Pediatric Annals

editorial 

A Pediatrician's View: Commitment

William A Altemeier, III, MD

Abstract

When I think about prominent pediatricians from my past - the ones who have had the greatest influence - a disproportionate share have been women. The following describes the earliest two - Dr. Mildred (Millie) Stahlman and Dr. Sarah (Sally) Sell. Both were faculty while I was a medical student and then resident in the early 1960s. This editorial will begin with recollections of the way things appeared at that time and what these two meant to our training. This is followed by information derived from them recently, to compare how things seemed and how they really were.

How it appeared: Dr. Sell directed infectious diseases. She was the kindest, most gracious member of the faculty - happy, devoted to her work and family, and successful in that she was a nationally recognized expert for Haemophilus influenzae. She worked part time and taught through conferences and consultations, but rarely served as an attending on very sick patients. Sarah's biggest contribution for us was her resident-student clinical microbiology lab. We plated and read all of our own cultures, from throats, wounds, skin, urine, bloods, and spinal fluids. Much of these skills were passed down from senior to junior residents, but the lab was her baby, her idea. It was a beautiful way to learn microbiology by following individual diagnoses from the patient to the lab to the patient. I later brought this teaching technique to the University of Florida and then Nashville General Hospital, until regulations made this type of education almost impossible a decade ago.

Dr. Stahlman took a different course. She was a neonatologist who never married and who devoted her life to her career. She served as a model for total pediatric focus and commitment, probably to a greater degree than anyone I have known. Millie's field was hyaline membrane disease. During the 1950s, she had done some training in Sweden, where newborn physiological research was more advanced than in the United States. Dr. Stahlman has maintained this Scandinavian connection and there has been a steady flow of fellows and attendings between there and her nursery over the decades.

In the late 1950s, Millie began studying prematures with hyaline membrane disease by observation - clinically, laboratory-wise, and radiologically. After initial definition of problems with arterial oxygen, carbon dioxide, metabolic and respiratory acidosis, temperature control, glucose metabolism, potassium, and fluid maintenance, she began the first trials of treatment by assisted ventilation. These started in October 1961, early in my internship. Dr. Stahlman was, I believe, the first to apply intense nursing and medical care that included artificial ventilation to babies with hyaline membrane disease. Her strategy was based on the clinical and pathological observation that patients with mild disease often recovered fully after 2 or 3 days of oxygen and other general support measures. So maybe the more severely affected babies would do the same if given more intense care, including assisted ventilation.

In 1961 and 1962, we and her nurses had strict instructions to call her immediately anywhere, anytime when one of these prematures arrived or was expected. Within 20 minutes, she would appear with a brown cardboard suitcase from the 1930s. Millie's father owned the Nashville Banner newspaper and was one of the most influential people in Nashville, whereas Millie lived a simple, frugal life. Her passion was her work and her nursery babies. She would move into the nursery, sleeping on a cot in the utility room for however many days it took until the patient was out of the woods.

We managed most of the normal babies and nonrespiratory diseases while she managed the respiratory…

When I think about prominent pediatricians from my past - the ones who have had the greatest influence - a disproportionate share have been women. The following describes the earliest two - Dr. Mildred (Millie) Stahlman and Dr. Sarah (Sally) Sell. Both were faculty while I was a medical student and then resident in the early 1960s. This editorial will begin with recollections of the way things appeared at that time and what these two meant to our training. This is followed by information derived from them recently, to compare how things seemed and how they really were.

How it appeared: Dr. Sell directed infectious diseases. She was the kindest, most gracious member of the faculty - happy, devoted to her work and family, and successful in that she was a nationally recognized expert for Haemophilus influenzae. She worked part time and taught through conferences and consultations, but rarely served as an attending on very sick patients. Sarah's biggest contribution for us was her resident-student clinical microbiology lab. We plated and read all of our own cultures, from throats, wounds, skin, urine, bloods, and spinal fluids. Much of these skills were passed down from senior to junior residents, but the lab was her baby, her idea. It was a beautiful way to learn microbiology by following individual diagnoses from the patient to the lab to the patient. I later brought this teaching technique to the University of Florida and then Nashville General Hospital, until regulations made this type of education almost impossible a decade ago.

Dr. Stahlman took a different course. She was a neonatologist who never married and who devoted her life to her career. She served as a model for total pediatric focus and commitment, probably to a greater degree than anyone I have known. Millie's field was hyaline membrane disease. During the 1950s, she had done some training in Sweden, where newborn physiological research was more advanced than in the United States. Dr. Stahlman has maintained this Scandinavian connection and there has been a steady flow of fellows and attendings between there and her nursery over the decades.

In the late 1950s, Millie began studying prematures with hyaline membrane disease by observation - clinically, laboratory-wise, and radiologically. After initial definition of problems with arterial oxygen, carbon dioxide, metabolic and respiratory acidosis, temperature control, glucose metabolism, potassium, and fluid maintenance, she began the first trials of treatment by assisted ventilation. These started in October 1961, early in my internship. Dr. Stahlman was, I believe, the first to apply intense nursing and medical care that included artificial ventilation to babies with hyaline membrane disease. Her strategy was based on the clinical and pathological observation that patients with mild disease often recovered fully after 2 or 3 days of oxygen and other general support measures. So maybe the more severely affected babies would do the same if given more intense care, including assisted ventilation.

In 1961 and 1962, we and her nurses had strict instructions to call her immediately anywhere, anytime when one of these prematures arrived or was expected. Within 20 minutes, she would appear with a brown cardboard suitcase from the 1930s. Millie's father owned the Nashville Banner newspaper and was one of the most influential people in Nashville, whereas Millie lived a simple, frugal life. Her passion was her work and her nursery babies. She would move into the nursery, sleeping on a cot in the utility room for however many days it took until the patient was out of the woods.

We managed most of the normal babies and nonrespiratory diseases while she managed the respiratory unit. There were usually one to six babies there, placed inside of negative pressure tank ventilators of various sizes and shapes, like those used for polio then. Their bellows were moving at rates up to 150 times per minute. Tubes were going in and out of the tanks for fluids, rectal temperature probes, and umbilical arterial and venous catheters. AU procedures had to be performed through tank portals. The atmosphere was one of organized chaos, but, above all, there was the excitement of discovery. The worst cases (those babies who could not be maintained by a tank alone) were also intubated and one of our jobs was to occasionally take a turn at hand ventilation by bag, but only if you were trusted. Losing a baby after a hard 5-day fight was always tough.

Millie demanded absolute commitment from herself and everyone she worked with. She has never weighed more than 100 pounds, but if on rounds you did not have all the information and have it correct, you were in for some pain. You learned attention to detail, organization, and that the baby comes first in a way that was not easily forgotten. It was also a model of applied physiology, organized by the clinical problems of individual patients. But it worked for us and the babies. Other nurseries quickly began trying similar managements and modern neonatal intensive care nurseries sprang up nationally during the next 6 to 8 years. By 1970, this was the standard. Some of her preliminary results were published in 1964.1 And a 39% survival rate among a series of 80 babies, who would have been expected to die without respiratory assistance, was published in 1970.2

I called Dr. Stahlman a few weeks ago. She had just returned from receiving an award in Sweden. She seemed unchanged, except now she is fighting for all children. Her talk "Who Will Save Our Children?", presented when she accepted the 1996 American Pediatric Society John Howland Award at the Pediatric Academic Societies' meeting in Washington, DC, will give the reader a view of her fire.3 Her research, leadership, honors, and publications continue.

I also talked with Dr. Sarah Sell and found that all was not as idyllic as it seemed for these two women. They were good friends and had roomed together some before Sally married her second husband, Dr. Gordon Sell, who passed away 3 months ago. Sally's first husband had also been a physician. After Sally received a master's degree in microbiology, she and her first husband had moved to Appalachia to practice "city medicine in the country." He started her in medical school when he went overseas for World War II. When he died during her sophomore year, she continued to train as a resident under Katy Dodd in Cincinnati and then did an infectious disease fellowship at Charity Hospital in New Orleans. She met Gordon, a cardiologist, and came with him when he took a position at Vanderbilt. Floyd Denny left Vanderbilt soon thereafter and this opened a position in infectious disease for Dr. Sell.

Life was not easy for these two women. Sally was paid $2,500 per year for "part-time" work that was 6 hours per day for 6 days a week. This just about covered car and child care expenses while she worked. She published widely on H. influenzae and feels she "fell into" her leadership position. "One day they needed to know and I was a world authority." A vaccine was desperately needed, but the national leaders in this field were feuding. Dr. Sell saw a way she could bring these warring male scientists together "so they could fight disease instead of each other." She did this by organizing a national H. influenzae conference held at Vanderbilt in 1972. It went well, results were published, and a repeat conference was scheduled in 1982. She feels this was her most important contribution because it led to a "club" of researchers in H. influenzae vaccines that gave us the first usable product by 1985.

Sarah describes how she and Millie "talked it out," sometimes all night, when they roomed together. Millie decided that both a career and a full family life would not work for her, whereas Sally needed both. Dr. Sell comments that "Millie has her awards and I have two wonderful sons and four grandchildren." Dr. Stahlman was paid less than her technician at times and Sarah said there was a national perception, 38 years ago, that women in academic medicine should be supported from elsewhere. She quoted a statement from Boston that "you can get a great woman for less than a poor man would cost." But Dr. Stahlman went on to help create five chairs at Vanderbilt from family money that would have gone to her.

Obviously, things were not as they appeared. What comes out of this, however, is the tremendous sense of commitment these two, and many others like them, gave to those they trained and to pediatrics. It seems as if more of those pediatricians who make an impact, a difference, are women than one would expect. I first met Jane Schauer, our guest editor for this issue, when she came to Vanderbilt as a visiting professor and gave the most moving banquet presentation ever. Instead of the usual speech, a piano was brought in and she played "Scenes from Childhood" by Schumann while she talked about his difficult life, his fight with mental illness, and, above all, his total commitment to music. Although this banquet occurred some 17 years ago, the memory is as vivid as Dr. Stahlman's garden of tank ventilators. Would a man try something such as this at a banquet? Maybe.

A quote in Pediatrics (1998;101:A-76) from the lay book Do We StHl Need Doctors?4 hit like a ton of bricks:

Something is Missing

Today's academic medical center may not be the best of all possible worlds . . . something very crucial is missing from the center ... we don't need more information, we need more commitment.

REFERENCES

1. Stahlman M. Treatment of cardiovascular disorders oí the newborn. Pediatr CIm Non* Am. 1964;?:377-397.

2. Stahlman MT, Malan AF, Shepaid FM, Blankenship WJ, Young WC, Gray J. Negative pressure assisted ventilation in infants with hyaline membrane disease. J Pediatr. 1970;76:174-182.

3. Stahlman MT. Acceptance of the 1996 American Pediatric Society John Howland Award: Who WiU Save Our Children.' Pediatr Rt1. 1996;40:772-773.

4. Lantos JD. Do We Stai Need Doctors' New York: Roudedge; 1997.

10.3928/0090-4481-19990301-06

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