The following is an abridged version of a speech that Dr. Janney delivered to the St. Louis City Hospital Housestaff Association on May 14, 1992, during its reunion gathering at the Clarion Hotel in St. Louis.

That was the year --
I came to St. Louis as a callow, 23-year-old medical graduate who had been quite successful in a small Kansas puddle and was quite anxious about trying what was perceived as the much larger and more competitive St. Louis lake. My immediate goal was to obtain a medically diverse, hands-on experience as a rotating intern in a large city hospital setting. I saw the internship as only a necessary step to the already-applied-for post-graduate training in ophthalmology at Washington University, and ultimately returning to western Kansas to join my father in practice.

That was the year --
City Hospital was at its apogee as a fine housestaff training program. That staff's single-minded, intensely-concentrated, 24-hour-a-day devotion to the program made it really shine and soar. Little did we realize then how the war would destroy the homogeneity of the group's commitment. After the war, both residents' and interns' intensity was much diluted and in the subsequent years that I was associated with City, never returned to the '41-'42 level. It became a much more individual matter and individual excellence was still very much in evidence. Though the training was still good, the tremendous pressure that the unified group put on its individual members to learn and improve was lost. Eventually the teaching programs and the hospital succumbed to the inability of St. Louis to sustain a very expensive uncooperative employees union and antiquated plant which served an ever-decreasing part of the population. All us were very luck to have been there that year.

That was the year --
I had four medical experiences that to me were apocalyptical.

In those days, three of these patients would have turned up in teaching hospitals rarely; and if they had, the opportunity for an intern to have had any responsibility in their treatment would have been nil. There was a strong commitment by the medical profession of the time to take care of the poor and the indigent. We interns shared in that and our patients were cared for well and with respect. We made the judgments regarding their care carefully with our residents and peers but without sharing the process with the patients. We did only the tests that we felt were indicated and cost benefit debates were frequent on rounds; there was little concern regarding litigation as long as one had witnessed operative permit before surgery and a similar permit before autopsy. The few legal suits usually related to poor outcomes traceable to operative oversights. As far as I know, the hospital carried no malpractice insurance for the housestaff. Most of the patients were cooperative as well as appreciative, and I believe that most thought that their City Hospital doctors took good care of them. Thus the medical-legal climate and the type of patients available were important parts of the reason that City was a fantastic place to learn medicine at that time. And now to the cases:

Case 1 arrived on Division 19 late at night. He was a 40-plus-year-old, cyanotic man grunting with severe pleuritic pain and shaking with a severe chill, His temperature was over 104 degrees. First came the wonderful satisfaction of making the diagnosis of right mid- and left lower lobar pneumonia by physical findings before it was confirmed by X-ray. Next was the excitement of being able to type the pneumococci which predominated the bloody sputum as Type XXII and giving the type specific rabbit anti-serum IV without anaphylactic reaction. A few hours later came the abrupt transformation to a man who appeared well -- temperature nearly normal, breathing easy without pain, no longer cyanotic. WOW!

Case 2 was a young diabetic admitted unconscious with stertorous respiration, very high blood sugar and 4-plus sugar and acetone in the catheterized urine specimen. Again, the admission was late at night, the diagnosis was quite evident, and the treatment well-known but never previously witnessed by me. I will never forget the thrill of seeing that young fellow come back to life during the night as I did my hourly urines and, with the assistant resident, manipulated the insulin dosage and fluids. What excitement to understand and be able to manipulate the seriously deranged physiology. Again, wow!

Case 3 was a man in his mid-30's with a long history of severe hypertension. He arrived late at night in a very severe dyspnea and orthopnea which had wakened him abruptly from sleep a short time before. He was quite cyanotic and in great distress; his lungs were full of sibilent and moist rales bilaterally from bottom to top; his heart was considerably enlarged with tones hardly audible; no cervical venous distension was present, the liver was not enlarged and there was no edema; the blood pressure was 170/130. We recognized this as a textbook picture of acute pulmonary edema secondary to left ventricular failure from hypertensive cardiovascular disease. We had no specific medication at that time for elevated blood pressure. The immediate treatment was IV morphine, IV Salyrgan (an organic mercury compound and the only available potent diuretic) and rotating tourniquets. With this, he improved somewhat; dissatisfied with the response, we did a therapeutic phlebotomy of about 500cc. By morning the patient improved greatly, but his hypertension did not. Digitalization followed and the patient was able to resume sedentary activity, but a few months later died of a stroke. What a dramatic, therapeutic triumph only to be followed by the tragedy of premature death. That jump-started my intense interest in hypertension and heart disease.

Case 4 was a young man who was presented at conference with a history of congenital heart disease diagnosed as a patent ductus arteriosus. About a year before, he had experienced gradually diminishing exercise capacity and had lapsed into mild right-sided failure. Ultimately, this led to surgical consultation with Dr. James Mudd, who, as I recall, was the only surgeon in town who had previously ligated a patent ductus. I believe this young man was his fourth case and had been successfully restored to near-normal activity. Really exciting! As with everyone else, it started me thinking about the future of surgical intervention in heart disease.

These and other cases convinced me that I wanted to be a part of that kind of challenge and involvement with patients -- something I could no longer see in ophthalmology. In addition, I found that I really appreciated and admired the manner of many of the residents as they went about teaching us; I realized that I stretched hard to respond to their demand for and no-nonsense expectation of high levels of performance. Though no one hinted to me that I was approaching even a satisfactory level of performance, I sensed that they appreciated my effort. I was awed by the depth of their knowledge and their ability to share it in meaningful ways. I aspired to that kind of knowledge and decided that I would try to become involved in that kind of teaching.

Thus that was the year --
I changed my career goal to internal medicine, as difficult as it was because of my plans with my father. Because of my commitment to internal medicine and interest in teaching, it appeared unlikely that I would return to Dodge City. To his great credit, my dad respected my decision without rancor, but with obvious disappointment; also importantly, he continued to help financially, which was pretty important when you were on our salary of $25 per month with $15 of that held until the end of the year (in case of breakage), wanted to get married and knew that good residences didn't pay much more.

I have never been sorry for that decision and it is obvious that the City Hospital milieu was the critical factor in the change. I know that many of my fellow interns had similar maturing experiences at City which they consider to be important in their lives. Because of that we have nurtured for some years a desire to reassemble the group of residents who served as our composite role model so that we might in some little way thank them for their guidance.

While I appreciate the role and influence of the residents at City greatly, it is important to note that my fellow interns had a very important influence as well. As you who were there well remember, there was very strong peer pressure 24 hours a day. I had experienced the usual peer involvement in medical school, but it was nothing like this. If you inadvertently missed feeling the slightly enlarged spleen of your fifth admission of the day at 4:00 a.m., the assistant resident who checked on you would see that every one else on the service was informed at rounds about 7:30 a.m. By the time you went to lunch you wouldn't want any because by that time every intern in the hospital would have reminded you that you "flubbed it" -- on and on, ad infinitum, ad nauseum. That would not stop until someone else made an error, and even then the whole thing would be revived by the extremely loud voice of the late Paul Wheeler, if you were unfortunate enough to have the patient involved go to autopsy.

Furthermore, some of your "friends" had an indelible memory for your transgressions which was matched only by their intentional amnesia for their own. You can tell from my emotional reaction to this subject that I was more often a "flubber" than my bruised psyche wishes to recall; you can also judge how extreme my efforts became to try to avoid this trauma. This negative motivation that became ingrained in the fight for emotional survival at City Hospital led to an important positive habit -- always try to make your best effort. It's still very important to me today.