This is Oral History Interview #40 with Dr. Charles W. McLaughlin. Dr. McLaughlin received his Bachelor of Science in Medicine from the University of Iowa, Iowa City, Iowa. In 1929 he received his medical degree from Washington University [School of Medicine] in St. Louis, Missouri. He interned at Montreal General Hospital in Quebec, was a resident in Pathology at McGill University, and a Fellow in Surgery at the University Hospital of the University of Pennsylvania [in] Philadelphia. He was the Traveling Fellow in Surgery and went to the University of Edinburgh in Scotland. He has been certified by the American Board of Surgery in 1940, and has been in the private practice of surgery and on the teaching staff of the Department of Surgery of the University of Nebraska Medical Center from 1935 to the present.
Dr. McLaughlin, I notice that your father was an M.D. Is this why you decided to become a medical doctor, also?
Basically, that is the reason that I did enter medicine. My father was a family practitioner in Washington, Iowa, a town of about 4,500. I started going with him on his country trips at the age of six, carrying his bag, and continued to do so all the way through secondary education until I went off to college. I really didn’t seriously consider any other field of work other than medicine from early childhood.
I notice your degree from the University of Iowa was Bachelor of Science in Medicine.
I took my liberal arts education at Iowa and at that time one could get into medical school with a limited number of hours. So I took two years of academic work in liberal arts at the University and an additional summer to get off some requirements and entered medical school at the end, really, of two years of college work. Therefore, I was able to obtain a degree, Doctor of Science, at the end of my second year in medicine. I left the University of Iowa after my first two years in medicine because in the spring of my sophomore year they had a very unfortunate political upheaval in the faculty in which about nine of the leading clinical people left the employ of the University. Since Father had graduated there and I intended to graduate there, I was fearful that the next two years would be disrupted, so elected to transfer, if I could so arrange it, for my final two years. I fortunately landed at Washington University.
How did you happen to choose Washington University?
My father had taken a graduate course here under Dr. McKim Marriott and he thought very highly of this university. So, when I decided to transfer I considered only Harvard and Washington and fortunately, Washington accepted me. I grabbed it and came here.
Do you remember any outstanding professors either at Iowa or here?
I remember vividly some at both schools. Since we’re on this campus, I remember particularly those here. Dr. [Evarts] Graham had a tremendous influence upon my thinking, upon my life. [Dr.] Ernest Sachs was likewise a tremendously able teacher and was not only a teacher – both of these gentlemen were friends, and I retained that until their demise. I remember with affection Dr. [Harry L.] Alexander, Dr. [David P.] Barr, Dr. [McKim] Marriott, Dr. [Otto H.] Schwarz and half a dozen more of that same group, all of whom were superb teachers and gave us [an] unusual number of hours in student-faculty relationship.
So the faculty was not distant from the student body at that time?
I cannot imagine a closer relationship than existed [between faculty and students]. These men met their lectures, they met their ward walks – residents conducted almost none of these – and we saw the full professor or the associate professor on almost every occasion. It was an intimate, concentrated teaching experience. It really was.
That’s very interesting. Unfortunately, I don’t believe—
It no longer exists anywhere that I know. But we had a small class of seventy-two, [and] the University was a close-knit corporation at that time. I was privileged to live in as a substitute intern, taking the place of those who were ill about half of my senior year, which was then called “being in the house.” It was a rare experience because you would go to school but you carried on an intern’s duties in the off hours and at night. It was a rare privilege because I got to see how a busy hospital operates. At that time the senior student did not do as much himself on the wards as he does today, so this was a great experience.
Was there much competition between students?
I was not impressed with that. We were kind of a fraternity – everybody was trying to help each other – and I did not sense that there was competition for honors, for AOA [ed. note: Alpha Omega Alpha, the medical honorary society], or for those various things. We were all struggling to pass, actually.
So the standards were high?
The standards were very high. There were seventeen transfers in my group that came in at the junior year. We went through that entire junior year with an asterisk after our names on the roll, which meant that we were called upon with greater frequency than those names not so designated. Unfortunately, eight of that seventeen did not survive and they went to other schools to obtain their degrees.
Why did you pick Montreal General Hospital for your internship?
Dr. Campbell Howard, whose father had been [Sir William] Osler’s teacher, came from McGill to Iowa as Professor of Medicine. [He] was a beloved and respected consultant and a good friend of my father. He then returned to McGill to become Professor of Medicine. Because of this relationship, with three other former Iowans, I journeyed to McGill to take my internship.
I notice the next year you were a resident in pathology. Does that mean that you were considering other fields besides surgery?
Basically, I took a full year of pathology after my initial year of internship because in the English and the Canadian systems, you could not advance in residency without having a very extensive background in pathology. All their residents went through a year of path before going on to either advanced medical or surgical residencies.
So you spent two years, then.
It was two years at the Montreal General Hospital. That was one of the most valuable years of my entire experience, because this was a 600-bed hospital that ran a 100 percent autopsy record consistently. It was extremely active, in a port city, and we saw a variety of things that I’d never seen in any other institution.
The next step in your career, I notice, was to accept a Fellow in Surgery in the University Hospital, University of Pennsylvania. How did this come about?
I was looking for advanced training in surgery because I had decided this was what I wished to do. In 1931 there were relatively limited numbers of places where one could go to get three or more years of training. Barnes Hospital presented such training and the Mayo Clinic presented such training. The Leahy Clinic did not, and relatively few of the university hospitals then had a full program. So I applied at Pennsylvania because at that time it was one of the “name” services. I went down there with 20 out of the original 200 who were candidates and having made my interview was certain that this was a waste of time because they never had taken a non-Pennsylvania graduate as a surgical fellow before, and there were only two openings. God was good to me and I was fortunate to get one of those two, so I had my three subsequent years of training, which they called a Fellow but was really a residency, at the University.
I notice that you have on your curriculum vitae that you were in the service of Eldridge Eliason?
Eldridge Eliason, who was the Clinical Professor of Surgery at the University, had one of the two major surgical services along with Dr. George Mueller. There were only two general surgeons in the 600-bed hospital, so we had half of the general surgery and the other half was on the opposite service, with two Fellows on each service.
How did you win the Traveling Fellow in Surgery?
My chief wrote to Sir David Wilkie and arranged that I could go there. The only unfortunate thing about it – this was in the bottom of the Depression, so there was an appointment but no money. I was able to scrape together enough dollars to go to the Royal Infirmary in Edinburgh and get between six and nine months of training under Sir David Wilkie, who at that time was one of the great general surgeons in the British Empire.
What did you do after you came back to the United States?
I was looking for someplace to go to work. The Depression was still on, I was a Midwesterner – no universities were hiring because of lack of money – so I elected to go to a Midwestern city that had a medical school where I, hopefully, might work. I elected Omaha because it had the University of Nebraska Medical School. They were good enough to give me a spot where I could work five mornings a week – for nothing – but I had a very active surgical experience for those first years when one was struggling to establish a practice.
I notice you advanced through the ranks from Instructor to Professor to Senior Consultant at the University of Nebraska Medical Center.
That is correct. At age sixty-five one gives up [the] professorship and becomes a Senior Consultant, if you are still actively teaching, which I happen to be.
Since you mention teaching, what kind of teaching did you do over these years?
Early on, I carried a full lecture schedule at the University and ward walks there. In more recent years, as our classes have increased from 72 to 150, we carry on a very heavy teaching program in the private hospitals. I am the director of the teaching program in the Nebraska Methodist Hospital where we have about twenty medical students on surgery and two surgical residents on rotation. Our teaching is with them; we present to them a whole set of conferences, path conferences, etc., which is part of their surgical education.
Did you specialize in any one branch of surgery or were you a general surgeon?
I have been all my life a general surgeon. Early on, I was very interested in pediatric surgery and when we opened our Children’s Hospital, I was chief of that division and learned pediatric surgery the hard way, by doing it, because there were no pediatric surgeons at that time. I carried that on for about fifteen years until we got a trained pediatric surgeon and I relinquished it then to his care. That’s why a lot [of my] early publications are in pediatric surgery.
I noticed that you list over 100 publications. You were too modest to send me the first two pages of your bibliography, and I’m a little curious as to what is on them. Were most of these in pediatric surgery?
A lot of those were in pediatrics.
Here’s page three.
Most of the early ones were in pediatric surgery. These in the Navy Bulletin were during the war years when I was writing about some of the interesting things that we were encountering. It was in trauma and in [pediatrics], mostly, the first two years.
Perhaps this is a good time to talk about your Navy career. I notice that you had active duty in the U.S. Naval Reserves starting in 1942 to 1946. That you were Chief of Surgery at the Great Lakes Training Station and Chief of Surgery at the U.S. Naval Hospital in Texas and on the aircraft carrier, U.S.S. Essex, CV9 Flagship. What type of surgery did you do during these years? Was it combat wounds?
The first year at Great Lakes was all reparative surgery. This was in the first year of the war and I was at a place called McIntire Dispensary, named for the surgeon general, Ross McIntire. This was one of his darlings. We had a 500-bed surgical unit there in which we repaired hernias, hydroceles, hemorrhoids, circumcisions – everything that the recruit needed fixed when he came in the service. At that time, that base had 3,000 new recruits in every night and we shipped 3,000 to the fleet every night, so they stayed on the base from three weeks to six weeks, during which time we repaired those things that they needed done. This was the nature of that. I did 1,500 hernias there in nine months and about 500 acute appendices.
At Corpus Christi I was Chief of Surgery there. That was a standard naval hospital with the run-of-the-mill [cases] that you would see in any air base with about 35,000 people. The service on the aircraft carrier – I was surgeon on that [for] the last nineteen months of the war. There was some trauma that occurred on the ship – relatively little combat except the one time that we were hit with a kamikaze, because in naval warfare it’s usually all or none for the pilots. If they’re hit, they don’t come home; you have relatively few wounded. But you do have a sizeable city in that there are 3,500 men on one of those carriers. There are lots of accidents that happen. There are acute appendices, they are hernias; all sorts of things happen to them.
I noticed that you were discharged with the rank of Commander, awarded seven battle stars, presidential unit citation, and personal navy citation from Admiral Richard Spruance [ed. note: Raymond Ames Spruance], Commander of the Pacific Fleet. After World War II I notice that you were designated as the first honorary consultant in surgery to the Strategic Air Command. What did this involve?
When I came home from the Navy, the Air Force had just been severed from the Army. Instead of being the Army Air Force, as it was all during World War II, it suddenly became the United States Air Force. In Omaha was established the headquarters of the Strategic Air Command, which is our offensive weapon in case of war. It controls all of the bombers, it controls all of the submarine offensive warfare with missiles, and it controls all of the ground missiles which would be used for offense. They established this base here but the Air Force had no established medical department at first. I was asked to cover the surgical end of the Headquarters, Strategic Air Command, which I did completely for five years and then have remained their consultant to the present. Later on, I became one of the general surgical consultants to the United States Air Force and I still am in that position.
What does that involve?
That basically involves visiting various Air Force hospitals, meeting with the surgical residents, seeing patients with them, conducting educational exercises, and evaluating them for the Surgeon-General.
Among your awards and positions there’s one that I’m not sure I can pronounce: King Aksarben—
King Aks-ar-ben. That is “Nebraska” spelled backwards.
And with the Roman numeral LXXI.
Aksarben is an organization in Omaha which embraces Western Iowa and all Nebraska. It was founded as a business organization but it is now agricultural, business, educational, and philanthropic. We have 60,000 members who pay a twenty dollar membership fee. We operate the Aksarben track, which has a ninety day season. Aksarben, in addition to its funds from membership, makes about two million dollars a year, which is given to charity in Omaha, and in Nebraska and in Western Iowa. Annually, they have an Aksarben Ball, which is comparable to your Veiled Prophet Ball or the Mardi Gras. A king is selected from the community who has been, presumably, a prominent citizen and the queen is the daughter of a prominent family. They reign in the court for a year.
You mention a track.
A race track. We have about 2,000 horses there right now. It’s one of the better tracks in the whole Midwest.
I notice you also received the Governor’s Meritorious Service Award in 1973, the fourth citizen in the state of Nebraska to receive this honor. Do you care to comment on that?
For one reason or another, the Democratic governor gave this to me, as a Republican, for, apparently, service in medicine to the state.
I notice that you also have the Distinguished Service to Medicine Award from the University of Nebraska Medical Center and have been on the Board of Directors of the Omaha Chamber of Commerce, the Omaha Symphony Board, and a member of the President’s Council. What is the President’s Council?
The President’s Council is a council of people in the state of Nebraska who meet four or five times a year with the President of the University of Nebraska, who are his agents in that we are briefed on the functioning and the position of the University, and are, hopefully, able to transmit through multiple groups of private citizens, the problems of the University and aid its consideration by the legislature, on which it’s dependent for funds.
I notice that you’ve also been very active in professional organizations in Nebraska and nationwide. In 1974 and 1975 you were elected the President of the American College of Surgeons. This came after a long series of offices held with [the College]. Would you care to tell us something about the American College of Surgeons, [its] membership requirements, and what it tries to do?
The American College of Surgeons is the largest surgical organization in this country, with some 40-plus thousand members. Membership requires a minimum of five years’ training with certification in your board of surgery [and] an ethical record which must withstand critical evaluation, to become a Fellow of the College. It is dedicated to improving the care of the surgical patient in the United States. Its great contribution early on was the establishment of the first system for inspecting American hospitals, which it undertook in 1910 and carried on for thirty years alone, until the JCHA (or the Joint Commission on Hospital Accreditation) took it over when the burden financially became so great that the College could no longer carry it on. Today, we’re the greatest educational body in American surgery with our Clinical Congress, our sectional meetings in the spring and fall, C-SAP, which is a great ongoing educational exercise which is put out every year or two by the College and which most all of our people take to remain current in their field.
What is C-SAP? Is it an exam?
It is a large compend with about two or three hundred questions with five possible answers, all of which are good, put together by a group of seventy dedicated surgeons who work about eighteen months to make each exam. Then there is a compend at the end which gives you the correct answer and the reason why that is the correct answer. It is a superb educational exercise that covers all of the general branches of surgery.
That sounds like a very important means of keeping up the skills of doctors who have graduated in past years.
It’s tremendous.
Is that compulsory to the membership?
It is not compulsory although certification in general surgery after 1980 will be limited for a ten-year period and then you will have to have some form of re-certification. Those of us certified prior to 1980 have no limitation on our certificate. The type of examination, specifically, which will be given to those people in the future has not yet been decided. It is still being discussed at high levels.
So certification will begin for new surgeons in 1980?
Well, we are all certified, but those who will take the board [examination] for the first time in 1980 and be certified will have a ten-year span on their certificate and then they will have to rejuvenate it – be re-certified. Those prior to 1980 – of course I took it in the second group in which it was given, in 1940 – we have our [certificates] in perpetuity.
And now it will be limited to a ten-year span. Do you think this is a good idea?
It’s [being] discussed. Some feel it is not [a good idea] as a requirement. I’m not sure that this will hold as an absolute requirement. You see, it’s almost eleven years off before that would become effective. I think great changes will happen in that time. I’m sure that there will be more and more graduate work going on, which there is today. But whether or not you will be forced to go through a specific re-certification process, I think is still debatable.
I notice that you were elected by the American College of Surgeons as their representative to the Council of Medical Specialty Societies and that you held this position from 1971 to 1976. What sort of topics were discussed at these meetings?
This is an organization of the twenty-two specialty groups, or designated groups, including Family Practice. Membership on the Board of the CMSS (Council of Medical Specialty Societies) is [limited to] one member on the Board for every 5,000 members in the specialty. If you had 30,000 members in Family Practice you could have six members in the coordinating council. They meet four times a year to discuss common problems of medicine in so-called specialties. We deal with a multiplicity of things from training to government problems, etc.
Are you now first vice-president on the executive committee of this organization?
I’m no longer on it. I have finally graduated from that, although the president of that [group] right now is a gentleman on this campus, Dr. Tom Ferguson, who is in thoracic surgery here at Barnes. He’s doing a very able job, incidentally.
From 1973 to 1976 you served on the Interspecialty Advisory Board of the AMA. What did this involve?
That’s a similar group, sponsored by the American Medical Association to give specialists an input into the AMA. Actually, it is a sounding board for the AMA officers to tell representatives of specialties what they’re doing, etc. It has really no major function.
You have published an amazing number of articles during your career. Would you consider yourself a clinical member of the faculty or were you on the full-time staff? These seem to be the divisions here at Washington University and I’m trying to place you in one or the other.
I’m definitely in the clinical group. We have just adopted that designation in our school. We have not used it until right now. I happen to be serving on the committee that is bringing in that recommendation. If I’d lived in the succeeding thirty years, I would have been Clinical Associate Professor. I have never received any money from the University for forty-five years of teaching; that’s all been gratis.
I would say that you have published much more than most clinical [professors] find time to do. Your publications seem to be in almost every field of surgery. I did notice that presently you seem to show a great deal of interest in the treatment of cancer. Is that right?
My basic interest [during] the last fifteen years has been in breast cancer. I’m interested in gastric cancer and colon cancer but my principal interest has been in breast cancer. I have been [interested] in practice; I’ve published in this field; we have quite a sizeable series of these in our private practice that I have followed now for thirty years, carrying the follow-up off at home or doing it after hours at home because we did not early on have a hospital system of a good follow-up. We now have that on the computer and it makes it very easy. I did it over a period of thirty years by writing to the doctors – over half of whom are now dead – writing to family, writing to priests, writing to ministers, writing to grocers, writing to sheriffs, anything to follow these people. It’s been a fascinating work.
Was it the results of that work that you published in the American Journal of Surgery?
Yes, just recently.
In August of ’78. Could you tell us the results of your study?
We have found that we still [find] almost one-quarter of the people in Nebraska are advanced when we first see them – they’re advanced by strict clinical criteria. If you take the overall survival, it’s a little over 60 percent [for] five-year survival, if we take all comers. If we have them selective, it’s about 85 percent five-year survival. There are about 90,000 new cases of breast cancer in the United States each year, [and] there are about 33,000 deaths in the United States each year from breast cancer. Of our people we find that of those who have cancer, about 70 percent of them will succumb to their breast cancer, ultimately – if you take 200 of them consecutively. About 20 percent will die of some other medical condition – of course, heart and stroke are the two most common – and about 9.8 percent will die of a second independent malignancy – a second, unrelated cancer.
If a woman is going to get recurrence in our area – and by the way the average age in Nebraska is sixty-nine when she gets a tumor – she’s not a young girl, the average age – if she’s going to get a recurrence, we will see 70 percent of them within the first five years. We will see another 18 percent in the second five years. So, if they make ten years after their mastectomy and initial treatment, [a woman] has a relatively small chance of developing a recurrence from that cancer, but she still has an 8 percent chance of developing cancer on the other side.
What treatment do you recommend for cancer of the breast?
We still believe that in the operable cases, a modified radical mastectomy is the treatment of choice. We only use radiation therapy if they have more than four axillary nodes involved. My work suggests to me that an appraisal of the axillary nodes is one of the very important things in doing an axillary dissection. Because if they have less than four [involved] nodes they have twice as good a chance of survival as if they have more than four involved nodes. We only radiate those that have four or more nodes; I use no chemotherapy in the postmenopausal patients prophylactically, but I do use it in the younger ones, the pre-menopausal ones, because it is only in this group that experience all over the country has shown it to be of value.
I notice that you have written articles on these subjects and that there has been a controversy between those advocating total mastectomy and those advocating, would you call it a limited or simple mastectomy?
Yes. I just don’t believe that they are correct because I am convinced from my own experience that doing an axillary dissection with the mastectomy removes tumor, and that’s the name of the game when you’re dealing with cancer. Second, it’s the important single prognostic thing we have on telling you how that patient is going to do and [it] helps you to delineate their subsequent therapy. I admit that this is controversial; there are some fine clinics that would disagree. But after all, one must live by what his own experience tells him.
You have done a lot of consecutive long-term studies. I notice this one in 1968: a report of 375 consecutive patients with long-term follow-ups.
We’re now at 650 with a long-term follow up.
Perhaps you could restate at this point the results of this follow up.
The follow up still shows that about 60 percent will be alive at the end of five years, if you take all comers. If you take the selected ones with small tumors seen early, there will be about 80 to 85 percent alive. We include in ours those that are advanced, those [that] are aged, those that are tremendously big tumors, and we still see about a quarter of them that should have been in much earlier.
I have an article here entitled “What to Expect in Cancer of the Pancreas.”
Bad news is the principal thing because it is one of the cancers that is increasing in frequency nationally. Cancer of the stomach is getting less frequent. Breast [cancer] is increasing, ovary is increasing, stomach is decreasing, pancreas is gradually increasing. It is a bad tumor in anybody’s hands. It is silent early on; our diagnostic methods, while improved, are still not accurate. Therapy is most discouraging.
To what do you attribute the fact that in some areas cancer is increasing, like the pancreas? I believe you said the stomach [cancer] is decreasing.
Nobody can really answer why these things happen. The trend today is increasing evidence that environment has much to do with malignancy. People are beginning to study this more and more, and obviously your recovery is dependent tremendously on inherent resistance to that tumor. This is well-established, except we don’t know how to measure it yet. We do know that individual resistance determines much how well you’ll do and we also know that environment has a tremendous amount to do with the incidence of malignancy.
I believe in one of your articles you illustrated the idea of individual resistance to disease. A woman in the Middle East had contracted another disease which made her less resistant to cancer and as a result had a recurrence. Am I stating that right?
Certain things undoubtedly will decrease a patient’s resistance to cancer, although we can’t measure. For instance, a great tragedy in a family will very often be accompanied by a subsequent recurrence of malignancy. It happens more often than just chance would seem to dictate. We can’t measure that, but we see that happen so frequently that one day we will know how to measure a patient’s resistance. There’s a tremendous amount of work being done on the lymphocytic series and what it has to do with individual patient’s resistance to tumor and susceptibility to tumor. But we’re still walking in a great morass of fog. I hope the next generation will unravel this; there are some wonderful minds working on it.
In April 1970 you published an article about bile duct exploration. Has your thinking on that changed?
We reviewed these common bile duct explorations on a series of, I think, 1,500 or 1,600 consecutive gall bladders. We outlined what things we thought dictated opening the common bile duct. We found that in about 25 percent we felt it necessary to explore the common bile duct and our incidence of stones was recorded. It’s relatively low when you explore that many. About a year after this we started doing routine table cholangiograms, namely, taking an x-ray of this duct to see whether there were stones in it and to see if we needed to open it.
You might ask, “Why didn’t you do that earlier? Why didn’t people do that fifteen or twenty years ago?” There’s a very good reason for it. Our anesthetics at that time were explosive and you couldn’t bring an x-ray machine safely into the operating room nor could you use the actual cautery in the operating room because a spark might blow your patient up and you with him. It was only when we got non-inflammable anesthetics that we could use the cautery for hemostasis and bring an x-ray machine into the operating room. We now do table cholangiography on almost every patient; take an x-ray and decide whether we need to open the common duct. We have reduced our incidence of exploration from 25 percent to 10 percent and quadrupled our take on stones when we do look in now, because we know they’re there – we’ve seen them. We’re publishing a follow-up paper to that this year covering another, almost, 500 patients done with table cholangiogram.
In 1960 you published what seems to me a very important paper. I’m not sure that I understand it all but perhaps you could explain the significance of it.
We were, and continued to be, convinced that there is a certain pattern seen in some women’s breasts when you biopsy them for so-called fibrocystic disease that suggests that that is a potentially dangerous breast to develop cancer. Fibrocystic disease is a very common thing in women’s breasts; over half of them have some degree of it. It’s a little shoddiness, a little irregularity, some cyst formation, incident to the constant changes in that breast in the menstrual cycle, which goes on from puberty to the menopause in the female. We noticed in doing a large number of biopsies in fibrocystic disease that there was a small group, perhaps 10 percent, that showed a very marked activity of the cells – a piling up of the cells – evidence of stimulation which was not only was two or three layers but filled a whole duct. If that broke through the duct, that’s cancer. If it just filled the duct, it’s still localized and we called that “pre-cancerous epithelial hyperplasia.”
When I published this paper, or when it was first given at the Southern Surgical [meeting] in 1960, it was received with some skepticism. A great many people didn’t believe this was true because they felt that fibrocystic disease was a safe entity. I’m happy to tell you that a great many people, including Dr. Warren Cole from this School and others, now believe with us that there is a very definite relationship between this hyperplasia and cancer.
We’ve been also interested in malignancy in other organs, including the pancreas which we just discussed, and in cancer of the thyroid, which is reasonably common in our area. Fortunately, it has a much better prognosis, except for the small-cell type which is hopeless always, and fortunately makes up less than 10 percent of them. The papillary and the papillary-follicular types of carcinoma of the thyroid, which are seen quite frequently in young people, have a very excellent prognosis. In our experience it’s done very well. As a matter of fact, we’ve only had a small number of deaths and that is in those people who were much older when they first got their papillary carcinoma. It is a pretty good cancer, if you have to get one, because it can be handled quite well surgically.
Colon cancer – we have a great interest in that today because it is increasing in its frequency and it involves both sexes. It is, after lung [cancer], the male’s most common tumor. After breast and uterus and cervix [cancer] it is the female’s most common cancer, so it has a very wide interest. Colon cancer is triply interesting because one, it’s increasing in this country a great deal; two, it’s a very insidious tumor that doesn’t show up, doesn’t have very many symptoms until often it’s quite advanced; three, it probably is environmental in some respects in its origin. It’s a very interesting thing that the African native or those peoples who eat a tremendous bulk diet and have three or four bulky stools per day, almost never get cancer of the colon. While in this country where we subsist on concentrated foods and [have] small fecal output, cancer of the colon is increasing dramatically. That’s true in all the countries in the world that live on concentrated foods. This may be a factor; I doubt if we’ll go to the other, but it may give us some thoughts on etiology.
Our search starts with your latest article. To work backwards, do you have comments on these others?
[ed. note: Dr. McLaughlin looks through reprints of his articles and comments as follows]
Cancer of the pancreas, as I said before, is most discouraging. We presented 100 consecutive patients that we had seen in our private practice. They were most discouraging; we had almost no long-term survivals. With radical resection of the Whipple-type we had one six-year survival and one three-year survival out of about eight very radical procedures. The balance all were palliative procedures and the average expectancy is about nine months after surgery – [maximum]. It is a very distressing, distressing operation.
Carcinoma of the gall bladder and the extrahepatic bile ducts. I was interested in that because the first paper I wrote while a resident in path [pathology] at McGill was on tumors of the extrahepatic bile ducts. I went back into all of those extensive records of the Montreal General Hospital and I found four patients at that time with extrahepatic bile duct tumors. Interestingly enough, I reread some of the protocols of Sir William Osler, who as a young man had been a pathologist in this same department. These were handwritten path protocols in Osler’s handwriting that I went back over. Historically, [that] was fascinating to me. These are bad tumors today, both gall bladder and bile duct tumors. Relatively few [patients] ever survive. [In] cancers of the gall bladder the only ones that survive are those that you find incidentally and have a very small one that you take out, not suspecting it. When you have an obvious, big cancer of the gall bladder, even with hepatic resection, the results are very, very poor.
Large benign gastric ulcers. This was a fascinating study of gastric ulcers three centimeters or above; that’s an ulcer over an inch and one half, to twelve centimeters or three inches in diameter. We found a sizeable number of these and reported them. Some of them are benign; a surprising number of them are both benign or malignant; they’re about half and half separated. The point I was making in this is that when you operate upon these and you look at them and you have them in your hands, [with] some of them it’s very difficult to tell whether they’re malignant or benign. Even with the initial microscopic sections they’re hard to tell [apart]. We found that we were wrong both ways – saying they were benign when they were malignant or [saying] they were malignant and they were benign – in 24 percent. Both ways, in a quarter of them, in other words, you couldn’t tell till you got your final sections through.
(Looking at titles)There’s more on breast. Infancy and childhood – I don’t want to discuss that anymore. I’ve been out of it too long.
Are there any other areas of surgery that you’d like to discuss?
At this stage in the game, I don’t believe so. I’m most interested now in the future of how medicine is going to go because I think that we’re at the threshold of some great changes. I believe that the dramatic growth in our hospital system has reached its zenith and is going to begin to taper down. In other words, a lesser number of people will be hospitalized in the future than there are today and much more will be done on an outpatient basis of one kind or another. This is going to come about by economic prodding.
I think that there is a sizeable amount of the work today that is done in-hospital [that] can and will be done in an extra-hospital setting, utilizing hospital facilities but not being admitted. I would guess that maybe a quarter of the patients that we see in hospital will be handled outside. I’m sure this is true in surgery. Economically, it will save whatever the per diem is per bed. It’s $105 in our hospital; I’m sure at Barnes it’s probably $130 – I don’t know, but it’ll be higher. This is going to be one of the great trends, I am convinced, as we go along. We’re also making every effort in medicine and in surgery today to curtail costs in taking care of a given problem, by more critically looking at what we must do to arrive at the same amount of information. In other words, not do everything on everybody, but in a much more selective method work up a patient in [an] effort to reduce its cost, because the costs are horrendous. Hospital costs in America went up 15 percent in ’77. In ’78 they went up 12.6 percent. This year we hope to hold them at 11.6 percent but in the first three months they’ve gone up 14.6 percent, basically because both food and fuel in this same period went up 14.1 percent. We can’t control this; we have to buy energy and we have to buy food. So, until the federal government and the administration can make some dent in the overall inflation you’re not going to see much happen in hospital costs.
Do you see any other trends in medicine?
Of course, the most striking thing is the tremendous number of people going into family practice today. I think many more are going into it than will stay in it, but that’s only an impression. I do not believe that this will satisfy nearly as many as are starting the training. I’ve watched this over a period of years and I think that you’ll find a sizeable number of those people who have taken a basic training in family practice finding that it does not quite satisfy them and going into some specific specialty. Because medicine is such a big entity – it is so complex, it is so demanding – that the ability of one person to keep even reasonably current in that broad a spectrum is almost impossible. So I don’t think that the idea of specialization is dead simply because 50 percent of people have to be in primary medicine today because the government said so. They [the government] now say 60 percent. Well, what they say and what happens doesn’t necessarily follow.
Dr. McLaughlin, could you tell us something about your family?
I am married to Beatrice Reimers, a Nebraska girl, and I’m very much in love with her after forty years. We have one son, who lives in Chicago. He works for Crown Zellerbach Paper Company out of San Francisco and he is in industrial sales, traveling the eastern half of the United States in their tab carton division. We lost a second son some ten years ago in a car accident. We have a happy family; we live in Omaha and just built a new town house, which has been a delight, in the last year or so.
Are you still actively practicing surgery?
I am still carrying a full surgical schedule. I don’t operate nearly as much as I did ten years or twenty years ago, but I go to the hospital each day when I’m in the city, and that’s most of the time. I have two very able associates who are carrying an increasing amount of the load. I have a consultant practice and I’m in the office four days per week. [We] spend the month of July in northern Minnesota where we have a summer place.
Where in northern Minnesota?
Just south of Bemidji – between Bemidji and Park Rapids in the Paul Bunyan Forest. We’re on Lake Mantrap.
When you talk to a surgeon, usually malpractice insurance premiums come up. What has been your experience with the cost of malpractice insurance?
Of course, it escalated very rapidly about three or four years ago and hit its peak in our area. Our [costs] are now going down somewhat, probably because of a little better experience with the settlements. Our [premiums] peaked out about three years ago and surgical cost in our office is down about 20 percent from three years ago. I am hopeful that it will continue to improve, but it’s never going to go away – I’m sure of that.
Dr. McLaughlin, you were comparing Washington University School of Medicine to other medical schools in the period while you were a student here. Could you tell us a little bit more about that?
I would like to answer that in the context of what is my most vivid impression, after fifty years, of this School where I was privileged to be a student for two years. Coming from a very fine medical school, namely the University of Iowa in Iowa City, I found a tremendous difference in Washington University. Because at that time, while it was a relatively small school with only seventy-two in my class and a similar number in the other classes, it had developed an international reputation which was shared perhaps only by Hopkins, Harvard, perhaps Michigan, and very few other schools. During that two years there was a constant procession of brilliant young people from Scotland, from England, from France, from Germany, [and] from the Far East, coming through various divisions.
I remember particularly those who came through the surgical division to visit Dr. [Evarts] Graham’s and Dr. [Glover] Copher’s clinic. The same thing was true in Pediatrics under Dr. [McKim] Marriott, the same thing in OB/Gyn under Dr. [Otto] Schwarz and his group, the same thing was true in Radiology under Sherwood Moore, [Joseph W.] Larimore and those people, and the same thing was true with Ernest Sachs and [Roland M.] Klemme, his right hand at that time. It rather opened one’s eyes to the fact that medicine was a fantastic field that involved the whole world; that there were great people and competent people all over the world but they would come to those special centers to pick up the things that were being developed. And they certainly were being developed at Washington [University School of Medicine] at that time. For this, I owe a very particular debt to this University, which I gratefully acknowledge.
We want to thank you very much for taking time to give us this interview and for the interesting things you said.
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