© 2003 American Thoracic Society
A Respiratory Physiologist by Hook or by CrookMeakins-Christie Laboratories, McGill University, Montreal, Quebec, Canada Correspondence and requests for reprints should be addressed to: Dr. Joseph Milic-Emili, McGill University, Meakins-Christie Laboratories, 3626 St. Urbain Street, Montreal, QC, H2X 2P2 Canada. E-mail: joseph.milic-emili{at}mcgill.ca The article "Improved Technique for Estimating Pleural Pressure from Esophageal Balloons" (Milic-Emili J, Mead J, Turner JM, and Glauser EM. J Appl Physiol 1964;19:207–211) provided the standard method for measuring esophageal pressure. How did it happen that I became a world expert in this area? Through a misunderstanding! By hook or by crook! To explain the background of the 1964 article, I need to step back in time to 1955. After obtaining my medical degree in 1955 at the University of Milan, Italy, I joined the Department of Physiology of that institution because I liked "the class and style" of Professor Rodolfo Margaria, who was a world-renown expert in exercise physiology. At that time, he was also one of the few physiologists who used diagrams and mathematical formulas in data analysis. The first project that Margaria assigned to me was to assess the relationship between ventilation and tidal volume during recovery after exercise in normal subjects and athletes. With my colleague F. Cajani, we showed that the relationship was not linear. To underline this point, we constructed an elegant diagram (including isopleths and power functions!) according to the precepts of Margaria. To our astonishment, he did not like our analysis, reflecting the propensity of senior investigators for straight lines, and found a more accommodating young investigator who produced linear relationships in both trained and untrained subjects. After this experience, Cajani abandoned physiologic research and became a prosperous dentist. In spite of my precarious situation, I persisted. In fact, I benefited a lot from this experience, although our results were published only in abstract form. Indeed, our analysis was the object of my first communication at a meeting. To my great surprise, my presentation was highly praised. Only later did I realize that my success was due to the fact that I presented my results in classical "Margarian" style, including isopleths and mathematical formulas. This was the legacy of Margaria, who taught me to present results in a clear and concise fashion. Good presentation is fundamental. In fact, one of the greatest respiratory physiologists, Hermann Rahn, gave me this advice: "Milic, when you are at a seminar, pay more attention to the good points in the presentation than to scientific aspects. For the latter, read the relevant publications." Our analysis of the relationship of ventilation to tidal volume was rediscovered in 1966 and is now known as the "Hey Plot." After my "nonlinear" fiasco, Margaria assigned a new project to Dr. Manzotti and me. One day Margaria came to our laboratory (such visits were rare and were usually the portent of bad news) and said that within 2 months a Belgian physiologist, Dr. Jean-Marie Petit, was coming to our laboratories "to learn how to measure esophageal pressure." I responded that such measurements had not been done in Milan and that we did not have esophageal balloons. My colleague added that we did not have pressure transducers. Margaria curtly said this to him: "You build a transducer!" He next said this to me: "You make the balloons." We promptly set out to do as ordered. On arrival of Dr. Petit, a pressure transducer had been constructed by Dr. Manzotti, but it had such a baseline drift that it was useless. My task had been simpler because I had a high school friend who worked for Pirelli S.p.A., the tire manufacturers. He told me that Pirelli was assessing the feasibility of manufacturing condoms, and for this purpose, a small laboratory had been opened near Milan. He phoned the director of this unit who was extremely nice and helpful: together with normal condoms, he manufactured the minicondoms that we were going to use as esophageal balloons. The employees of that laboratory, mainly young women, kept asking me with merriment who was going to use the minicondoms. At any rate, by the arrival of Dr. Petit, I had the best esophageal balloons that I have ever seen. At this point, I should stress that in Milan not only the esophageal balloon technique had never been used but also that respiratory physiology had never been studied. It was an exercise physiology laboratory! Thus, through a misunderstanding between Margaria and Petit, I became involved in my first study of respiratory mechanics (incidentally, Margaria never told me why he invited Petit to Milan). Dr. Petit was a very capable individual, in fact he was the best experimentalist that I have ever met. He immediately gauged our level of expertise in respiratory mechanics and made contingency plans for his 3-month stay in Milan. Because we had only a water manometer, our measurements of esophageal pressure had to be confined to static conditions. We chose to measure the static elastance of the esophagus using Pirelli balloons of different diameter and length, positioned at different levels of the esophagus. This study, which was published in 1958 in the Journal of Applied Physiology (Petit JM, Milic-Emili G. Measurement of endoesophageal pressure. J Appl Physiol 1958;13:481–485), allowed us to determine the "optimal" operating length and circumference of the esophageal balloon and to assess the error introduced by the esophageal elastance in measurement of pleural pressure. This experience converted me into a passionate "methodologist" and was the kernel for my life-long interest in developing new techniques. Furthermore, I learned the advantage of being poor because "necessity is the mother of all invention." In fact, most of the new methods and approaches that I have developed are basically very simple and cheap (e.g., mouth-occlusion pressure, closing volume, detailed analysis of breathing cycle). The 1958 article had another important impact on my life, as described later here. Dr. Petit, who became a close friend, invited me to join his laboratory in Liège, Belgium, which was very well equipped for studies of respiratory mechanics. Together, we published a large number of articles in this field. In Liège, we continued to operate according to the motto that "necessity is the mother of all invention." In fact, we started measuring the electrical activity of the diaphragm by inserting a long needle through the chest wall into normal human volunteers (sic!). Not surprisingly, after a few successful attempts, we induced a pneumothorax in one of our volunteers—the son of the dean of the medical faculty of Liège. After this failure, out of necessity, we promptly developed the method to measure the electrical activity of the diaphragm via electrodes attached to a catheter, which was introduced through the esophagus to the level of the cardias. During the 1957–1959 period, I was commuting between Liège and Milan, having the benefit of Margaria, a great theoretician, and Petit, a supreme experimentalist. In addition, for the first time in my life, I was well paid, being an assistant professor in Milan (poor pay) and an assistant professor in Liège (good pay). In addition, I became the assistant inspector for mental disease in the Belgian province of Vallonie (very good pay). Dr. Petit was the chief inspector. Our task was to reconfirm every year that mental patients were still ill (and alive!) by visiting all of the town halls of Vallonie, where the patients and mayor were assembled. Dr. Petit would see the patients, and I would put an official stamp on a document. Although I was very happy in Liège, my wife Ann, who is a Londoner, and wanted to live in a large anglophone city, asked me to get a job in such a place. Although I had no inclination to move because of professional and financial reasons, to show my good will, I wrote a letter to Dr. J. Mead at Harvard, a great respiratory physiologist, asking if there were any positions available. Actually, I did not send a real CV because I did not want to move from Belgium. To my surprise, a job offer came almost immediately: Through a fortuitous coincidence, he was one of the two reviewers of our 1958 article, and he liked it! I was soon on my way to Boston, where with Dr. Mead and his group we published the 1964 definitive article on measurement of esophageal pressure. Without noticing it, in Boston, I completed my scientific apprenticeship and became part of the history of mechanics. What did these events teach me? First, that working with exceptional individuals is immensely beneficial. Second, if you listen to "how they say it," you improve your communication skills. Class and style are part of it. Third, although in line with Margaria, I have tried to fit an explanatory equation through the main events of my formative years in research, but I can fit neither a straight line nor a smooth curve to connect these events. Instead, my progress was "by hook or by crook" quite the opposite of the orderly progression expected from young investigators by research grating institutions. All the time, my research was governed by an inborn "rage for order," namely to produce concise formulations out of apparently disorderly arrays of data—stating it more pompously, like making music out of notes. In the last analysis, however, I will conclude with the words of Aldous Huxley (1894–1963): It is a bit embarrassing to have been concerned with the human problem all one's life and find at the end that one has no more to offer by the way of advice than "try to be a little kinder." This article has been cited by other articles:
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