E Dr. Warfield Monroe F i r o r Discusses William S. Halsted Walter E. Dandy and I- Dean D. Lewis'" :;: Comments About the S u r g i c a l Chiefs a t the Johns Hopkins Hospital Between 1918 and 1938, an unpublished paper by D r . Firor bound with t h e two interviews. PREFACE , D r . Warfield Monroe Firor (1896- ) of Baltimore, Mary- land has been i n t i m a t e l y involved with t h e Johns Hopkins Medical I n s t i t u t i o n s since he entered medical school i n 1917. He has been connected with t h e Department of Sur- gery of t h i s i n s t i t u t i o n since 1921 and h i s i n t e r n e s h i p on the s u r g i c a l service of D r . William S. Halsted. His close t i e s with the Johns Hopkins Department of Surgery through the years a s w e l l a s h i s important and respected r o l e with t h e American Board of Surgery and t h e Confer- ence Committee on Graduate Training i n Surgery make him uniquely q u a l i f i e d t o d i s c u s s and evaluate t h e c o n t r i - butions of men l i k e D r . William S. Halsted, D r . Walter E. Dandy, and D r . Dean Lewis. (There i s no taped i n t e r - view d e a l i n g with Dr. Lewis, b u t a copy of an unpublished manuscript w r i t t e n by Dr. Firor t h a t d e a l s w i t h D r . Lewis i n depth i s bound w i t h the interviews on D r . Halsted and D r . Dandy.) These interviews were held i n D r . F i r o r ' s o f f i c e a t 1 E a s t T h i r t y - f i r s t S t r e e t i n Baltimore, Maryland on Feb- r u a r y 9 and 28, 1967. D r . F i r o r was candid i n h i s com- mentary b u t e l e c t e d t o speak of some c o n t r o v e r s i a l matters 2 !'off the recordf1 ( n o t taped). I n the opinion of t h e interviewer, he was f o r t h r i g h t , completely honest, and had a superb memory f o r p a s t events. Peter D. Olch, M.D. History of Medicine Division National Library of Medicine CURRICULUM VITAE of Warfield Monroe F i r o r Graduated Baltimore C i t y College 1913 A.B. Johns Hopkins University 1917 M.D. Johns Hopkins Medical School 1921 D. Sc. (Hon. ) , Western Maryland College 1957 Resident i n Neurosurgery, Johns Hopkins Hospital, 1923-25 Vt f f Surgery 1) !? st 1926-27 Acting Surge on-in-Chief O? tt %? 1939-41 On t h e teaching s t a f f , Johns Hopkins Medical School since 1922 Professor Emeritus of Surgery, Johns Hopkins University I V i s i t i n g Surgeon .....Johns Hopkins Hospital Church Home &(]Hospital Union Memorial Hospital S i n a i Hospital Maryland General Hospital, (Chief of Staff 1949-58) Member: American S u r g i c a l Association ( P r e s i d e n t 1963-64) Society of C l i n i c a l Surgery Southern S u r g i c a l Association American College of Surgeons 2 S o c i e t y of University Surgeons American Physiological Society Society f o r Experimental Biology & Medicine American Medical Association \ American Board of Surgery, 1945-51; (Chairman, 1949-51) Founder Member, Conference Committee on Graduate Training i n Surgery, 1951-57 I Baltimore C i t y Medical S o c i e t y Medical & C h i r u r g i c a l Faculty of Maryland (Chairman of Council 1952-55) I Consultant f o r China Medical Board i n Korea, 1957, 1-958, 1961 Consultant f o r Rockefeller Foundation, Nigeria, 1963 Faculty, Gilman School Elder, Franklin S t r e e t Presbyterian Church During World War 11, represented the American S u r g i c a l Association on the National Research Council f o r t h r e e y e a r s , and was on one of the committees which advised t h e Surgeons General. I n 1948, moved h i s o f f i c e from Johns Hopkins Hospital and went i n t o p r i v a t e p r a c t i c e . Has continued t o teach on part-time b a s i s , and has maintained h i s i n t e r e s t i n research. Has w r i t t e n e x t e n s i v e l y on tetanus; t h e hormones; and was the f i r s t t o work out methods f o r removing t h e hypophysis i n 3 monkeys and r a b b i t s . Introduced i n t e s t i n a l a n t i s e p s i s i n preparation f o r surgery of the colon. Has w r i t t e n over f i f t y a r t i c l e s f o r the medical l i t e r - a t u r e , and a few f o r t h e o l o g i c a l journals. D r . Warfield M. Firor Discusses William S. Halsted This i s an interview held with D r , l i a r f i e l d M, F i r o r of Baltimore, T4arylando The interview i s being held i n D r , Firor% office, The date i s February 9, 1967. The interviewer i s D r , P e t e r D, Olch of the National Library of Medicine. Dr. 0 , : I b e l i e v e we agreed t h a t today we would spend p r i m a r i l y speaking about Dr, Halsted, Before we begin I would l i k e t o ask you when you f i r s t came t o the Hopkins I n s t i t u t i o n s ? I understand that you went t o undergraduate school a t Kopkins as well as t o medical school. D r . F, : Yes, I entered the undergraduate school i n 1913, graduated f o u r years l a t e r and entered medical school i n the f a l l of 1917'0 D r , 0, : Your contact with Dr, Halsted was both as a medical sbudent and l a t e r as a house o f f i c e r , Ye20 PTy f i r s t c o n t a c t with him was as a 3rd year student i n his Friday c l i n i c , I n my 4 t h year I s u b s t i t u t e d f o r one 2 of the s u r g i c a l i n t e r n e s and had the p r i v i l e g e of being on the operating team with Dr. Halsted, Then I had m y s u r g i c a l i n t e r n e s h i p under him and was the l a s t m a n t o be kept on as a n a s s i s t a n t r e s i d e n t before he died. My f i r s t contact with the professor was i n the F r i d a y c l i n i c s which he aonducted throughout h i s e n t i r e professorship, They were very formal, He would come i n t o the amphitheatre accom- panied by the r e s i d e n t . The r e s i d e n t would c a l l two students down i n t o the p i t and introduce them t o Dr, Halsted, The p a t i e n t then would be brought i n 9 and we would see Dr. Halsted question this p a t i e n t about; the p a r t i c u l a r s u b j e c t t h a t he was i n t e r e s t e d i n and then examine t h e p a t i e n t , This indeed was impressive, because of the gentleness, thoroughness, and p r e c i s i o n w i t h which he conducted t h i s examination, Invari- a b l y he would then t u r n t o the s t u d e n t s and. ask them t o make t h e i r own examination, The p a t i e n t would be taken from the amphitheatre and nr. Ealsted would then begin t o question the two s t u d e n t s about what they had seen and f e l t and con- t i n u e the e n t i r e c l i n i c by the S o c r a t i c method. And no time d i d he make an e f f o r t t o l e c t u r e o r address the e n t i r e s t u d e n t body. A s a matter of f a c t , i f a student d i d n ' t happen t o be i n the f i r s t two or t h r e e rows, h@ wouldntt hear what the professor said. 3 This, I think, l a r g e l y r e f l e c t e d D r , H a l s t e d f s i d e a t h a t i t was impossible t o teach s u r g e r y d i d a c t i c a l l y , t h a t surgeons were trained, and his attempt t o teach t h e s t u d e n t s was s i m - p l y t o s e t an example, n o t t o impart a v a s t amount of s u r g i c a l knowledge . These c l i n i c s were extremely thorough and one might say severe, ?bny s t u d e n t s were a f r a i d t o be c a l l e d down, because t h e y were s u r e t o be cross-examined. b y the professor. A t no time was t h e r e any l e v i t y . Always before the c l i n i c was over9 D r , Halsted would. c a l l a t t e n t i o n t o the s t a c k of books t h a t had been brought i n before t h e c l i n i c began. Each book would ..T have the p e r t i n e n t reference marked, Many of t h e c l i n i c s d e a l t with fundamental aspects of physiology and- surgery. Occasionally t h e r e would be emphasis on the h i s t o r i c a l devel- opment of a s u b j e c t , b u t t h i s was c e r t a i n l y n o t t h e primary purpose of the c l i n i c , and one l e f t w i t h the impression t h a t he had seen a g r e a t gentleman, a very e r u d i t e scholar, and a very c a r e f u l teacher, A small p o i n t , D r , F i r o r , b u t were any of these t e x t s t h a t were brought i n t o the c l i n i c i n f o r e i g n languages? I n other word-s, d i d he expect t h e students t o be able t o r e a d French, German, e t c , ? 4 D r . F. : Quite r i g h t , Yes. Dr, 0, : This c e r t a i n l y i s a change from today, The medical s t u d e n t of today does n o t have the language proficiency, D r , F. : When we entered medical school, one of t h e requirements was a reading knowledge of French and ?German. I . D r , 0, : Yes, which I g a t h e r was t r u l y a requirement then and n o t a f i a s c o as i t w a s i n l a t e r years. Dr, F . A It was More of a requirement when I entered than i t was twenty years later, Ply n e x t contact w i t h D r , I-Ialsted was on the wards, About once a week he would make rounds w i t h the stuclents assigned t o t h e s u r g i c a l wards, There he showed the g r e a t e s t gentle- n e s s i n dealing with p a t i e n t s , Frequently he would dwell upon one p o i n t €or the e n t i r e hour i n order t o emphasize it, A t no time d i d I ever see him hurried. He followed wh.at the p o e t described as an unperturbed pace, 5 My l a s t contact with him while a student was when I s u b s t i - t u t e d for one of the s u r g i c a l i n t e r n e s and was p r i v i l e g e d t o scrub on the team, I remember one instance i n which Dr. Halsted d i d a b i l a t e r a l herniorrhaphy, It took 3 hours, Throughout t h a t operation he demonstrated those p o i n t s i n technique for which he became famous : meticulous handling of a l l t i s s u e s , accurate d i s s e c t i o n , complete hemostasis. 'idhat was most impressive was t h a t he d i d - n o t leave when the major p a r t of the operation was f i n i s h e d and t u r n over the closure of the wound t o the assistant, He himself closed t h e wound with the same care and thoroughness with which he had conducted t h e e n t i r e operation, Actually lie remained t o see t h a t the dressings were p u t on p r e c i s e l y as he wanted them, D r , 0, z GJas t h i s c h a r a c t e r i s t i c of his a t t i t u d e toward surgery throughout h i s career? D r , F. : I c a n f t vouch for what h i s a t t i t u d e was i n Wew York before coming t o Baltimore, C e r t a i n l y he became known for a t t e n - t i o n t o d e t a i l , f o r the gentle handling of t i s s u e , f o r complete hemostasis, f o r the use of f i n e s i l k , and above a l l f o r a t o t a l disregard of time, t 6 D r , 0. : I was thinking of the p o l i c y which s o often i s n o t followed today) t h a t once the major p o r t i o n o f t h e procedure was completed, he would s t i l l remain and would do t h e closure of the peritoneum and s k i n and s o on, D r , F. : I am c e r t a i n t h a t this was a b s o l u t e l y c h a r a c t e r i s t i c i n his l a t e r years. D r , 0, : That i s i n t e r e s t d g , One occasionally reads t h a t he wou d occasionally s a y he was t i r e d and ask h i s a s s i s t a n t t o f i n i s h t h e procedure and s t r o l l out of t h e operating room, D r , F. : C e r t a i n l y t h i s was n o t c h a r a c t e r i s t i c of h i m , Two p a r s before he d-ied he had a major operation and recovered slowly, It i s p o s s i b l e t h a t what you refer t o occurred then, D r . 0. : Was there anything unique about the operating room set-up I Dr. Halsted required o r desired, e i t h e r i n comparison t o his colleagues of t h a t time or i n comparison with an operating room s e t up f o r a similar procedure such as herniorrhaphy today? Dr, F, : Well, t h e r e was much more a t t e n t i o n given t o a s e p t i c tech- nique. For instance when we scrubbed, we then soaked our forearms and hands i n potassium permanganate and took t h a t o f f with a c e t i c acid, We then soaked again i n a bichloride s o l u t i o n and p u t our gloves on i n bichloride s o t h a t i f an accident occurred and a needle punctured a glove, there would be a layer of a n t i s e p t i c material,, That "wet tech- nique" as i t was c a l l e d was not used anywhere else a s far as I know, b u t i t exemplified 16s i n s i s t e n c e on an approach t o p e r f e c t i o n i n technique, Dr. 0, : Was t h i s around 19205 D r . F, I: This was up u n t F 1 the time D r . Dean Lewis came, The wet tech- nique was used until Dean Lewis came. As a matter of f a c t ; a f t e r Dr, Lewis came, I i n s i s t e d on it f o r about a year and f i n a l l y was t o l d I was the only one i n the whole h o s p i t a l f o r whom t h e y had t o g e t out a l l of t h i s paraphernalia, They persuaded me t o use the d r y technique, Dr. 0, : From t h a t p o i n t on, i t w a s simply a matter of scrubbing up 8 f o r a required period of time, drying your hands on a s t e r i l e towel, and p u t t i n g on your d r y s t e r i l e gloves. D r , F, : Right. D r , T-Talsted would take g r e a t aoncern i n t h e prepara- t i o n of the skin. Iodine and alcohol were used r o u t i n e l y , D r . 0. : D r , F i r o r , would. you t e l l me how you decided upon, and how you were accepted i n the s u r g i c a l program a t Johns Hopkins? D r , F, : I d-ecicled t o go i n t o surgery because the r e s u l t s w i t h surgi- c a l p a t i e n t s were s o extremely s a t i s f a c t o r y , whereas i n i n t e r n a l medicine there were only t h r e e or f o u r s p e c i f i c remedies a t t h a t time, The boys who wanted an i n t e r n e s h i p i n surgery applied i n December, early i n December, The most d-esirable appointment however was the one i n the Hunterian Laboratory, because the chap who g o t tAUsappointment auto- m a t i c a l l y was k e p t on as a s s i s t a n t r e s i d e n t , Notice was given t h a t these appointments would be n1ad.e along with the i n t e r n e - s h i p appointments, b u t one member of the class announced t h a t he a l r e a d y had been given assurance of the p o s i t i o n before the r e s t of us had had a chance t o apply, I c a l l e d D r , Hal- s t e d a t - h i s home, n o t knowing t h a t this was a l i t t l e 9 i r r e g u l a r , and he was q u i t e d i s t u r b e d t o f i n d t h a t he had been misinformed. He had been t o l d t h a t there had. been only one applicant, He asked me t o come t o h i s o f f i c e t h e next day, When I went t o hj-s o f f i c e , the s e c r e t a r y s a i d he was i n d i s - posed and wanted me t o come t o his home, which I did. The b u t l e r took me t o his l i b r a r y and t o my amazement, D r , Hal- s t e d had looked up a l l the information t h e Deants o f f i c e had about me. He k n e w where 1 had graduated from college, the courses I had taken, my standing i n the c l a s s , and above a11 the f a c t t h a t 1 had had t u b e r c u l o s i s and was up a t Sara- nac, After probably half an hour t a l k i n g about t h e modern treatment of tuberculosis, he a b r u p t l y s a i d he d i d n ' t think I should apply f o r an i n t e r n e s h i p a t Elopkins, because the work was t o o strenuous, He suggested I go t o Union Memorial. However, the appointments were made s t r i c t l y according t o c l a s s standing, and I was e n t i t l e d t o an i n t e r n e s h i p i n sur- gery by v i r t u e of q y c l a s s standing, s o I d i d n o t withdraw t h e application. The next year the r e s i d e n t approached me and s a i d I had been considered for an a s s i s t a n t residency, b u t D r , I-Ialsted remem- bered I had had t u b e r c u l o s i s and thought i t would be f o o l i s h 10 t o keep me on. I pointed out t h a t I was the only i n t e r n e who hadn't missed any time ,and f o r three weeks had done a l l t h e work of D r , T as we11 as myself. That seemed t o persuade him t h a t i t was s a f e t o l e t me s t a y on, Dr. 0, : lbould you say a few word-s about D r . Halsted's r e l a t i o n s h i p t o his house s t a f f and a l s o the v i s i t i n g s t a f f , the attend- i n g nien i n surgery, D r . F. : By and l a r g e he had v e r y l i t t l e c o n t a c t with the house s t a f f , except w i t h the r e s i d e n t s , I n my i n t e r n e s h i p year, on t h e f i r s t o f January, he surprised us a l l by sending u s an auto- graphed r e p r i n t of his, describing the introduction of rubber gloves, The r e s i d e n t t o l d me t h a t i t was the f i r s t time he had ever known the professor t o do anything l i k e t h i s . He stopped one a s s i s t a n t r e s i d e n t by the s t a t u e one day and said, Why Doctor, I ' m s o glad t o see you, What a r e you doing now?" He said., rlIlm i n surgery." D r . Halsted said, "Oh, on what service?" The r e p l y was '!On yours, Sir.!! D r . Halsted leaned heavily during the p a r s t h a t 1 knew him on D r . Heuer and D r , Reid.. 1 presume also on Dr. Crowe. 11 I never remember seeing any of the v i s i t i n g surgeons i n h i s o f f i c e or t a l k i n g t o h i m , He was q u i t e aloof, D r , 0,: You had mentioned i n an e a r l i e r discussion an i n c i d e n t i n - volving an a s s i s t a n t r e s i d e n t , which i l l u s t r a t e d how sharp a decision D r , Halsted could make, Dr, F,: Yes. D r , Dandy t o l d me t h a t D r . G -was dropped from the s e r v i c e because of a remark he made i n D r , Halsted's pres- ence concerning a p r i v a t e p a t i e n t , who had complained about Dr, C * s roughness i n doing a dressing. During his l a t e r years, Dr. Halsted was more i n t e r e s t e d i n the research work going on i n the H m t c r i a n l a b o r a t o r y than i n c l i n i c a l cases. 1 remember one instance when he looked over the shoulder of a young man closing the abdominal i n - c i s i o n of' a dog and g e n t l y rebuked him by saying, "Oh, Doctor,, you could do t h a t s o much more d e l i c a t e l y , " The young man a f t e r D r , H d s t e d l e f t said,, %ee, I hope he d o e s n f t hold t h a t a g a i n s t meor! 1 t h i n k he did, Dr, 0,: In 1919, toward the close of Dr. I - l d s t e d ' s a c t i v e c a r e e r i n 12 surgery, Mr. Abraham Flexner was a p a t i e n t of Dr. Halsted, I n looking through some of Mr. Flexner's correspondence t h e r e are some r a t h e r i n t e r e s t i n g comrnents about D r . Dandy, D r . Dandy according t o Flexner was doing a l o t of the s e r - v i c e work i n 1919 and Dr, Halsted was n o t around very often, Ifere D r , Heuer and D r , Reid s t i l l around? Dr, F,: Wo, they were s t i l l there. D r , Halsted thought very, very highly of D r , Dandy's o r i g i n a l i t y , krhile a s s i s t a n t resident, D r , Dandy had worked out the mechanism of i n t e r n a l hydro- cephalus, He t o l d me t h a t D r , Halsted's comment was, "Oh, Dandy, i t i s such a tragedy t h a t you didb t h i s s o young, It i s seldom given t o a man t o make more than one g r e a t c o n t r i - bution i n h i s lifetime,rt Dr, Dandy always attended D r . Hal- s t e d ' s c l i n i c s and rounds if he were free t o do so, D r . 0,: It would seem t h a t Dr, Dandy was one of the s u p e r i o r products of t h a t sys tern, D r , F,: TJnquestioEabl;y, D r , 0,: Would you agree w i t h a statement I found i n the Flexner papers, credited t o D r , Halsted, t h a t D r , Dandy was actu- a l l y superior t o D r . Cushing? D r , F,: I a m sure t h a t impression i s c o r r e c t c D r , Ijalsted p u t great emphasis on o r i g i n a l i t y and i n v e s t i g a t i v e work, Cushing developed a school, b u t contributed very l i t t l e b a s i c a l l y t o neurosurgery, whereas Dandy worked out encephalography and many other contributions which we Will t a l k about some other time, Idhen i t came t o w r i t i n g s c i e n t i f i c a r t i c l e s , I think the p r o f e s s o r s e t a standard which has seldom been equaled, He took almost a y e a r t o prepare his t h e s i s on The Operative S t o r y of Goiter, Miss Stokes, his secretary, t o l d me t h a t he confirmed every one of the 375 references pa?sonally* He used t o tell the young men, ItAlways w r i t e for the LO per cent, n o t f o r t h e 90 per cent,tt D r , 0,: D r , F i r o r , what s u r g i c a l or medical s o c i e t i e s d i d D r , Halsted support and attend? D r . F,: He t o l d D r , Reichert once t h a t the only two meetings he cared t o go t o were those of the National !icaderny of Sciences, of which he was a member, and the American Sur- g i c a l Association. I doubt i f he belonged t o the Southern (Surgical Association), 1 know he d i d n o t belong t o the S o c i e t y of C l i n i c a l Surgery, I t h i n k he had no i n t e r e s t i n t h e A, M, A, Dr, 0,: Was he a member of the American College of Surgeons? D r , F,: He wasn't very a c t i v e i n t h a t , Finney w a s the leading s t a r i n t h a t , you s e e , He was President, Dr, Halsted never had a group of v i s i t i n g surgeons come f o r two o r t h r e e day demonstrations, i n g r e a t c o n t r a s t t o his SUCCeSSOrr D r , 0,: He d i d f r e q u e n t l y i n v i t e referring physicians t o a t t e n d the operation, d i d he not? Dr, F,: Quite r i g h t a That i s c o r r e c t o 1 a m s u r e he continued t h a t p r a c t i c e , but he d i d n ' t i n v i t e a group of f i f t e e n or twenty surgeons from IJilkes Barre or some place l i k e that; t o come, D r , 0,: Do you think this was because of a b a s i c shyness or an aus- t e r e feeling, n o t wanting t o be bothered with the personal contact with these men? D r . F,: I think i t was because he f e l t t h a t they would g e t very l i t t l e out of it, It would be a waste of t h e i r time and his, He f e l t i t took years t o t r a i n a surgeon, and they got nothing from j u s t mere observation. Dr. 0,: C e r t a i n l y this i s the a t t i t u d e toward teaching medical s t u - dents and, i f you will, the l e s s t a l e n t e d r e s i d e n t as opposed t o the t a l e n t e d r e s i d e n t . It undoubtedly c a r r i e d over i n t o his relations-hip w i t h the general medical and s u r g i c a l com- munity. Dyl, F,: He was a b s o l u t e l y committed t o the pyramidal system of pro- gression i n the residency system, He could be very b r u t a l i n dropping a man a f t e r 4 o r 5 years, i f a more favorable 16 candidate was on the horizon, Toward the end he brought over D r , Schlaepfer from Germany with the i d e a of making him resi- dent, I n f a c t he t o l d me t h a t he planned t o have h i m the r e s i d e n t a f t e r D r , Holman, b u t his d.cath intervened and changed things. D r , 0,: I n s p i t e of h i s close a s s o c i a t i o n w i t h the German and Austrian surgeons, he did n o t have many Europeans j o i n h i s house staff o t h e r than Schlaepfer, did he? D r , F.: He i s the only one 7: know o f , I am c e r t a i n t h a t some of the people who have w r i t t e n b i o - graphical m a t e r i a l about D r . Halsted have exaggerated h i s i d i o s y n c r a s i e s and have given a p i c t u r e which i s almost a caricature. He may have s e n t his s h i r t s t o P a r i s t o be laundered, b u t he c e r t a i n l y was n o t an e c c e n t r i c individual. He had his small c o t e r i e of cronies t h a t played w h i s t a t the l\.laryland club, I know he went t o Pale alumni banquets, I a m sure be had c o r d i a l r e l a t i o n s h i p s w i t h many r e f e r r i n g doctors and a l s o with D r , Finney and other prominent sur- geons i n the coimtqyo 17 I remember c l e a r l y when Dr. Heuer came from Cincinnati t o operate on D r , Halsted i n h i s f i n a l i l l n e s s , A t the time of D r , Walsted's death, t h e r e w a s v e r y l i t t l e n o t i c e taken of i t i n the press, I n f a c t the f u l l s t a t u r e of the man was n o t appreciated by more than a handful of people, b u t through t h e followzing decades, 1 have been impressed by how his rep- u t a t i o n has grown, A t a recent meeting of the American S u r g i c a l Association, s i x authors referred- t o some of -his contributions and showed t h a t h i s influence i n Anerican sur- gery l i v e s on. Cr, 0,: Do you believe t-his growing influence, s t a r t i n g some years a f t e r h i s death, was more the r e s u l t of the teaching of some of -his former r e s i d e n t s o r the gradual zwanmess t h a t i n his w r i t i n g s are many lessons t h a t we should have learned i n the intervening years since his death? D r . F,: I think both Tactors were a t work. C e r t a i n l y some of h i s r e s i d e n t s d i d a superb job i n carrying out h i s i d e a s and propagating the residency system and t r a i n i n g other meno Index o f Names Crowe, Samuel J . , 10 Cushing, Harvey, 13 Dandy, Walter E. , 11-13 Finney, J . M. T . , 14, 16 Flexner, Abraham, 12 Heuer, George J. , 10, 12, 17 Holman, E m i l 9 16 L e w i s , Dean D . , 7 Reichert, Frederick L . , 14 Reid, Mont R., 10, 1 2 Schlaepfer, Karl, 16 Dr. Warfield M. Firor Discusses Walter E. Dandy This i s an i n t e r v i e w with D r . Warfield M e Firor, held i n Dr. F i r o r ' s o f f i c e on February 28, 1967. The interviewer i s D r , P e t e r D e 01ch of the National Library of ;"ledicine. The t o p i c f o r discussion today i s D r . Walter E. Dandy (L 8 86-1946) Dr. Firor: I got t o know Dr, Dandy extremely well because I was the second f u l l time r e s i d e n t on t h e neurosurgical s e r v i c e a t Johns Hopkins, D r , Frederick Reichert was the f i r s t , Be- f o r e t h a t Dr, Dandy had one of t h e assistavlt r e s i d e n t s on the s u r g i c a l service who worked p a r t time with him and p a r t time with other surgeons, D r , OZch: What were the d a t e s of your tenure as r e s i d e n t with D r , Dandy? Dr. F,: I began on July 5, 1923 and stopped on January 29, 1925. S h o r t l y before 1 began a s his r e s i d e n t , he had discovered ventriculography, o r the i n j e c t i o n of a i r i n t o the 2 v e n t r i c l e s of the b r a i n for the l o c a l i z a t i o n of b r a i n tumors, This was ind.eed an epochal event, because up t o t h a t time only one t h i r d of b r a i n tumors could be l o c a l i z e d by a neuro- l o g i c a l examination or by the use of dyes and X rays. As soon as D r , Dandy h i t upon the i d e a of p u t t i n g a i r i n the v e n t r i c l e s and following the course of the a i r from the l a t - e r a l v e n t r i c l e s through the v e n t r i c u l a r system o u t i n t o the subarachnoid space, the l o c a l i z a t i o n of b r a i n tumors moved up t o 90 o r 95% accuracy, I remember the t h i r d p a t i e n t i n whom a i r was i n j e c t e d . She was a p a t i e n t on whom Dr, Cuskring had done a subtemporal decompression and w a s unable t o l o c a t e the turnor. With a sharp needle and syringe, Dr, Dandy a s p i r a t e d from the l a t - e r a l v e n t r i c l e over 200 ml. of cerebrospinal f l u i d and replaced this w i t h a i r . Following the X rays he attempted t o a s p i r a t e as m c h of the a i r as possible, b u t a great d e d had a l r e a d y passed through i n t o the t h i r d v e n t r i c l e and through the aqueduct and f o u r t h v e n t r i c l e , He t o l d me t o t a p the l a t e r a l v e n t r i c l e every two hours because he was a f r a i d the a i r would be i r r i t a t i n g and the p a t i e n t would develop increased i n t r a c r a n i a l p r e s s u r e , She did, 3 This was done. A s a matter of f a c t , we had t o continue t o decompress the v e n t r i c l e f o y almost f o u r weeks before D r . Dandy was able t o remove the tumor i n the t h i r d v e n t r i c l e which had been b e a u t i f u l l y v i s u a l i z e d by the ventriculogram. On one occasion with this p a t i e n t he claimed t h a t I had given her meningitis from c a r e l e s s n e s s and t h a t I had k i l l e d her, Fortunately, she was s t i l l l i v i n g , the: s p i n a l fluid remained s t e r i l e , and he f o r g o t about the accusation, D r . 0,: I g a t h e r t h a t by 1923 there was a d i v i s i o n ~ Z n e u r o s u r g e r y , D r , F,: It wasnit a s t r i c t d i v i s i o n , It was s t i l l a subdivision of g e n e r a l surgery. However, D r , Dandy had his own r e s i d e n t , and one i n t e r n e would be assigned t o t h a t s e r v i c e every month. D r , 0.: bdas he known as Professor of Neurosurgery? D r , F.: Not a t t h a t time, 4 Dr. 0,: Did he do any general surgery a t this time? D r , F,: Yes, One summer during the interregnum between D r , H a l s t e d f s death and the appointment of D r , Dean Lewis, most of the v i s i t i n g men were out of the c i t y and some of the i n t e r n i s t s i n s i s t e d on D r , Dandy's doing a few abdominal cases, which he d i d with e x q u i s i t e s k i l l , Actually, i t was the b e s t ab- dominal surgery t h a t I had seen up t o t h a t time, Dr. 0.: C e r t a i n l y i n his e a r l y days he was s t i l l doing a l o t of general. surgery. D r . F,: He t o l d me t h a t he had planned t o go i n t o neurosurgery when he entered medical school. He entered with advanced stand- ing, and while working under Dr. Nall i n neuroanatomy, he described what was then the e a r l i e s t human embryo which i s known as the "Dandy embryofr. He was chosen by D r . Halsted t o work i n the Hmterian laboratory, H i s resid-ency follow- i n g graduation covered 8 years. The last two years of which 5 he was the s e n i o r r e s i d e n t , During h i s a s s i s t a n t residency, he worked out the mechanism of i n t e r n a l hydrocephalus and Dr, Halsted remarked t o D r . Edwards A, Park t h a t i t was a shame t h a t Dandy had made such an e x c e l l e n t contribution s o e a r l y i n l i f e , because i t was seldom given t o a man t o make more than one g r e a t discovery. Dr. Dandy d i d a f a i r amount of neurosurgery w h i l e r e s i d e n t , because Dr, Heuer who took Gushing's place turned over the ward cases t o h i m . Once D r , Dandy- t o l d m e t h a t he was So disappointed t h a t Cushing d i d n ' t tc&e h i m up t o P e t e r Bent Rrigham i n 1912, t h a t he figured h i s whole c a r e e r had been ruinedr Actually, i t turned out t o be the b e s t thing t h a t ever happened t o h i m , Dr. 0,: Is i t your impression t h a t the c o n f l i c k between Dr. Cushing and D r , Dandy originated during the period they were work- i n g together i n the Hunterian, o r t h e following year on the c l i n i c a l service when Dandy was Cushingt s a s s i s t a n t ? Dre F e z No, I think the antagonism began when Cushing refused t o take Dandy t o Boston and took Dr. Ragley i n s t e a d , It was 6 accentuated by the temperament of the two men and also by the f a c t t h a t Dandy was extremely o r i g i n a l and Cushing was not, There was bound t o be a c e r t a i n jealousy, The b i g g e s t f r i c t i o n developed over the publication of the treatment of a c o u s t i c nerve tumors. Gushing had brought out a book i n which I believe he s a i d i t was impossible t o remove a11 of the tumor and the capsule, Whereas Dandy s h o r t l y t h e r e a f t e r published a paper saying t h a t he had s u c c e s s f u l l y done this. I remember very c l e a r l y Gushing coming down t o Baltimore and coming up t o the operating room and saflng, Wliere i s t M s fellow Dandy? I: want t o t a l k t o h i m about t h i s a c o u s t i c nerve paper,Ir The heated exchange t h a t took place t h e r e a f t e r was exceedingly i n t e r - e s t i n g t o a neophyte. Actually, the misunderstanding and f e e l i n g between these two men was never resolved, I remember D r , Candy t o l d me t h a t when the American Neurosurgical Association was or- ganized and D r , Sachs of S t , Louis asked him t o j o i n , he s a i d he dLdn't c a m t o a s s o c i a t e with such people, Never- t h e l e s s , when t h e second meeting of the Association was held, he sent me up t o Boston t o l i s t e n t o the papers and. t o watch Cushing operate. T h i s was p a r t l y because I was overworked and needed a change, and I think also, because 7 he wanted t o know what was r e a l l y going on, A t t h a t time I saw s u c t i o n used f o r the f i r s t time by D r , Cushing and his r e s i d e n t D r , Elnile Eolman, When I came back and re- ported t o Dr, Dandy, he brushed the use of s u c t i o n aside 2s "not necessarytr, b u t l a t e r came t o use i t r e g u l a r l y , Dr, 0.: I d i d n ' t r e a l i z e t h a t Dr, H o l m a n of Hopkins went t o P e t e r Bent Brigham with Cushing, Dr, F.: That's r i g h t , Iie w a s up there as r e s i d e n t a f t e r he f i n - i s h e d as residtent a t Johns Hopkins, D r , 0,: 1 gather t h e r e was another d i f f e r e n c e between Dr, Cushing and D r , Dandy, You might s a y D r , Cushing was a man of l e t t e r s , a p r o l i f i c w r i t e r and a f a i r l y good w r i t e r as opposed t o Dr, Dandy, who may have w r i t t e n a f a i r amount, b u t l e f t something t o be d e s i r e d as f a r as h i s s t y l e , spelling, e t c , I n other words he was n o t the polished w r i t e r t h a t D r , Cushing was, 8 D r , F,: That's r i g h t , D r , Cushing founded a school of neurosurgery and was indeed a v e r y e r u d i t e and polished scholar. Dr, Dandy would w r i t e r a p i d l y i n long hand and seldom c o r r e c t t h e manuscript, I n his early days, i t used t o concern D r , Halsted a g r e a t deal. I n f a c t he once s a i d t h a t he thought he would employ a s t u d e n t of English t o r e w r i t e Dandy's papers for h i m * Nevertheless, Dr, Halsted, before he died, said. t h a t Dandy was the g r e e t e s t r e s i d e n t t h a t he had ever t r a i n e d , D r , 0.: Was Dr, Dandy ever on full-time a t Hopkins? D r , F,: Yes, the year a f t e r his residency he w a s on full-time. He w a s s i c k a good b i t of t h a t year a s a matter of f a c t and then went out i n t o p r a c t i c e , b u t always had an o f f i c e a t the h o s p i t a l , His o f f i c e across town on S t , Paul b S t r e e t was s o r t o f an empty gesture. D r , 0,: So a c t u a l l y he was more geographic full-time, 9 Quite r i g h t , Ke always was what we would now c a l l geo- graphic full-time I was asked t o w r i t e D r , Dandy% obituary f o r one of the medical j o u r n a l s and gave some thought as t o the f a c t o r s t h a t contributed t o h i s genius. Surely one of them was his power of observation, I remember an i n s t a n c e when lie was c a l l e d over t o the medical wards t o see a c r i t i c a l l y ill p a t i e n t who was thought might have a b r a i n tumor. D r , Dandy simply stood a t the f o o t of the bed, watched the woman for a minuto o r two and then walked away and said, !!She i s dying of pneumonialt. She died within a few hours and a t autopsy the diagnosis was confirmed, Idhen asked how he made t h a t diagnosis, he said, "1 simply watched her breathbg, Another f a c t o r t h a t contributed t o his greatness was the i n t e n s i t y of his concentration, This i s p o s s i b l y a l u d i - crous i n c i d e n t , but i t i l l u s t r a t e s a p t l y what I j u s t s a i d , D r . Dandy was married i n the home of his bride, Only six or seven of h i s medical f r i e n d s were i n v i t e d , The cere- mony took place i n the parlor w i t h the minister standing i n f r o n t of the mantelpiece. D r , Dandy and -his bride 10 were facing the mirror back of the minister. Half way through the ceremony i n which D r , Dandy was r e p e a t i n g the vows a f t e r the minister, t h e r e was a pause, The minister repeated this p a r t i c u l a r vow, "1 thee with a11 my worldly goods endow" and there was s t i l l no response, He nudged D r , Dand-y, who came t o and a f t e r the sentence was repeated a t h i r d time, Dr, Dandy s a i d it, When the ceremony was over I went up t o him and said, What i n the world were you looking a t during the ceremony when you f a i l e d t o say what you were supposed to say?f1 He said, ftYou know F i r o r , t h e r e was a f l y walking across t h a t mirror and I was i n t e n t t o see i f i t would g e t t o the end before the s e r v i c e e n d e d 2 1% really happened, "1 thee with all q~worldly goods end o-fllr ---... ...- complete I .- silence t I would think t h a t another f a c t o r t h a t was extremely char- a c t e r i s t i c of Idalter Dandy w a s t h a t he thought and acted i n absolute terms, Everything was e i t h e r black or white. There were no intermediate shades, I can i l l u s t r a t e this by h i s having given ward rounds every week, every Saturday morning for s i x weeks t o the f o u r t h year students, and I a f t e r going through the d i f f e r e n t i a l diagnosis and the ex- amination of the p a t i e n t , he would wind up by saying, Y!JOW this p a t i e n t has such and such a tumor a t p r e c i s e l y this 11 place, I f you come u p s t a i r s i n another hour, I w i l l have the b r a i n exposed and demonstrate this t o you,'' Every time f o r s i x successive weeks he was wrong, But t h a t made no difference, for i t was really superb teaching. A l s o a t the Southern S u r g i c a l once, he gave a paper on d i s c s and said with the same absolute, p o s i t i v e , unwavering cer- t a i n t y , rfDiscs always occur a t the f o u r t h i n t e r s p a c e , Pow need no X ray o r c o n t r a s t medium," The next year he got up and said, "Only 50% of the d i s c s occur a t the f o u r t h interspace, You ccmnot g e t along without c o n t r a s t mediaeff When confronted with the inconsistency-, he said, "Yes, I s a i d t h a t l a s t year, because t h a t ' s what I thought then," D r , 0,: Mas his a s s o c i a t i o n with others i n the f i e l d of neurosur- gery a f a i r l y f r i e n d l y one or was he a rough enough char- a c t e r t h a t he rubbed a few people the wrong way? D r , F*: I would say i t was anything b u t f r i e n d l y , He had g r e a t admiration f o r S i r Victor Worsley, b u t I never heard him speak i n f r i e n d l y terms about any American neurosu-rgeon, He never joined the Society of Neurological Surgeons or The Harvey Gushing Society, 12 D r , 0.: ?dko were h i s close associates? D r , F,: He had many veyy warm friend-so During h i s e i g h t years i n the h o s p i t a l , the House Officers had a b a s e b a l l team, He was the Captain and for the r e s t of h i s l i f e , h i s i n t i m a t e s always c a l l e d him ltCaptainrt, The team used t o p r a c t i c e on the s i t e where the Phipps I n s t i t u t e now stands, On Sunday afternoons they would take on some other team i n Baltimore and go out t o Druid. l - E l l Park for the game, He was always very friend.ly with t h e members o f the house staff who stayed on, Eddie Broyles, A l a n Woods; he was devoted t o Dr. Reichert, There was a group of people he would play g o l f with, He and Dean Lewis were extremely intimate, Speaking of playing golf, as long as I knew D r , Dandy, he? loved s p o r t s , He played a very e x c e l l e n t game of tennis and again and again would s l i p o u t a f t e r a b r a i n operation and. p l a y with A1 Blalock. He played g o l f up u n t i l the week before he died, He loved t h e game of bridge and would go down t o e i t h e r the Baltimore Club or the Maryland Club t o p l a y w i t h some of hd.s f r i e n d s , 13 I d i d n ' t completely f i n i s h my a n a l y s i s of h i s s a l i e n t characteristics. I tkdnk i f I had t o pick out one ex- ceptional t r a i t which accounted f o r this man's g r e a t - ness and f o r his discoveries, i t would be t h a t he had the f a c u l t y of i n c e s s a n t l y asking himself questions. Iive seen him stop i n the middle of an operation and t h i n k f o r a minute and say, 'IFiror, why can% we do i t this way?" I n f a c t his discovery of ventriculography came from ask- i n g the technician who was developing some X ray p l a t e s , what t h a t black round s p o t meant on a p a r t i c u l a r p l a t s , Actually, he bawled out Rubin and s a i d , IIRubin! You've spoiled t h a t p l a t e P The P o l i s h technician s a i d , rtNo sir, Dr, Dandy, t h a t i s an a i r bubble i n the colonoll Dandy asked, !!Does i t make a black mark l i k e t h a t ? 1 can p u t a i r i n the ventricle!It Suddenly, asking himself what the black area wiis, he had it. 1 remenber also, when I was h i s r e s i d e n t , the f i r s t year he was n o t married and he would i n v a r i a b l y come back t o the h o s p i t a l a f t e r dinner t o go over the f i l m s t h a t had been taken t h a t d.ay. He would see t h i n g s t h a t nobody e l s e saw. He would make a s s o c i a t i o n s t h a t nobody e l s e thought of, I got t e r r i b l y d-iscouraged because I was as i n a r t i c - u l a t e as a bump on a log, u n t i l f i n a l l y i t occurred t o me t h a t the key t o his success w a s h i s incessant i n q u i s i t i v e - ness, But, he was n o t asking o t h e r people questions; he was simply bombxrding his mind with questions a l l of the time. I was s o impressed with t h i s t h a t when Dean Lewis asked me t o stay on full-time and teach and p u t myself down for any courses "cat I wanted., 1 s a i d t h a t I would p u t down s u r g i c a l pathological conference simply t o teach the students t o ask themselves questions, not merely t o make tha r i g h t diagnosis o r l e a r n any pathology, For some twenty years I gave t h a t courseo Possibly the l a s t c h a r a c t e r i s t i c t h a t 1 would want t o em- phasize, was h i s a b i l i t y t o c u t r i g h t i n t o the very core o r center of a problem. He had no time f o r s u p e r f i c i a l i t y , He had the a b i l i t y t o see the e s s e n t i a l p o i n t and go r i g h t t o it, He had a d i r e c t n e s s of approach, O f course, he was technically- the b e s t surgeon I have ever seen, and the boldest. I remember one Labor Day when one of the House Officers brought h i s f a t h e r i n semicomatose, D r , Dandy w a s up in. Frederick w i t h Fred Reichert, I called. him and asked him to come back, t h a t we had t o operate on this man. That evening we explored the cranium and found an inoper- able glioma involving the temporal and f r o n t a l lobes. The House Officer subsequently came t o D r , Dandy and asked i f i t would. be p o s s i b l e t o remove the e n t i r e hemisphere and D r , Dandy said, IIYes, i f you want i t d-one,'* So he and I removed, I presume for the f i r s t time i n history, the en- t i r e liemisphere of a man's b r a i n , The dead space f i l l e d up with f l u i d a n d l a t e r became i n f e c t e d with Nicrococcus tetragenes which we cleared up w i t h i r r i g a t i o n s , The p a t i e n t had a t o t a l change of p e r s o n a l i t y , His i n h i - b i t i o n s were a l l gone, He would use f o u l language i n the presence of his wife a d nlinister. He l i v e d f o r about e i g h t months Dandy had absolute courage, I remember he once walked i n t o my o f f i c e and said, ! ' D i d n ' t you and I once pinch off both i n t e r n a l carotids?ll I s a i d , W o sir." ffllget i e d o f f one once, b u t t h a t was all.1f Ne said, tfYou know I thought we d i d and I t r i e d i t today and t h a t p a t i e n t died, I never mind l o s i n g a p a t i e n t , i f I l e a r n something from t h e case,fl D r , 0,: Would i t be s a f e t o say t h a t he was bold t o the p o i n t of being foolhardy, or would t h a t statement be u n j u s t i f i e d ? 16 D r , F,: I d o n ' t think lie was foolhardy, b u t he was c e r t a i n l y cou- rageous avid bold, A s I s a i d earlier, he was exceedingly dexterous , D r , 0,: I r e a l i z e t h a t D r , Dandy was a f o r c e f u l i n d i v i d u a l , He undoubtedly rubbed some people the wrong way, Is this the b a s i c reason s o many people have h e s i t a t e d t o w r i t e his biography? D r . F,: I was approached by I'lacMillan, 1 believe, I f o r g e t the f i r m , I turned i t down, because t o do i t w e l l would have taken a f u l l year and I couldn't a f f o r d t h a t much time, Nany of the boys who were h i s r e s i d e n t s d i d n ' t l a s t out t h e i r full time because of c o n f l i c t s with D r , Dandy, At l e a s t f i v e times during my residency he accused me of hav- i n g k i l l e d a p a t i e n t , but f o r t u n a t e l y none of them died a t t h a t moment, The very next week he would tell my f a t h e r t h a t he d i d n ' t know how he could g e t along without rie, t h a t I was his r i g h t hand, Dr. Dandy had a very generous s i d e t o h i m t h a t many people d o n ' t know anything about. He went t o one r e s i d e n t who was poor and who had a year before he was t o take up h i s Pro- f e s s o r s h i p a t a southern medical school and s a i d t o him, tYl%is i s a year when you could have a l o t of fun and I a m going t o give you a Cadillac c a r s o t h a t you can d r i v e around and have a good time, because once you g e t d-own t o Duke, you*llhave t o work s o hard Ynat you wont t have any opportunity f o r When I had mumps meningitis during m y residency with him, he s e n t me out t o Colorado Springs f o r a month t o recuper- a t e with a l l expenses paid, When I came back, I had some money l e f t over and returned i t t o him and he said, ffNo, keep it," He wasn't very p r a c t i c a l , I was l y i n g on the ward w i t h mumps, s i c k as all g e t out, and he s e n t me a basket of c i t r u s fruit! A c o l o r f u l person who sees things i n black and white terms obviously lends himself t o any number of apocryphal s t o r i e s , which I presume i t i s n o t necessary t o go i n t o . The time he went i n t o the wrong s i d e of the head for i n s t a c e , 18 A s r e s i d e n t i t was one of nly d u t i e s t o arrange f o r D r . Dandy's f o u r t h year c l i n i c s and ward rounds, He was an e x c s l l e n t teacher because f i r s t he thought c l e a r l y , he could organize t h e m a t e r i a l , and was s o p o s i t i v e t h a t the s t u d e n t s i n v a r i a b l y c a r r i e d away from the session a very d e f i n i t e impression, Index of Names Bagley, Charles, 5 Blalock, Alfred, 12 Broyles, Edwin N . , 12 Cushing , Harvey, 5-7 Halsted, William S . , 4 , 5, 8 Heuer, George J . , 5 Holrnan, Emile, 7 Horsley, V i c t o r , 11 Lewis , Dean D. , 4, 12, 14 Park, Edwards A . , 5 Reichert, Frederick L., 1, 12, 14 Sachs, Ernest, 6 Woods , Alan C. 12 C Q l i l i B M ~ABOUT THE SURGICAL G.IIEI% AT 'E%.JOHNS HOPYJMS. HWPXTAL BETWEEN 1918 AND 1938c, During the l a a t years of Ds. Halsled's tenwe he beom@inoreaaingfy inactive. 1-k relied upon Dr, Weuer and Dr. Reid for nearly all af the adstihistration and teaching, Unfortunately they both l e f t f o r Cincinnati shortly before BY. &lsted's death on Septazber 13, 31922, During the enauing inter(* regnum of three year8 Dr, JrM,T. Finnep was nominally.in aharge, but: his large practice and many, olhex coIcan;ttiwnts made i t imperative that the acttual running Nillex, Jr, DP. Hughaon had j u s t graduated in k918, wd had had $m@ training \ s OUX second shock c m e in t h ~ operating roomr Indead of D r r H'falsted'ar painstaking. and d e l i b x a t e execution of every detail in every operatian, along with total disregard of tima, we saw Dr. h w i s bmme through gastro* entsrostomy SA 25 ~ h t e s . Kochar clamps were used as haoatatat* Large bite of tissue 'w8xe included in 0very suture, Ghromio catgut repl&credfine, d l k . ' i o nten because D x , Lewis ' ployed 'two yomg octors to work in t h e la hypophysectomize do on sf the anterior remained after partin tion, he gave up the idea . I for a paper at the American Surgical Association m e d i n g cgl lateral ciPcrulationy - lie asked me t o get som data and lantern slides, I: w i x ~leaving on vacation and turned this chore r t o Stinson and Shaakolford- who prtrepc?frrsd - I -I.- o s s s a ~ ymaterial T h d r Eindinqs and were a t complete V ~ X p l p c a Y he wrote.. t o him, he read the for publioatfo It is unnecess studies of the highest quality, Hi5 collected papere testify t o thia. In the ears of his failing health he would v i s i t 'the laboratory, but not the hospital, Dr. Halsted's r o l e in the establishment of the reoidency training sysQem well known, Hia great purpose was t o develop B f e w surgeona in thorough and comprehensive manner. IIe chose h i s resident8 after a long probatfan period, The prime requisite seemed t o be proved capwity for investigation, He wag uncompxomjsing and a t times bxutal. A t one time hs dropped a potential resident because of the latter's crude and ungramnatioal criticism o f & patient - , ( # t h e old iddy done me d i r t , Pwofessor'',), ,After s i x years aF ,sex\ricts Dr* PZant: Reid would six rnonthls, Sad t o rdate, Dr. Gray died three monthe later during the influenset pandmio. On c o n i i ~ gto Baltiinoro, Dr., Lewis announced that he would permit Dts.Reichert, Firor and Hart to f i n i s h their training program, a f t e r which ha would shorten the residency, '\ €le 1,ater came to see the value of the long apprenticeship, and actually - 7 - . * put yourself down f o r iihatever COUXSBPI you care t o teaoh." He read B paper OA the' subject of training young eurgeona, and endorsed this l a i s ~ e z - faire policy. However, almost every week ho would look in a t the ulhssee OX enquire how many students were present. He enjaytad long vacations, and arranged witkt tho Advisor ard for ma t o take d n e at: Jekyll fsland.e\tery I 4 wintex. This meant that n the sexvice e ~ s ~ i8tummei, y. binning the firat year 1 was resident. In their publication ast dfference between the two men a n again be recorded. In 1920'Dr. Halstad published "The Qp0 he had taken almost 0 years to prepare thfaJ classi secretary, told me t h a t he had perused every on8 af the 575 refbrences, and personally chec the bibliography of t h s a r t i d e . collect& reprint8 I . reveal not -only thoroughnes but exquisite care in the choice of wordral and ' in plams a ' s t y l e that ;I6 r ~ a l i ygroat prhss, tipl adequate contrast oart be dram by the following inciddnk: one Saturday aftexnoon 1 dropped i n t o f f i c e and found that ha was writing three articles, "Hw do you , do this?" 1 a s k y, ky wxiting'a 1iLtPe on one until yoti g e t tired, and then changing t o another". He finished all thre r3lftexnoonr Meedless I to add, his desk was piled hPgh with books io~dJ 8 which were serving as > SQUYCB matsri His.publictations must have sxce c t busy X B ~ ~ _- t h a t he airnply did not have time t o be thorough, He entered B contract with the Prior Coxripany to e d i t "Lewis's 3ystan o f Surg e discovered that the following subjeots had bee ttad: bunds; lbtanusg Gas Gangrene. He asked me t o ~ 0 ~ t1h e ;m chaptexs within tha month, Again hs asked me to write t h i r t y inted pages on Pre and Postd&eratic$e Care# as he wan loatsing for Europe the next When t h i s waa finished 1 discovered that "Feeding t h e Suxgical Patisnt"! Another area needs coirment, and this might be dubbed'"Public Relatfons"e Dr, kh3sted attended only two meeting8 ti year, the American Surgical Aasooiatian and tho &ational. Acadefiy of Sdsnce. He seldon, Sf ever, entertained visiting groups. ' 9b seiamed Q cold arlstwxAf,ahcmt anti-social, Dr. Lewis attended evexything - surgical meetings, opera, athletla contests, and crab feastsr knew more doctors than any man in the cclw\trj, 80 it: wab not surpxirsing that he.w m elected pre8ltdsnt sf the American Kedical Aoaociation. ' Although