APPENDIX II



M E D I C A L  R E S E A R C H  P R O G R A M S

O F T H E

V E T E R A N S  A D M I N I S R T A T I O N





GEORGE M. LYON, M. D.

ASSISTANT CHIEF MEDICAL DIRECTOR

FOR
 
RESEARCH AND EDUCATION
	The results of the research activities of the
investigators are published in the professional, scientific,
and technical journals so that information so derived can be
made available not only to other VA personnel but to the
interested professions as well.  In this manner the public,
at large, may benefit from the research achievements within
the VA Research Program.  A surprisingly large number of
these publications indicate a joint authorship in which one
of the authors is a full-time employee of the Veterans
Administration and the other is a member of the faculty of
the medical school or university associated with the VA
hospital.  This is but one of the many evidences of a
community of interest that contributes so much to the
Medical Program of the Veterans Administration.

	There have, unfortunately, been times when some of our
associates have been a bit neglectful of giving us proper
credit for work they have done in close association with our
research workers.  While we are not pleased when this occurs
we do have the satisfaction of knowing that we have
contributed to their success through our cooperation and
participation and that they have inadvertently paid us a
compliment, even thought not widely advertised, by thinking
so highly of our contribution that they would like to "hog"
the credit for it to themselves.

	In general, we encounter much the same problems of
human relations that characterize comparable situations
within medical schools and university hospitals. 
Fortunately, we do have a minimum number of instances
wherein a senior person may try to get his name on all
publications within his service (in a medical service or
department), regardless of the validity of his contribution
thereto.  The Research Committees serve an important and
beneficial influence in moderating these abuses which, if
not moderated, can have a most disturbing influence on the
attitudes and the morale of the other research workers.  I
mention this only to point out that we are concerned with
many of the same problems with which deans of medical
schools and heads of departments in universities are
concerned.  Sometimes these problems can be most
disconcerting to the responsible research administrator. 
Within the VA Medical Research Program we are rather
fortunate because there has been displayed, as a general
rule, an exemplary spirit of fairness and sportsmanship-like
attitudes in such matters.


PART II

VA RADIOISOTOPE PROGRAM

HISTORICAL 

	During the Fall of 1946 and the Spring of 1947, General
Paul Hawley, who was then Chief Medical Director, became
deeply concerned about the problems that atomic energy might
create for the Veterans Administration due to the fact that
the Armed Services were so actively engaged in matters of
atomic energy.  After consultation with the representatives
of the Manhattan Engineer District, General Hawley convened
a conference within his office to consider this matter.  The
conference, held on August 7, 1947, was attended by
Lieutenant General Leslie R. Groves, USA, Commanding
General, Manhattan Engineer District; Colonel James Cooney,
MC, USA, Chief Medical Officer, Manhattan Engineer
District,; Major General Raymon Bliss, USA, Surgeon General,
U. S. Army; Rear Admiral W. L. Willcutts, MC, USN, Deputy
Surgeon General, US Navy; Major General Malcom Grow, Air
Surgeon, U.S.A.F.,; Surgeon General Leonard Scheele, U. S.
Public Health Service; General Hawley and myself.  General
Groves described, in general, characteristics that these
problems might include and them stressed the importance of
having personnel trained, qualified and equipped with the
facilities required to meet them.

	General Hawley then requested Doctors Stafford Warren,
Hymer L. Friedell, Shields Warren, Hugh Morgan, and Perrin
Long to constitute a committee to advise him on matters of
atomic medicine and to make recommendations as to what steps
would next be taken to meet the problems discussed at the
August 7th conference.

	On September 5, 1947, this committee held its first
meeting.  the Veterans Administration was represented by
General Hawley and myself.  at this time the objectives of
the Atomic Medicine Program were formulated and the broad
aspects of a scheme for establishing a radioisotope program
to support the more inclusive Atomic Medicine Program were
drafted.  The advisory committee was given the name,
"Central Advisory Committee on Radioisotopes", as it was not
desired at this time to publicize the fact that the Veterans
Administration might have any problems in connection with
atomic medicine especially the fact that there might be
problems in connection with alleged service-connected
disability claims.  The committee recommended, (a) the
establishment of an Atomic Medicine Division within the
Department of Medicine and Surgery and the appointment of a
Special Assistant for Atomic Medicine to head up the
Division and to represent the Chief Medical Director in the
handling of atomic medicine matters, and (b) the
establishment of a Radioisotope Section to implement a
Radioisotope Program.  It further recommended that, for the
time being, the existence of an Anatomic Medicine Division
be classified as "confidential" and that publicity be given
instead to the existence of a Radioisotope Program
administered through the Radioisotope Section.  General
Hawley took affirmative actions on these recommendations and
it was in the manner described that the Radioisotope Program
was initiated in the Fall of 1947.

	The unique qualifications of the members of the Central
Advisory Committee on Radioisotope merit consideration. 
Doctor Stafford Warren, now Dean, Medical School, University
of California, Los Angeles, was formerly Chief Medical
Office, Manhattan Engineer District (1943-1946).  Doctor
Hymer Friedell, now Professor of Radiology, Western Reserve
Medical School, was Deputy Chief Medical Officer, Manhattan
Engineer District (1943-1946).  Doctor Shields Warren, now
Professor of Pathology, Harvard Medical School, was
Director, Division of Medicine and Biology, Atomic Energy
Commission (1947-1952).  Each of these individuals had
participated in one or more atomic bomb tests in positions
of individuals had participated in one or more atomic bomb
tests in positions of senior responsibility.  Doctors Morgan
and Long have, for may nears been leaders not only in
academic and civilian medicine but in military medicine as
well.  

	The Radioisotope Program was initiated in the Fall of
1947.  Most of that Fall was spent in planning.  The first
radioisotope laboratory was opened at VA Hospital, Van Nuys,
Calif., in February, 1948, under the direction of Dr. M. E.
Morton, one of the pioneers in research with radioisotopes
at the University of California.  This was but a few months
after radioisotopes became generally available for medical
purposes by the Atomic Energy Commission.

GENERAL STATEMENT OF OBJECTIVES AND PRINCIPLES

	A major objective of the Radioisotope Program was, 
from the very beginning, to provide the Veterans Administration
with qualified professional, scientific, and technical
personnel, as well as the specialized facilities, required,
(a) to meet the varied and unique problems of atomic energy
that might be of concern to Veterans Administration,
particularly in respect to the problems associated with the
study and analysis of alleged service-connected disability
claims, and (b) in connection with certain responsibilities
that the Veterans Administration may have in civil defense. 
Much of the support for the Radioisotope Program has been
predicated on, and justified by, the implications of this
major objective.  In this respect, it differs somewhat from
other activities carried on within the VA Medical Research
Program and supported form research funds (Program 8200).

	The specific objective of the Radioisotope Program has
been, and is, to employ radioisotopes within selected
hospitals of the Veterans Administration, (a) in medical
research, (b) in clinical diagnosis, and (c) in the medical
treatment of veteran patients.  Here again the Radioisotope
Program differs somewhat form other activities supported
form research funds in that it includes activities involving
clinical diagnosis and treatment as well as research.  as a
matter of fact, in the larger and more active Radioisotope
Units perhaps as much as one-half of their energies are
expended in clinical diagnosis and treatment, particularly
the former.

	Radioisotope laboratories are established only in VA
hospitals  having affiliation with medical schools.

	The Atomic Energy Commission has established certain
criteria and standards of health protection, not only for
the patients receiving radioisotopes, but as well for
individuals who work with, or might be inadvertently exposed
to, radioisotopes.  These requirements are strictly observed
within the VA Radioisotope Program.

	Certain policies recommended by the Central Advisory
Committee on Radioisotopes and established by the Chief
Medical Director have been established and compliance
therewith is a firm requirement within all VA hospitals
where radioisotopes are employed.  These include:

	a.  medically sound policies and practices with respect
to all human applications of radioisotopes

b.  sound policies and practices with respect to
radiological safety, including appropriate technical and
administrative requirements and a radiological safety plan
formally drawn up and approved by the Radioisotope Committee
and the Chief, Radioisotope Section

c.  sound, conservative policies and practices with          
respect to both publicity and public relations,

d.  supervision of the radioisotope program within an
individual VA hospital by a Radioisotope Committee
representing the Deans Committee affiliate with that
hospital.

	As a statement of principle, it is maintained that a
conservative stand should be taken with respect to the
position of radioisotopes in medicine within all VA
hospitals in which radioisotopes are employed.  This is
particularly true in respect to treatment.  The situation is
very much more encouraging believed, however, that the main
contribution that radioisotopes can make to medical care
will be as a tool in biological and medical research.

	With in VA Radioisotope Program, radioisotopes may be,
and are, investigations.

	The Radioisotope Program Complements but does not
duplicate, or take the place of, the program conducted by
the Atomic Energy Commission.  This agency has no means
whereby it could provide either the research or clinical
services involving the use of radioisotopes that are
required within the Veterans Administration, nor does any
other agency of government.

	The Radioisotope Program, as an integral part of the
over-all Medical Research Program of the Veterans
Administration, augments and extends the accomplishments of
the research program within VA hospitals.  It is closely
integrated with the medical research programs within these
hospitals.  Insofar as practicable, radioisotope
laboratories have been placed in close proximity to the
medical research laboratories within an individual hospital.

	Because of the unique requirements associated with the
employment of radioisotopes within hospitals, particularly
in a large hospital program such as that of the Veterans
Administration, a much greater degree of central control is
needed than is required in the other medical research or
clinical investigation programs.

	Radioisotopes may be used only in VA hospitals for
which the Chief Medical director, upon recommendation of the
central Advisory Committee on Radioisotopes, has
specifically authorized the establishment of a radioisotope
Unit.

	Within a VA hospital in which there has been
established a radioisotope unit, there is freedom of use of
radioisotopes provided, (a) applicable requirements of the
Atomic Energy Commission and of the Veterans Administration
are observed, and (b) such use has previously been approved
by the Radioisotope Committee appointed to represent the
deans Committee in the supervision of the Radioisotope
Program within that particular VA hospital.

	In general, the same policies and principles pertaining
to the Medical Research Program, as described earlier in
this presentation, are applicable to research involving the
use of radioisotopes.

	During the first four years of the program,
representatives of all VA radioisotope units met twice
yearly in a working conference intended to provide exchange
of information concerning intended to provided exchange of
information concerning, (a) administrative matters, (b)
scientific and technical matters unique to the employment of
radioisotopes, (c) the planning, organization, and conduct
of research with radioisotopes, and (d) the results of
research work and clinical investigations in which
radioisotopes were used.

ORGANIZATION AND ADMINISTRATION WITHIN CENTRAL OFFICE

GENERAL STATEMENT

	The Special Assistant for Atomic Medicine serves as
Chief, Atomic Medicine Division.  He is responsible for the
over-all administration of the VA Radioisotope Program and
for its coordination within the professional services.

RADIOISOTOPE SECTION

	The Radioisotope Program is administered throughout 
the Radioisotope Section, Atomic Medicine Division, Research 
and Education Service.  The Chief, of those matters with 
which the administrative divisions within a VA hospital are
concerned.

	The Radioisotope Section is assisted, both in an
advisory capacity and in a service capacity, by the Central
Advisory Committee on Radioisotope Section.  The members
also serve as special consultants to the Radioisotope
Section.  Three members also serve as special consultants to
the hospital programs within certain regions.  These are,
(a) Eastern United States, Dr. Shields Warren, (b) Central
United States, Dr. Hymer Fridell; and (c) Western United
States, Dr. Stafford Warren.  Obligations incurred in
connection with these services, and those of other special
consultants in atomic medicine, amount to $10,000 annually.

	The Radioisotope Section provides assistance and
support to the Radioisotope Units, (a) in professional,
scientific, and technical matters, (b) in administrative
matters (personnel, finance, budget, supplies, and
equipment, construction, etc.), (c) in program analysis, (d)
in dissemination of information gained from semi-annual
progress reports submitted by the Radioisotope Units, (e) in
serving as a medium for exchange of information, and (f) in
providing a wide variety of advisory services.

	To assist the VA hospital in initiating and
administering a radioisotope program, certain aids have been
prepared by the Radioisotope Section and are provided to the
Deans Committee and the Manager of the hospital concerned. 
These include, (a) "Suggestions for Planning and Initiating
a Radioisotope Program with in a VA Hospital", (b)
"Suggestions as to Plan of Organization and Operational
Procedures of a Radioisotope Unit within a VA Hospital ",
(c) "Suggestions as to Supply and Equipment Operations for a
Radioisotope Unit", and (d) "List of Initial Supplies and
Equipment for Radioisotope Units".  These have proven to be
most helpful to those concerned with the development and
administration of the radioisotope programs within the VA
hospitals having radioisotope units.

	The Radioisotope Section has also planned, organized,
and administered a program designed to train VA personnel to
serve as monitors and monitor leaders in the radiological
safety aspects of civil defense.  to accomplish this, in the
summer of 1949, the section also prepared for, and provided
to, the VA hospitals a training guide under title, "Training
Plan for Course in Radiological Defense (Monitors)".  By the
summer of 1950 within VA hospitals having Radioisotope
Units, more than 400 VA employees, other than physicians,
dentists, and nurses, had received the training.

	The Radioisotope Section, in 1950, cooperated with the
Federal Civil Defense Administration in preparation of
"Health Services and Special Weapons Defense" (AG-11-1).

	The Radioisotope Section, in 1951, assisted in the
preparation of two manuscripts which were reproduced and
widely distributed by the Council on National Emergency
Medical Services of the American Medical Association.  The
were:  "Planning and Organizing for Radiological Defense in
Civil Defense", and, "Training Plan for Courses in, (a)
Medical Aspects of Radiological Defense, (b) Medical Aspects
of Atomic Warfare, and (c) Radiological Defense (Monitors)". 
These were modifications of manuscripts already prepared for
use within the Veterans Administration.

RADIOISOTOPE UNIT

	The organizational element within the VA hospital
concerned with the use of radioisotopes is the Radioisotope
Unit.  It is under the immediate supervision of a director
who is a physician qualified in the use of radioisotopes as
well as in the field of clinical medicine and medical
research.  the director is appointed with the approval of
the Chief Medical Director.

	The director is assisted in an advisory and a
supervisory capacity by the Radioisotope Committee
representing the Deans Committee of the hospital.  The
duties of this committee are:

	a.  advise the Manager as to policy in regard to        
	radiological safety, public information, and            
	public relations

	b.  make recommendations as to the qualifications,
	appointment and employment of professional,
	scientific, and technical personnel required in  	
	the unit, including the director and all 
	consultants to the unit

	c.  review and, if approved, recommend proposed         
	research activities involving radioisotopes, and        
	proposed clinical uses of radioisotopes, and


	d.  review, and when appropriate, approve, (1) such     
	papers as may be proposed for publication, and (2)      
	such exhibits as my be proposed for presentation        
	before scientific groups when either involves the       
	use of radioisotopes.

	Membership on the Radioisotope Committee is not limited
to members of the Deans Committee.  Members may not be full-
time employees of the Veterans Administration.  Usually the
members are qualified individuals within the teaching staff
of the associated medical schools or universities.

	Consultants may be professional, scientific, or
technical personnel and need not necessarily be physicians.

	Within the VA hospital and laboratories, the director
is responsible, (a) for the administration of the
Radioisotope Program, (b)for the human application of
radioisotopes, and (c) for all radiological safety measures.

	The Director is assisted by three principal assistants
as indicated in the accompanying organization chart.

	As a rule, the Radioisotope Unit is organized in this
manner:

			DIRECTOR

ASST. DIR.		ASST. DIR.		ASST. DIR.
RAD. SAFE&		SCIENTIFIC		CLINICAL
ADM. MATTERS							


SECRETARY 	SCIENTIST	TECH.	TECH.	TECHNICIAN
                                                 CLINICAL


	The Director and the Assistant Director (Clinical are
physicians employed under Department of Medicine and
Surgery.  They are not paid form research funds (Program
8200).  The others are employed under regulations of the
Civile Service Commission.  They are paid from Research
funds (Programs 8200).  Only citizens of the United States
may be employed in any of these positions.

	Of funds made available for the Radioisotope Units, 80
per cent is utilized for the payment of salaries of the
scientist and technical personnel, other than physicians,
dentists, and nurses, 5 per cent for consultants and 15 per
cent for supplies and equipment.

SCOPE

         The scope of the Radioisotope Program includes:

	a.  Employment of radioisotopes in medical research 
in a great variety of applications in the broad field of 
medical research.  Special attention has been give to
study of (a) thyroid function, (b) diseases, and
disorders of the thyroid gland, (c) metabolism, (d)
cardiac function, (e) peripheral vascular disease (f)
electrolyte balances, (g) blood volume determinations, 
(h) hemodynamics of cardiovascular system, and (i) etc. 
 
	b.  Clinical diagnostic procedures have been 
developed and are employed in a variety of conditions 
including (a) practical diagnosis of hyperthyroidism and
hypothyroidism, (b) the location and diagnosis of
metastatic carcinoma of the thyroid, (c) diagnosis and
localization of brain tumors, (d) determining pumping
efficiency of the heart, (e) peripheral vascular
function, (f) blood volume determinations, and (g) skin
grafts, etc.

	c.  Treatment of (a) toxic hyperthyroidism, (b)
carcinoma of thyroid and metastases, (c) leukemia, (d)
polycythemia vera, (e) carcinoma of testicle, (f)
carcinoma of the prostate, (g) certain tumors by
(interstitial infiltration), and (h) basal cell
carcinoma of the skin.

OUTSTANDING ACHIEVEMENT

	Outstanding technical achievements have been (a) the
application of scintillation counters in clinical diagnosis
and treatment as well as in medical research, (b) the
application of the texas well counter to medical research
uses and (c) the development of the automatic "Scanner" for
making "scintigram"
tracings of the outline of the tyroid gland and of brain
tumors.


PART III

VA PROSTHETICS AND SENSORY AIDS RESEARCH PROGRAM

INTRODUCTION
  
	Faced with considerable numbers of individuals who 
had suffered amputations in active service during World 
War II, the War Department turned to the National Research 
Council for assistance in the rehabilitation problems of these
individuals.  there was established then in 1947 through the
National Research Council, a Committee of Artificial Limbs,
supported first by the Office of the Surgeon General and
later the Veterans Administration, to outline a continuing
program of research and development in this field.

	The purpose of this program has been to develop
improved prosthetic and orthopedic appliances and sensory
aids, exclusive of dental prostheses, and includes the
practical utilization of these devices by veteran patients. 
The aim of the program is to conduct research and
development of new and improved prosthetic and orthopedic
appliances and sensory aids and to afford an opportunity for
the testing and fitting of these devices so that the
problems of successful utilization may be understood and
surmounted.  there exists a large number of disabled
beneficiaries (most recent estimate - 257,500) who, under
federal statutes, will remain permanently entitled to
prosthetic and sensory aids and unless the Veterans
Administration conducts an active prosthetics research and
development program in this field, the interest of veteran
individuals who are handicapped and disabled will not be
served to the best advantage.

AUTHORITY 

	Public Law 729, 80th Congress, gives specific
authorization for the Prosthetic and sensory Aids Research
Program, and authorizes the appropriation of up to
$1,000,000 annually for this purpose.

ORGANIZATION AND ADMINISTRATION

	The Prosthetic Research Program is coordinated with
other Veterans Administration medical research and is
administered as to financial and contractual matters by the
Assistant Chief Medical Director for Research and education. 
The program is developed, planned, and supervised, however,
by the Director, Prosthetic and Sensory Aids Service,
Central Office.
SUBJECT TO APPROVAL AT NEXT MEETING

NOT FOR PUBLICATION

NATIONAL ACADEMY OF SCIENCES-NATIONAL RESEARCH COUNCIL

Division of Medical Sciences  

MINUTES OF THE COMMITTEE ON VETERANS MEDICAL PROBLEMS

29TH Meeting - 20 April 1954

ATTENDANCE:

Committee:                  Dr. Wilburt C. Davison, Chairman
			    Drs. J. E. Finesinger, A. McGehee
			    Harvey Esmond R. Long, Perrin H.
			    Long, Herbert *** Marks, and H. 
			    Houston Merritt.

			    Absent:  Drs. M.E. Debarkey, A. 
			    LeRoy Johnson, Donald Mainland, 
			    and J. Roscoe Miller.

Veterans Administration:    Drs. George M. Lyon, Martin 
			    Cummings, Theodore B. Moise, Robert 
  			    E. Stewart, and Augustus Thorndyke.


U. S. Army:		    Dr. Ardie Lubin, Psychology
			    Department, Army Medical Service   
			    Graduate School, Walter Reed
			    Hospital.

Selective Service System:   Lt. Col. Clark Young

Bio-Sciences Information
Exchange:  		    Drs. Stella Deignan and Harley N. 
			    Gould

National Research Council:  Drs. R. Keith Cannan, Philip
			    S. Owen, G. W. Beebe, Thomas
 			    Bradley, B. M. Cohen, J. O.
			    Cole, Seymour Jablon, Edgar M.
			    Neptune, Jr., and L. H. Warren.

	The meeting was called to order at 10:00 a.m. by the
Chairman, Dr. Wilburt C. Davison.

I.  Consideration of the Minutes of the Previous Meeting

The minutes of the previous meeting were approved without
change.

II.  Some Results of the Artificial Lime Program

	Dr. Augustus Thorndyke, Acting Director, Prosthetics
and Sensory Aids Service of the Veterans Administration,
briefly described the VA prosthetics research program.  (See
Appendix I.)  Dr. Thorndyke mentioned that the work is
primarily contractual but that the devices are evaluated in
30 VA centers by orthopedic and prosthetic appliance teams. 
this talk was illustrated by a display case containing old
and new upper-extremity prostheses.  Two amputees
demonstrated upper- and lower- extremity prostheses.  the
upper-extremity, above-elbow prosthetic was manipulated by a
plastic hook attached to a grafted pectoralis major muscle
tunnel.  this muscle, according to the demonstrator, is
capable of developing a maximum power of 100 pounds.

APPENDIX VII	BULL.CVMP - Page 662

TABULATED SUMMARY FROM ANNUAL PROGRESS REPORTS OF
RADIOISOTOPE UNITS 

On December 31, 1953, there were 33 Radioisotope Units
either established or in process of activation.  Of these 22
were actually using radioisotopes to varying degrees.  The
others were procuring equipment and personnel and several
have received their first allocations of radioisotopes since
January 1, 1954.

On duty in the Units at the end of 1953 were:

Full time physicians, under DM&S		 	29
Full time Civil Service employees		       173
Residents assigned for part time 			17
Consultants rendering services			 	65
Others (on grants, etc.)				11

The work of the Units may be summarized under three
headings, with summarized totals which are approximate:

1.	RESEARCH

Active research studies under way			211
Articles published in journals during year 		 85
Articles accepted for publication later			 51
Lectures and other presentations to groups
other than VA staff meetings				169

2.  DIAGNOSIS EMPLOYING RADIOISOTOPES

Thyroid uptake studies, varying 
techniques & times			6279 studies, 4551 patients
Thyroid clearance studies			       699
Thyroid scanning procedures			       788
Protein-bound iodine determinations		      1055
Thyroxine synthesis rate determinations		       443
Blood volume determinations using human
serum albumin, or P-32				       457
using Cr-51, (red cell volume)		      	       537
Radiocardiographs					 4
Circulation time studies			       109
Peripheral vascular studies		 	       208
Studies using Fe-59 (red cell survival, etc.)	       167
Brain tumor localization			       180
Scanning for liver metastases, pyelograms, etc.	       129
Miscellaneous diagnostic procedures		      1812	      
              

3.  THERAPY USING RADIOISOTOPES

Polycythemia vera			    62 doses to 48 patients
Chronic leukemia 
(lymphatic or myelogenous)		    111		42
Thyroid carcinoma			     89		25
Hyperthyroidism				    329	       271
Thyroid ablation for cardiac disease	     50		32
Prostate carcinoma			     19		19
Pleural effusion by radiogole collid	     46		42
"    	  "	     chromic radiophosphate  18		13
"	  "       Yttrium-90 colloids	     16		11
Radiogold interstitially		      5		 5
Chromic radiophosphate interstitially	     74		74
miscellaneous therapeutic procedures	     25