STEWART G. WOLF An Autobiographical Account Of Life In The Golden Age of Medicine (Edited by Paul J. Rosch, MD., F.A.C.P) FORWORD by Paul J. Rosch, MD, FACP . 4 PREFACE by John Hampton, MD . .13 Introduction . .17 Acknowledgement and Dedication . .18 Chapter 1: The Early Days of Growing Up (1914-1927) . 19 Chapter 2: Andover and Yale (1927-1933) . 34 Chapter 3: Back in Baltimore – Johns Hopkins (1933-1934) . 40 Chapter 4: The Medical School Years (1934-1938) at Johns Hopkins . 44 Chapter 5: Cornell (1938-1942) . 60 Chapter 6: War Stories (1942-1945) . 75 Chapter 7: Cornell After the War and Medicine A (1945-1952) . 82 Chapter 8: Moving West to Oklahoma (1952-1966) . 92 Chapter 9: Totts Gap Medical Research Laboratory (1958-Present) . 107 Chapter 10: The Marine Biomedical Institute, Galveston, Texas (1969-1977) . 116 Chapter 11: Decades of Change (1977-Present) . 123 Afterward: A Renaissance in Medicine . 133 Essays and Commentaries . 146 Education in America . 146 Our Dependable Brain -- As An Adapter . 152 Appendix . 172 Samples of Dr. Wolf’s Research Work. 188 Pemphigus Vulgaris: Failure of Treatment with Riboflavin and Smallpox Vaccine . 188 Old Terms and Modern Concepts in Medicine. 193 The Measurement and Recording of Gastroduodenal Blood Flow in Man by Means of a Thermal Gradientometer. 195 The Relation of Gastric Function to Nausea in Man. 204 Presidential Address: On Building Walls. 211 Talking with the Patient. 214 An Invitation to Danger. 222 The Final Studies of Tom. 225 The Pharmacology of Placebos. 233 Stress and Heart Disease. 249 Human Values. 255 Gastricsin. 256 The Bradycardia of the Dive Reflex -- A Possible Mechanism of Sudden Death. 257 The Turned-Off Heart. 266 Social Readjustment and Illness Patterns: Comparisons Between First, Second and Third Generation Italian-Americans Living in the Same Community. 282 The Place of the Person in Medical Examination. 290 Bill Bean in New Guinea. 294 Presidential Address: Social Anthropology in Medicine: The Climate You and I Create. 295 A Preliminary Study in Medical Anthropology in Burnei, Borneo. 312 QT Interval Prolongation as Predictor of Sudden Death in Patients with Myocardial Infarction. 325 Social Forces, Neural Mechanisms, and Health. 329 Lessons from Roseto 20 Years Later: A Community Study of Heart Disease. 334 The Courage to Think. 340 Roseto, Pennsylvania 25 Years Later -- Highlights of a Medical and Sociological Survey. 341 Studying the Person in the Patient: A Look Back at Development. 352 The Medicine of the Lateral Pass. 355 References . 366 Foreword : “A MAN FOR ALL SEASONS” Anyone who has worked with Stewart Wolf or knows him well will immediately recognize that much has been omitted or minimized in this autobiography because of his humility and modest nature. It is also likely that Stewart may be unaware of how much he has benefited countless friends, colleagues and students and contributed to their success through his wise counsel and other generous and unselfish efforts to promote their future success. Throughout this book he frequently refers to how lucky he was to have been placed in a certain situation or to have met someone - when in actuality, the reverse was more apt to be true. Tom, the patient with the esophageal stricture whose gastric function he studied for years in New York and Oklahoma is one example that reminds me of Thomas Jefferson’s “I am a great believer in luck and I find the harder I work the more I have of it.” Once Stewart embarked on any assignment, he was always an indefatigable and painstaking researcher. Tom is also an illustration of Pasteur’s assertion that “Chance favors the prepared mind”, as were the decades of Roseto investigations and so many of Stewart’s other achievements, many of which he failed to mention or miniaturized. There is no reference to his presidency of the Psychosomatic Society in 1961 (and his vigorous promotion of a scientific basis for that discipline), presidency of the American Society Of Clinical Pharmacology And Chemotherapy in 1966 and numerous other honors and achievements. He neglected to note that as president of the Pavlovian Society, he resurrected it after Horsley Gantt passed on and was responsible for its subsequent growth by attracting other distinguished clinicians and basic science researchers. He also downplayed his role as editor of its journal and deciding to rename it Integrative Physiological and Behavioral Science to more accurately reflect Gantt’s goals and values. When the American Institute of Stress established its annual International Congress on Stress in Switzerland in 1988 to commemorate the memory of Hans Selye, Stewart was the unanimous choice to be the recipient of the first Hans Selye Award. He was an active participant in all subsequent Congresses and although he refers to these events and to me in a very laudatory fashion, he neglected to mention how much he contributed to their success through his presentations and discussion of other papers, all of which he attended, usually in the front two rows so he would not miss anything. His professional renditions of La Vie en Rose and other songs in various languages during get togethers in the Hotel’s main salon after dinner set the festive tone for these soirées and the collegial character of our annual Congress. He was often accompanied by some of the other distinguished participants who were also accomplished musicians, and from past experience had brought their own instruments. Stewart’s interests were diverse and eclectic, ranging from a thorough analysis of what was known about the practice of medicine in Mesopotamia several thousand years ago and a biography of the Nobel Laureate Charles Richet, who was responsible for Walter Cannon’s concept of homeostasis, to complex mechanisms underlying the dive reflex and baroceptor influences on heart rate variability that are still not fully appreciated. Numerous recent reports have now clearly demonstrated that decreased heart rate variability (HRV) is associated with significant health problems and predicts increased risk for sudden death. This observation was first made by his neurocardiology group at the University of Oklahoma in the early 1960s based on a ten year prospective project designed to identify physiological and behavioral factors that might contribute to sudden death in patients following a myocardial infarction. It was found that neither age, serum cholesterol, good and bad cholesterol ratios, nor treadmill testing results had any significant prognostic power. The only predictive indicators for mortality were specific electrocardiographic changes reflecting diminished HRV, when compared to survivors. These preliminary findings were submitted to several medical and cardiology journals, but were rejected by all, with one reviewer commenting, “we have known about heart rate for centuries. The authors’ findings concerning variability of heart rate could hardly have significant medical importance”. Talk about tenacity, it was not until 30 years later, that Stewart was able to publish the complete results of this study in a paper entitled, “Oscillatory Functions Affecting Outcome of Coronary Heart Disease: The Hazard of too Much or too Little Stability”. In a masterful summary, he pointed out that particular periodicities are peculiar to all living systems, ranging from cells to civilizations. Recent advances in our understanding and interpretation of time domain measurements and spectral analysis of power components of heart rate variability suggest that HRV may be the most accurate method of assessing the significance of certain stressors as well as the severity of cardiovascular and other stress related disorders. Diminished HRV is seen during depression as well as anxiety, which may explain why these stressful emotional states are associated with increased cardiac morbidity and mortality following a heart attack. There are also very important metabolic correlations with obesity, insulin resistance and metabolic syndrome that result from stress related increases in cortisol. Although resting heart rate does not change significantly with advancing years there is a progressive decline in HRV. Conversely, regular physical activity, which can slow down the aging process as well as reduce stress, raises HRV, which is why it is also being used as a method for determining athletic fitness as well as “biological” as opposed to chronological age. So much for the reviewer’s assertion that Stewart’s’ “findings concerning variability of heart rate could hardly have significant medical importance.” Heart rate variability refers to the imperceptible alterations in beat-to-beat time intervals that occur during respiration that differ by only a few milliseconds and can only be accurately measured by computerized electrocardiographic monitoring techniques. Heart rate increases slightly during inspiration and the reverse occurs when exhaling. This normal variability called sinus arrhythmia is a measure of how well you are able to adapt to changes in both the internal and external environment. A decrease in HRV reflects a relative inability to maintain homeostasis that could be potentially dangerous. Stewart was one of the first to recognize this, and as he concluded in his paper, “proper physiologic balance requires some degree of instability, but not too little or too much”. He noted that Walter Cannon, in his initial description of homeostasis, had credited the French physiologist Charles Richet for proposing this principle in 1900, when Richet wrote “The living