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JOHN RODMAN PAUL
April 18,1893-May 6,1971
BY DOROTHY M. HORSTMANN AND
PAUL B. BEESON
JOHN PAUL was born in Philadelphia, Pennsylvania, the third
child in a family of eight. His father was Henry Neill Paul,
and his mother had been Margaret Crosby Butler of Yonkers,
New York. The Pauls trace their ancestry to Joseph Paull of
Illminster, England, who emigrated to this country in 1685,
settling with William Penn's Quakers in Philadelphia. On his
mother's side, John was a descendant of Theophilus Eaton, the
first governor of Connecticut, and of Benjamin F. Butler,
Andrew Jackson's attorney general. His maternal t,randfather
was William Allen Butler, an eminent lawyer and poet.
John's father was also a lawyer and a man of broad scholarly
interests. He loved Shakespeare and Elizabethan drama, was
Dean of the Philadelphia Shakespeare Society for many years,
and published a number of Shakespeare commentaries as well
as The Royal Play of Macbeth, a scholarly analysis of the origins
of the play. His interests were also in natural history. In the
1880s, while at Princeton, he had taken part in expeditions to
Montana for geological and paleontological explorations. His
accounts of these trips fascinated John, who later counted them
as a major factor in awakening his interest in science at a very
early age.
This interest was further encouraged when the Paul family
settled in Chestnut Hill, then an open suburb of Philadelphia,
323
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324
BIOGRAPHICAL MEMOIRS
with woods, streams, and fields where the Paul children could
roam and bring home to their family museum minerals, butter-
flies, birds eggs, and even Indian arrowheads. Summers were
spent at Beach Haven on the New Jersey shore, and shells and
sea specimens were also added to their collections. A love of
the out-of-doors was a deep and sustaining influence throughout
John Paul's life, as well as the source of many of his hobbies—
bird watching, archeology, wood carving, building stone walls,
watercoloring, and photography, etc. It was also responsible
for his being an active and articulate conservationist as early as
the 1930s, long before the need for preservation of the environ-
ment became a popular cause.
As a child, John is said to have been reserved, rather shy, but
with a strong humorous streak. He had stamina and energy but
was not robust, so to improve his health he was sent to New
Hampshire at age eleven, where he was tutored and spent much
time out-of-doors during the winter before entering St. George's
School, in Newport, Rhode Island. The six years at St. George's
were important and happy ones: he was an outstanding student
and won many scholastic prizes in Latin, Greek, and history.
He became editor of the school magazine, manager of the foot-
ball team, and coxswain of the school crew.
In 1911 John entered Princeton. At first he led a relaxed
and carefree life there without any particular scholarly focus—
until he came under the influence of Edwin Grant Conklin,
professor of biology. Conklin was the kind of professor who lit
fires under his students; from then on John took off scientifically
and spent as much time as possible in the laboratory. Still he
lived a full life at Princeton: he was very popular in his class,
was an editor of the Princeton Tiger, a member of the Ivy Club,
and manager of the crew and sometimes its coxswain.
The decision to study medicine came about through associa-
tion with Cecil Drinker, one of John's heroes at the time and
subsequently Dean of the Harvard School of Public Health.
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JOHN 1tODMAN PAUL
325
The Paul and Drinker families had been neighbors and close
friends during summers at Beach Haven, where Cecil had
taught John to sail the Drinker's yawl. Cecil's younger brother,
Philip, and John were the same age and became fast friends.
Later they roomed together all through St. George's School and
Princeton. During the Princeton years, Cecil, Philip, and John
sailed together in the summers and it was on these pleasant
cruises that Cecil persuaded John that he should go to medical
school. The advice was accepted, and after graduation from
Princeton in 1915, he enrolled at the Johns Hopkins Univer-
sity School of Medicine. His goal, he said in later years, was
"to be a medical scientist just like Cecil," rather than a prac-
ticing physician, the role his family had in mind for him. He
never swerved from his commitment to a career as an investi-
gator.
In 1917, when he was in his second year of medical school,
the United States entered World War I. In June, along with
thirty-one other medical students, Paul joined the Hopkins unit
as an enlisted man and sailed from New York in the first U.S.
convoy of World War I to head directly for France, carrying
combat and other troops—the vanguard of Pershing's army. The
major part of the army transport on which he found himself
was occupied by seasoned soldiers, and (as he wrote later) the
medical contingent "consisting of the Johns Hopkins Hospital
Unit, a hastily assembled and motley group of raw recruits,
occupied a place befitting their military experience—far astern
and deep in the bowels of the ship." After eighteen long days at
sea, often in submarine-infested waters, the overcrowded ships
finally reached St. Nazaire, where the men received a warm wel-
come from the French. The Hopkins unit went on by train to
Bazoille sur Meuse, where Base Hospital #18 was set up, well
back of the front line. John's assignments were as bacteriolog-
ical technician and substitute ambulance driver. The bac-
teriology laboratory was a valuable experience that apparently
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326
BIOGRAPHICAL MEMOIRS
had considerable influence in shaping his subsequent career.
His first duty was to determine the effectiveness of a new method
of treating wound infections by continuous irrigation with a
sodium hypochlorite solution devised by Dakin, an English
chemist. The mountainous task of doing daily smears and bac-
terial counts on swabs from the wounds of the many patients
who had infections with gas-forming bacilli eventually proved
dull work; and since the results did not prove to be helpful as
indicators of the course of infection, the study was finally aban-
doned. Driving an ambulance turned out to have greater re-
wards, which involved a month at St. Nazaire assembling Ford
ambulances (they arrived two in a box) and proudly driving the
finished products back to Bazoille.
After a year in France, Paul, his great friend John M. T.
Finney, Jr., and others of the students at Base Hospital-#18
were persuaded that they should return to Hopkins to complete
their medical education. By a fortunate stroke of fate, Paul
missed the ship on which he was scheduled to return—one that
was torpedoed and lost—and came through on another, which
sailed successfully from Brest to New York. Shortly after his
arrival in Baltimore, the 1918 influenza epidemic erupted and
the wards of the Johns Hopkins Hospital were filled with
desperately ill patients, many of them professors and staff mem-
bers. Apparently the wave of relatively mild respiratory illness
that had swept France in 1917 was the forerunner of the more
severe 1918 epidemic, and infection with the agent in France
conferred immunity on those who had had experience with it,
including John Paul. At that time he had had no clinical train-
ing but in the desperate situation was put to work on the wards
as a substitute intern, to care for the patients as best he could.
It was a harrowing ordeal, since the mortality rate was extremely
high. The helplessness of the physicians made a deep impres-
sion on the young Paul. As he wrote years later:
"Many were the nights I passed, making do with a few hours
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J OHN RODMAN PAUL
327
of uneasy sleep grabbed as best I could from a 20-hour day,
tossing and twisting and deciding that it would have been better
if the influenza patients had never come to the hospital. The
lessons we learned in those days were not how to treat patients
who had postinfluenza pneumonia with drugs, but rather how
to save their lives by preventing exposure on the isolation
wards by mixing them up with cases of tonsillitis and scarlet
fever. If the patients with influenza were kept by themselves
they had a far better chance of avoiding cross-infection with
pathogenic bacteria, especially the hemolytic streptococcus.
This was an epidemiological principle reminiscent of the days
of Semmelweis and puerperal fever." ~
Although his military experience caused him to miss his
third year of medical school, Paul graduated with the class of
1919. He immediately joined W. G. McCallum, professor of
pathology at Hopkins on a trip to Lima, Peru, where the sum-
mer was spent working on bartonellosis. The routine consisted
of doing autopsies at the hospital in the mornings and exploring
the city and its archeologic treasures in the afternoons.
On his return to Baltimore, John joined McCallum at Hop-
kins as an assistant in pathology. Two of his classmates, Arnold
Rich and Leslie Webster, did the same, and the three had a
lively and productive year in the laboratory. Paul's first con-
tribution to medicine was made during that year—a paper on
the histopathology of measles conjunctivitis. Thus his first work
dealt with a virus infection—a prophetic note since he devoted
most of the rest of his professional life to investigations in that
held.
The next two years were spent as an intern at the Pennsyl-
vania Hospital in Philadelphia. In 1922 he was appointed
Director of the Ayer Clinical Laboratory of the Pennsylvania
~ J. R. Paul, "A Clinician's Place in Academic Preventive Medicine: My
Favorite Hobby," Bulletin of the New York Academy of Medicine 47(1971):
1264 (hereafter cited as "Clinician's Place").
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328
BIOGRAPHICAL MEMOIRS
Hospital, a post that had previously been held by Dr. Warfield
T. Longcope. Activities during the six-year period at the Ayer
Laboratory resulted in papers on a variety of subjects dealing
with bacteriology and pathology, including the fir.c~ ones on
1 · ~ ~ · .
rheumatic fever, a disease that was to engage much of his at-
tention in the ensuing years. In fact, it was when he presented
a paper on the pleural and pulmonary lesions in rheumatic
fever at the clinical meetings in Atlantic City in the spring of
1928 that he was invited by Francis Blake, professor of medicine
at Yale, to join his department as an assistant professor. Thus
began Paul's long association with Yale—one that continued
until his death forty-three years later.
In the 1920s, the Yale Medical School was in the midst of a
renaissance under the dynamic leadership of Dean Milton C.
Winternitz. Winternitz had gathered together for the recently
created full-time faculty a stellar group of young clinician-
scientists, including among others Francis Blake, John P. Peters,
Grover Powers, and James Trask. According to Dr. Paul, they
were all "young, eager, and well trained men, imbued with the
idea of making the fulltime system work." He himself fitted
into this setting perfectly and within several years of his arrival
in New Haven had launched into several major pieces of work
that proved to be important landmarks in clinical investigation.
Among these were the studies of rheumatic families, the dis-
covery of the heterophile antibody (Paul-Bunnell) test for in-
fectious mononucleosis, and the demonstration that the com-
monest clinical expression of infection with polioviruses is not
paralysis, but the "minor illness" or "abortive" form of the
disease that is often so mild as to go unrecognized.
The seeds of the scientific philosophy that characterized his
later work at Yale, and in fact ran throughout his entire pro-
fessional life, were planted early in John Paul's mind—when he
was a second-year medical student. At that time he attended a
meeting of the Federation of Biological Sciences in New York
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JOHN RODMAN PAUL
329
City at which there was a lively discussion of the disastrous
epidemic of poliomyelitis that had raged in New York and New
England during the summer of 1916. In looking back on that
occasion, he wrote:
"I must have been a singularly impressionable young man
at the time, and I was certainly engrossed in watching and hear-
ing the words of these great men, who were engaged in recount-
ing their efforts to attempt to solve the problem of epidemic
poliomyelitis, applying the very weapons which we had been
taught to use in our first years at medical school. Dr. Simon
Flexner was in the chair; Dr. Peyton Rous was at his side
as secretary; and Hideyo Noguchi, who was there as a speaker,
was introduced as a man of mystery, one who could almost
turn lead into pure gold, or at least turn the virus of poliomy-
elitis into 'globoid bodies.'
"As a rapt listener, the idea first dawned on me that the
religion of the true physician was incomplete without having
the concepts of prevention thoroughly ingrained in him. This
was particularly true when it came to the prevention of such a
colossal tragedy as the 1916 epidemic. My immature reasoning,
which I never lost, was that, together with attempts to cure
this pestilence, there should be attempts to control it, and this
should be done by clinicians who knew the disease best. In
other words, this concept should radiate from the top physicians
and pediatricians." ~
Once these ideas had taken root, they were nourished by
Paul's experience during the 1918 influenza epidemic and grad-
ually flowered in the 1920s and 1930s as his concept of "Clinical
Epidemiology" developed and took form. In his presidential
address to the American Society for Clinical Investigation in
1938, he said:
"The term, Clinical Investigation in Preventive Medicine,
~ Paul, "Clinician's Place," p. 1263.
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BIOGRAPHICAL MEMOIRS
is cumbersome and so I will not use it.... It presupposes the
existence of a so-called sister science, Curative Medicine....
Clinical Investigation in Epidemiology is better for the pur-
poses at hand; Clinical Epidemiology is best, and really what
I mean.... It is a science concerned with circumstances, whether
they are 'functional' or 'organic' under which human disease
is prone to develop. It is a science concerned with the ecology
of human disease. It must face the question of 'why' as well
as 'how'. Clinical Epidemiology differs, therefore, from the
orthodox science of Epidemiology, both in its aim, and its
locale, as it were. The orthodox epidemiologist must of neces-
sity deal dispassionately with large groups of people. It is the
multiplication of observations which give him his results. The
clinical epidemiologist, on the other hand, must of necessity
deal with small groups of people; people whom he knows well
and groups no larger than a family, or small community. The
restriction of the size of the group rests on the fact that clinical
judgment cannot be applied wholesale, without the risk of its
being spread too thinly to be effective.... The clinical epi-
demiologist, . . . starts with a sick individual and cautiously
branches out into the setting where that individual became
sick, the home, the family, and the workshop. He is anxious to
analyze the intimate details under which his patient became
ill. He is also anxious to search for other members of the
patient's family, or community group who are actually, or
potentially, ill. It is his aim to thus place his patients in the pat-
tern in which he belongs, rather than to regard him as a lone
sick man who was suddenly popped out of a health setting; and
it is also his aim to bring his judgment to bear upon the situa-
tion, as well as on the patient.
"Obviously there is nothing new to the family doctor about
this concept of Medicine. It is the heart and soul of family
practice and probably has been as long as family practice has
existed. But now that the emphasis has shifted away from the
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JOHN ELODMAN PAUL
331
home and into the Hospital or Dispensary, clinical epidemiology
will be practiced only if we take thought about it." ~
Dr. Paul never cared for the term "Preventive Medicine,"
although eventually his professorship and his section at Yale
used this terminology. He regarded it as "too boastful, too
suggestive that great things might be just around the corner."
His belief was that the focus should be on the teaching of the
underlying principles of prevention, i.e., epidemiology. In
championing these concepts he was perhaps ahead of his time,
but in the past decade his pioneering efforts have begun to bear
fruit. The best possible support is provided by his own achieve-
ments in which he combined so successfully the study of certain
diseases: at the bedside, in the laboratory, and in the natural
setting in which they developed.
In the New Haven Hospital in 1928 rheumatic fever was a
common disease. Paul took advantage of the opportunities this
situation provided and turned his attention to unraveling the
epidemiology of the disease. His focus was on rheumatic fever
in families and the factors involved in its spread. Many of the
social and environmental aspects were explored through in-
timate, long-term studies over an eight-year period of all mem-
bers of 122 rheumatic families and suitable control families.
When he began his studies, the role of the hemolytic strepto-
coccus was not yet appreciated, but based on his observations
Paul concluded that respiratory infection of some kind pre-
cipitated the acute attack. While not the first to suggest a
relationship between the hemolytic streptococcus and rheumatic
fever, it is fair to say that the book he published in 1930, The
Epidemiology of Rheumatic Fetter, and particularly the second
edition in 1943, set forth the evidence for a causal relationship
in such a way that there was never any further question about it.
it J. R. Paul, "Clinical Epidemiology," Journal of Clinical Investigation
17(1938) :539~1.
t Paul, "Clinician's Place," p. 1267.
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BIOGRAPHICAL MEMOIRS
It was in the course of serologic investigations of patients
with rheumatic fever that the heterophile antibody test for in-
fectious mononucleosis was discovered. This came about when,
having confirmed the observation made by Davidson in 1929
that agglutinins to sheep cells are present in the sera of patients
with serum sickness, Paul raised the question whether such
heterophile antibodies might not also be present in rheumatic
fever since there were similarities between the symptoms of the
two diseases. The results with sera of rheumatic patients were
negative, but quite by accident, among the control specimens
from patients with serum sickness and various other acute ill-
nesses, there was one with an extraordinarily high titer higher
than had ever been described in serum sickness or any other
clinical condition. The patient from whom the specimen
came was a medical student with infectious mononucleosis.
Gradually over the ensuing months several other patients with
this disease were also found to have high heterophile antibody
titers, while tests on some 275 controls gave consistently negative
results. In 1932 Paul and Bunnell, a medical resident who col-
laborated on the project, published their findings. The test,
which is still sometimes referred to as the Paul-Bunnell test, re-
mains today as the chief laboratory method in the diagnosis of
infectious mononucleosis.
The first investigations of poliomyelitis, the disease on
which Paul's main work was subsequently concentrated, also
began early in the 1930s. In Middletown, Connecticut, twenty-
six miles from New Haven, a small epidemic occurred in 1930.
Paul and his colleague lames Trask were struck by the wide
range in severity of the disease. Some suspected cases not only
did not have paralysis, but had little or no neck stiffness. Were
these also infections with the virus of poliomyelitis? The fol-
lowing year, New Haven experienced a sharp epidemic and the
opportunity to answer this question by attempting to isolate
the virus presented itself. Characteristically, Paul and Trask
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J OHN RODMAN PAUL
359
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1951
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~ ~ <~_- v ~ ~ _ - ~ ^~ ~ ~~111C4~.
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~ ~ it, ~ ~ , ~ _. ~ an, ~ ,, ~ ,, ~
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1958
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Representative terms from entire chapter:
biographical memoirs
