head of the department couldn't. He would go fight with the superintendent of the hospital; he needed equipment etc., [for example]. "You got plenty," [might be the superintendent's reply]. We'd come in and say, "You don't have enough equipment." The superintendent would come running down [to the department head]: "What kind of equipment do you want?" It changed the face of radiology. We were a group of academic radiologists, chosen for this particular work.

Rise of Radiology Specialization

BERGE: Soon after that, you said, the first beginnings of specialization were in the separation of diagnosis from therapy. Before we get into that, what period of time was that that you were talking about there?
MILLER: I would think in the late '40s and early '50s.
BERGE: Like I was saying, you said the first beginnings of specialization.
MILLER: I think I also mentioned that most Radiology departments in the early '50s were run by people who were therapists. That was the one thing that distinguished the radiologist from the general practitioner or urologists or other practitioners of medicine. At that time, the people interested in orthopedics,91 urology,92 heart disease, etc., all had x-ray machines, and they did their own interpretations. Then there developed a group of young people who began to specialize in their studies. For whatever reason, and I think part of it was these residency review committees, the Board of Radiology established diagnostics as well as therapy as separate. You could become a therapist or you could become "a radiologist [(a diagnostician)]." For instance, I'm a radiologist. When I had my exam in 1940, radioisotopes, therapy, and diagnosis were on the [licensing exam] questions. All phases. Today, forget it.
BERGE: A lot of that was a function of all the discoveries they made during that time. You couldn't be a radiologist and know about all of what you just described.
MILLER: Yes, we could! The amount was small then. There was more than that. What happened was that there came a time when the American College of Radiology (or the AMA) examined and visited private doctors' offices that had x-ray equipment. I was on these committees. If the machines were substandard, they couldn't have x-ray equipment. The radiologists became so good at the business of diagnosis that this private-practice part of the thing just died off. But it's not dead yet. I went to an orthopedist recently. He sent me to his own technicians for x rays and he interpreted them. I gave him some help.

Orthopedists, chest people, urologists, still do have some of their own stuff, but what happened was with the research; I think that is what you're referring to. It got to the point where there were things to do in every phase. For example, we fooled around a little bit with ultrasound,93 and I didn't think we'd ever have teachers [in that field]. Now, it's whole departments. We fooled around with radioisotopes, and now there are whole departments of Nuclear Medicine and there's Neuroradiology, Intervention Radiology, etc. There's CAT-scan94radiology. There's MRIs.95 Pediatrics, neuro-96 specialists. Somehow it just grew like Topsy.

We can take a look at a department at UC and other good universities and see the same thing. You see now a list of specialized activities; it's a mile long. When I started, there were four people in the department. When I checked it up a couple of years ago, there were over 200 people there. I don't know how many people there are now; it grows exponentially. There are whole fields of this clinical practice, and we have a research arm of every one of these specialties.

Study of Pediatric Patients With Congenital Heart Disease

BERGE: I'll be done in just a second. (flipping through the video transcript) There was one interesting—if I can find the page—one interesting little sentence in here that I thought you could tell about. Maybe there's a funny story behind it. It's about the pediatric patients and small size.
MILLER: This was the work that was done on the study of the x-ray movies on the patients with congenital heart disease.
BERGE:What was his name?
MILLER: Dr. Mary Olney. The only ones that were chosen for study, were those whose life expectancy was in terms of weeks—at most, months—and they were tiny.
BERGE:I'm sorry?
MILLER: Such serious congenital disease that they couldn't live.
BERGE:What were they being studied [for]?
MILLER: These were the ones that were sent for study. Angiocardiography97 was in its absolute infancy. We could inject the opaque material and take serial films. You'd get maybe five films or a few more. From this you had to try to interpret just how the flow occurred. In order to do this correctly or efficiently and effectively, you had to see all the phases, which meant movies. We didn't have image intensification. We didn't have any television at that time. We got special lenses to try to get the films.

The whole thing had to do with the reduction of dose. If we had taken adults and tried to do this with movies, we would have burned holes in them [from the high x-ray dose required]. In the case of the children, being infants and newborns, they were so tiny that one could use much much smaller dose, because they were so small.

It was to get the dose down, and to be able to study all the phases of the heart motion, you had to have movies, and this had to be done with main strength and awkwardness. We tried to get better lenses or better cameras and all this sort of thing. None of this did any good until image intensification and television. Now you could take movies of even adults through the belly and show the results without overexposing the patient.
BERGE: The way it was worded here, I was [mis]understanding it. I thought you needed them for the small size because you couldn't get a bigger-size glass [focusing lens] or something.
MILLER: That played a part. It meant that you could use a very small field.
BERGE:I don't understand why you had to use terminal patients.
MILLER: Because, number one, nobody knew much about congenital heart disease at that time and they were going to be exposed with high doses of x ray.

They had physical examinations and they could listen to the child; they could take a history and see how blue they were, etc., but they didn't really know what was going on. They didn't realize how many kinds of congenital heart disease there were. They understood a few, such as atrioseptal98 defects, ventriculoseptal99 defects, etc. There are hundreds now. This was the beginning of trying to understand some of the kinds of congenital heart disease in live patients.

Now it's hard to realize how little was known at that time. This was at the cutting edge. This type of thing was going on in a number of universities, [University of] Pennsylvania and Harvard, the good ones.
BERGE:Was this going to be diagnostic?
BERGE: [I get] a little confused about how everything is used. I may ask some silly questions some times.
MILLER: Therapy and diagnosis. In therapy you use the radiation to treat patients; in diagnosis, you want to give the least amount of radiation in order to understand what's wrong with the person. That's the difference.
BERGE: I'm interested in how your interest developed from the radioiodine studies to, later, the urine studies.

Physiologic Studies

MILLER: These were totally separate. The urinary studies were really physiologic studies of patients. The work with radioiodine was both diagnosis and therapeutic. It dealt with reaction of the thyroid to 131I.

The first part of the work dealt with the problems of handing the stuff, measuring the radiation from it, developing means of recording its accumulation and excretion from the thyroid, and developing units to express the dose. We used a radium standard for this.100

My primary job was x-ray diagnosis. As such, I directed examinations and interpreted the results. The diagnostic radiologist's job was looking at the x-ray films and together with the history, and [based on] what he saw, to come out with a diagnosis. It was apparent to me that this was always incomplete, because you had information about the anatomy; you did not have information about the physiology of the organs under study.

In order to do that, you needed to have movies, so that you could watch the anatomical thing, and you needed simultaneous information about pressures, size, shape, differences of pressure, and how one affected the other, etc. I became interested in the physiology of the lower urinary tract, and in the mouth and pharynx during speech and swallowing. These were ideal areas for the development of the combined anatomic-physiological studies. My interest was in trying to get the most information for the least exposure to the patient. This meant that you needed all of the anatomical, radiologic anatomical, and all of the physiological things simultaneously, over a period of time.

The patients with urinary problems were women with incontinence,101 inability to start urination, or recurrent infections due to incomplete voiding. The speech patients were those with nasal speech due to cleft palates or unknown causes.
BERGE:Why women?
MILLER: The woman has a short urethra; the man has a long urethra. We just gave up trying to study men; we couldn't do it. We could do women. Women are more prone to urinary problems.

For the study of the urinary tract, we developed a system, including TV transduction of the fluoroscopic image of the bladder and urethra, and the output of eight channels of strip-chart102 recordings of the physiological data simultaneously as a function of time. Sound recorded commands and responses. The strip charts provided material for further study. Movies were taken of a separate monitor. The whole thing was recorded on videotape for immediate replay and study.

The bladder was filled with opaque material. Catheters were placed in the bladder, urethra, colon, and anus. Squeeze pressures of the urethra, centimeter by centimeter, were made at rest. The patients were asked to strain, to "hold" urine and, ultimately, to void.

From these data we gained a complete understanding of the relationship between the various forces involved in continence, incontinence, and difficulty in starting urination. These studies opened the way for rational treatment of the various ills.

For the speech studies, we used [a] lateral view of the mouth and pharynx during speech and swallowing. Sound and sound spectrography were shown on each frame of the movie and videotape. As a result of these studies, rational surgical procedures for the cure of the nasality103 were developed.
BERGE:Thank you.

Previous page Table of Contents Next page