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Oral Histories
Radiologist Earl R. Miller, M.D.
Foreword
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
Appendix
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
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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? |
| MILLER: | Yes. |
| BERGE: | Thanks. (sips from a drink Miller has provided her) |
| MILLER: | Is that good? |
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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. |
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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. |
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| 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. |
| BERGE: | 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. |
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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. |
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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. |
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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? |
| MILLER: | Yes. |
| 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. |
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|
| 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. |
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