SURVEY OF OPHTHALMOLOGY
VOLUME
35 * NUMBER
REMEMBRANCES
3 0 NOVEMBER-DECEMBER
1990
OF THINGS
PAST
FREDERICK C. BLODI, EDITOR
Fifty Years in Ophthalmology ROBERT N. SUFFER,
M.D.
San Francisco, California
Abstract. This renowned glaucoma expert began his residency just as gonioscopy came into existence, to be followed shortly by tonography. In this memoir, Dr. Shaffer shares anecdotes and insights gained over a half century of ophthalmology practice. (Surv Ophthalmol 35: 236239, 1990)
Key words.
history
l
Shaffer,
Robert
N.
My residency at Stanford University began July 1, 1939. Hans Barkan was my professor. Otto Barkan, his brother, had just created a new classification of the glaucomas based upon accurate gonioscopy, and he had just cured a baby’s infantile glaucoma by goniotomy under gonioscopic control. Intrigued by his work, I found an unused Koeppe lens in a dusty drawer, cleaned it, and began to teach myself gonioscopy. Undoubtedly, I made many mistakes, but I was fortunate to be among the first in the country to see the closed angle of an acute glaucoma open completely after an iridectomy. I became an earnest proponent of the pupillary block mechanism. It was an exciting ten years helping Paul Chandler and Peter Kronfeld teach the true religion to ophthalmologists of this country. It was nearly ten years before Duke Elder and the European School accepted the concept. Nothing has been as exciting in glaucoma since then. Also, the recent advent of the laser has made iridectomy so safe that accurate gonioscopy and evaluation of risk factors have become almost unnecessary. When in doubt one uses the laser! Osteomyelitis of a knee was probably largely responsible for my becoming involved in a teaching
Fig. 1. 236
The author
preparing
for the Boards,
1942.
FIFTY YEARS IN OPHTHALMOLOGY career in ophthalmology. One of my hospitalizations occurred during my senior residency year. At that time ophthalmology faculties of Stanford and the University of California presented basic science lectures in the evenings to residents from both institutions. The Professor of Ophthalmology at the University of California was Frederick C. Cordes. He was sufficiently impressed by my hobbling to his night lectures on crutches that he offered me an assistantship in his department when my residency was completed. So I changed my allegiance from Stanford to the University of California. That same osteomyelitic knee made me ineligible for militay service, so that my war years were filled with teaching and ophthalmic practice. Teachers in eye departments at that time were almost entirely general ophthalmologists who earned their living in private practice and staffed eye clinics in their spare time. Dr. Cordes had been impressed by the specialty clinics being established at Columbia and Johns Hopkins and decided to organize the U.C. clinic along similar lines. With his strong support the first glaucoma clinic west of the Mississippi was established at U.C. in 1942, providing service to the glaucoma patients and a valuable research base for a glaucoma faculty. After World War II Michael J. Hogan had taken over many of the duties at U.C. One night after an overly enthusiastic cocktail party, Dr. Hogan took me to task for having had so much practical experience, but having produced no papers. Many years later, when Dr. Bernard Becker’s and my textbook, Diagnosis and Therapy of’ the Glaucomas, was printed, I inscribed the first edition to Hogan - “without whose alcoholic urging this book would never have been written.” Back came a letter from Dr. Hogan: “I worry about the long-term effects of alcohol. You have autographed my book upside down and backwards!” The textbook came into being as a result of a course I organized at U.C. and had the temerity to invite only teachers of glaucoma. We had a great faculty, with David Harrington in perimetry, Levon Garron in pathology, Fraser Muirhead in medical therapeutics, William McEwen, Earle McBain, and William Casey in research. At that time tonography was the exciting new topic and I asked Dr. Cordes to let me invite the high priest of tonography, Dr. Becker, to present his material. Dr. Cordes refused, saying, “We put on our own courses.” To our amazement and the stimulation of our faculty, Dr. Becker came as a student. Fortunately, he liked our approach to the teaching of glaucoma. From that contact has come a warm friendship and a textbook which has had gratifying success. After 25 years it is now in its sixth edition. The third to fifth editions
237
Fig. 2.
John Henderson presenting the author with an inscribed bowl commemorating his E. Bruce Fralick Lecture, University of Michigan, 1974.
were edited by Alan Kolker and Jack Hetherington, the sixth by Dunbar Hoskins and Michael Kass. All were colleagues of Dr. Becker and myself. The continuing clarity and general excellence of the text is due to their superb editing. Much of my success in teaching came from the excellent gonioscopic and external disease photographs taken with the Donaldson stereo-camera by my glaucoma secretary, Diane Beeston. Dr. Cordes always stressed excellence. To be sure we would use the new camera correctly he brought Dr. David Donaldson to San Francisco to teach us its use. When he arrived he was suffering from a painful boil on the top of his head. Being an enthusiastic surgeon, I took a scalpel and incised the pus-filled sac forgetting the vascularity of the scalp. The poor man sat bleeding on the clinic floor and finally asked plaintively, “Can’t 1 see a real doctor?” It has been my good fortune to have been asked to speak at many of the national and international eye societies and to have given a number of the socalled Name Lectures. The one which pleased me most was to be invited to give the Jackson Lecture in 1964. The mysteries of the DNA molecule had just been unravelled, and I spoke on “Genetics and the Congenital Glaucomas” in the crowded ballroom of the old Palmer House in Chicago. Listening in the back of the auditorium was Ed Maumenee. Looking at the beautiful diagrams of the genetic code which were being projected, he turned to the member beside him and exclaimed, “Listen to that ShafIer. He doesn’t know a damn thing about DNA!” - and
238
Surv Ophthalmol 35 (3) November-December
1990
SHAFFER
Fig. 3. Retirement party, 1989. Left tlD right: Anders Heijl, thez author, Dunbar Hoskins, and Jack Hethczrington.
he was quite correct. Another amusing anecdote came from a meeting in Heidelberg where Hetherington and I gave one of the first addresses on the continent stressing our belief that surgery for open angle glaucoma should be used only if medical therapy had become ineffective. After the meeting I was approached by Dr. Boberg Ans, a famous European surgeon. He shook my hand warmly and said, “Dr. Shaffer, I could not agree with you - less!” I belonged to the usual local and national societies and was president of several of them. It was a special honor to be made President of the American Ophthalmological Society and to receive its Howe medal. Central and South America have always had a fascination for me. South American ophthalmologists are cordial hosts and have always been most tolerant as I have limped through talks in many of the Latin American countries. A Spanish edition of Diagnosis and Therapy of the Glaucomas and a stereo manual of gonioscopy have been published. Francisco Rodriguez Vasquez of Bolivia, Roberto Sampaolesi of Argentina, and I formed the first Pan American Glaucoma Society. It is continuing to flourish as has its parent, the Pan American Association. Private practice has been a joy, working with my fine partners in glaucoma, Jack Hetherington, Dunbar Hoskins and Chris Dickens. The offtce now has several thousand computerized records which can be used in glaucoma research. With the encouragement and financial support of many patients, the Foundation for Glaucoma Research was founded in 1978. Since then it has developed a national program of education and research to improve patient care. The best known publica-
tion is Understanding and Living with Glaucoma. Over half a million free copies have been distributed and have now been translated into Spanish and Japanese. We promote public informational seminars and have a support group of glaucoma patients available to help others to adjust to the worries of such a diagnosis. New medications and surgical methods are studied. Interdiscipiinary conferences have been organized that bring together clinicians and basic scientists to gain fresh insight into better methods of diagnosis and treatment. The Foundation has organized a low-tension glaucoma study that brings together 34 research centers around the world to try to determine if decreasing intraocular pressure in low-tension or normal-pressure glaucoma is beneficial. The Glaucoma Research Eye Donor Network has been established to give basic researchers access to glaucomatous eye tissue. Some of the mysteries have been unveiled. There are many more to be solved. I hope to be around to add my applause. One of the most rewarding aspects in my ophthalmic life has been my association with the Directors of the American Board of Ophthalmology. These devoted men expend amazing amounts of time and talent in creating a valid examination for the Candidates for the written and the oral examinations. I was elected to the Board in 1960. After serving for eight years, I became Assistant Secretary-Treasurer until the retirement of Francis Heed Adler in 1980. I then served as Secretary-Treasurer until 1985 when William H. Spencer was named as the Executive Director. Although the American Board Examinations do not prove competence, they do protect the public
FIFTY YEARS IN OPHTHALMOLOGY from the ophthalmologist who clearly needs more training. Unfortunately, they do not protect the public from the entrepreneur who has had an ethical by-pass. Because of the risk of legal challenge by some failed candidate, all mention of ethics has had to be eliminated from the Board requirements. It is sad that legal challenges and governmental interference has tended to downgrade the profession of medicine to a commercial business. The rules of the marketplace should not be applied to the medical profession. In the Hippocratic oath the doctor
239
swears - by whatever he holds most sacred to lead his life and practice his art in uprightness and honor and that in whatever house he enters, it shall be for the good of the sick to the utmost of his power. When all ophthalmologists abide by that oath, ophthalmology will again become known as the Queen of the Specialties.
Reprint address: Robert Shaffer, Street, San Francisco, CA 94 102.
M.D., 490 Post
VOLUME
35 * NUMBER
REMEMBRANCES
3 0 NOVEMBER-DECEMBER
1990
OF THINGS
PAST
FREDERICK C. BLODI, EDITOR
Fifty Years in Ophthalmology ROBERT N. SUFFER,
M.D.
San Francisco, California
Abstract. This renowned glaucoma expert began his residency just as gonioscopy came into existence, to be followed shortly by tonography. In this memoir, Dr. Shaffer shares anecdotes and insights gained over a half century of ophthalmology practice. (Surv Ophthalmol 35: 236239, 1990)
Key words.
history
l
Shaffer,
Robert
N.
My residency at Stanford University began July 1, 1939. Hans Barkan was my professor. Otto Barkan, his brother, had just created a new classification of the glaucomas based upon accurate gonioscopy, and he had just cured a baby’s infantile glaucoma by goniotomy under gonioscopic control. Intrigued by his work, I found an unused Koeppe lens in a dusty drawer, cleaned it, and began to teach myself gonioscopy. Undoubtedly, I made many mistakes, but I was fortunate to be among the first in the country to see the closed angle of an acute glaucoma open completely after an iridectomy. I became an earnest proponent of the pupillary block mechanism. It was an exciting ten years helping Paul Chandler and Peter Kronfeld teach the true religion to ophthalmologists of this country. It was nearly ten years before Duke Elder and the European School accepted the concept. Nothing has been as exciting in glaucoma since then. Also, the recent advent of the laser has made iridectomy so safe that accurate gonioscopy and evaluation of risk factors have become almost unnecessary. When in doubt one uses the laser! Osteomyelitis of a knee was probably largely responsible for my becoming involved in a teaching
Fig. 1. 236
The author
preparing
for the Boards,
1942.
FIFTY YEARS IN OPHTHALMOLOGY career in ophthalmology. One of my hospitalizations occurred during my senior residency year. At that time ophthalmology faculties of Stanford and the University of California presented basic science lectures in the evenings to residents from both institutions. The Professor of Ophthalmology at the University of California was Frederick C. Cordes. He was sufficiently impressed by my hobbling to his night lectures on crutches that he offered me an assistantship in his department when my residency was completed. So I changed my allegiance from Stanford to the University of California. That same osteomyelitic knee made me ineligible for militay service, so that my war years were filled with teaching and ophthalmic practice. Teachers in eye departments at that time were almost entirely general ophthalmologists who earned their living in private practice and staffed eye clinics in their spare time. Dr. Cordes had been impressed by the specialty clinics being established at Columbia and Johns Hopkins and decided to organize the U.C. clinic along similar lines. With his strong support the first glaucoma clinic west of the Mississippi was established at U.C. in 1942, providing service to the glaucoma patients and a valuable research base for a glaucoma faculty. After World War II Michael J. Hogan had taken over many of the duties at U.C. One night after an overly enthusiastic cocktail party, Dr. Hogan took me to task for having had so much practical experience, but having produced no papers. Many years later, when Dr. Bernard Becker’s and my textbook, Diagnosis and Therapy of’ the Glaucomas, was printed, I inscribed the first edition to Hogan - “without whose alcoholic urging this book would never have been written.” Back came a letter from Dr. Hogan: “I worry about the long-term effects of alcohol. You have autographed my book upside down and backwards!” The textbook came into being as a result of a course I organized at U.C. and had the temerity to invite only teachers of glaucoma. We had a great faculty, with David Harrington in perimetry, Levon Garron in pathology, Fraser Muirhead in medical therapeutics, William McEwen, Earle McBain, and William Casey in research. At that time tonography was the exciting new topic and I asked Dr. Cordes to let me invite the high priest of tonography, Dr. Becker, to present his material. Dr. Cordes refused, saying, “We put on our own courses.” To our amazement and the stimulation of our faculty, Dr. Becker came as a student. Fortunately, he liked our approach to the teaching of glaucoma. From that contact has come a warm friendship and a textbook which has had gratifying success. After 25 years it is now in its sixth edition. The third to fifth editions
237
Fig. 2.
John Henderson presenting the author with an inscribed bowl commemorating his E. Bruce Fralick Lecture, University of Michigan, 1974.
were edited by Alan Kolker and Jack Hetherington, the sixth by Dunbar Hoskins and Michael Kass. All were colleagues of Dr. Becker and myself. The continuing clarity and general excellence of the text is due to their superb editing. Much of my success in teaching came from the excellent gonioscopic and external disease photographs taken with the Donaldson stereo-camera by my glaucoma secretary, Diane Beeston. Dr. Cordes always stressed excellence. To be sure we would use the new camera correctly he brought Dr. David Donaldson to San Francisco to teach us its use. When he arrived he was suffering from a painful boil on the top of his head. Being an enthusiastic surgeon, I took a scalpel and incised the pus-filled sac forgetting the vascularity of the scalp. The poor man sat bleeding on the clinic floor and finally asked plaintively, “Can’t 1 see a real doctor?” It has been my good fortune to have been asked to speak at many of the national and international eye societies and to have given a number of the socalled Name Lectures. The one which pleased me most was to be invited to give the Jackson Lecture in 1964. The mysteries of the DNA molecule had just been unravelled, and I spoke on “Genetics and the Congenital Glaucomas” in the crowded ballroom of the old Palmer House in Chicago. Listening in the back of the auditorium was Ed Maumenee. Looking at the beautiful diagrams of the genetic code which were being projected, he turned to the member beside him and exclaimed, “Listen to that ShafIer. He doesn’t know a damn thing about DNA!” - and
238
Surv Ophthalmol 35 (3) November-December
1990
SHAFFER
Fig. 3. Retirement party, 1989. Left tlD right: Anders Heijl, thez author, Dunbar Hoskins, and Jack Hethczrington.
he was quite correct. Another amusing anecdote came from a meeting in Heidelberg where Hetherington and I gave one of the first addresses on the continent stressing our belief that surgery for open angle glaucoma should be used only if medical therapy had become ineffective. After the meeting I was approached by Dr. Boberg Ans, a famous European surgeon. He shook my hand warmly and said, “Dr. Shaffer, I could not agree with you - less!” I belonged to the usual local and national societies and was president of several of them. It was a special honor to be made President of the American Ophthalmological Society and to receive its Howe medal. Central and South America have always had a fascination for me. South American ophthalmologists are cordial hosts and have always been most tolerant as I have limped through talks in many of the Latin American countries. A Spanish edition of Diagnosis and Therapy of the Glaucomas and a stereo manual of gonioscopy have been published. Francisco Rodriguez Vasquez of Bolivia, Roberto Sampaolesi of Argentina, and I formed the first Pan American Glaucoma Society. It is continuing to flourish as has its parent, the Pan American Association. Private practice has been a joy, working with my fine partners in glaucoma, Jack Hetherington, Dunbar Hoskins and Chris Dickens. The offtce now has several thousand computerized records which can be used in glaucoma research. With the encouragement and financial support of many patients, the Foundation for Glaucoma Research was founded in 1978. Since then it has developed a national program of education and research to improve patient care. The best known publica-
tion is Understanding and Living with Glaucoma. Over half a million free copies have been distributed and have now been translated into Spanish and Japanese. We promote public informational seminars and have a support group of glaucoma patients available to help others to adjust to the worries of such a diagnosis. New medications and surgical methods are studied. Interdiscipiinary conferences have been organized that bring together clinicians and basic scientists to gain fresh insight into better methods of diagnosis and treatment. The Foundation has organized a low-tension glaucoma study that brings together 34 research centers around the world to try to determine if decreasing intraocular pressure in low-tension or normal-pressure glaucoma is beneficial. The Glaucoma Research Eye Donor Network has been established to give basic researchers access to glaucomatous eye tissue. Some of the mysteries have been unveiled. There are many more to be solved. I hope to be around to add my applause. One of the most rewarding aspects in my ophthalmic life has been my association with the Directors of the American Board of Ophthalmology. These devoted men expend amazing amounts of time and talent in creating a valid examination for the Candidates for the written and the oral examinations. I was elected to the Board in 1960. After serving for eight years, I became Assistant Secretary-Treasurer until the retirement of Francis Heed Adler in 1980. I then served as Secretary-Treasurer until 1985 when William H. Spencer was named as the Executive Director. Although the American Board Examinations do not prove competence, they do protect the public
FIFTY YEARS IN OPHTHALMOLOGY from the ophthalmologist who clearly needs more training. Unfortunately, they do not protect the public from the entrepreneur who has had an ethical by-pass. Because of the risk of legal challenge by some failed candidate, all mention of ethics has had to be eliminated from the Board requirements. It is sad that legal challenges and governmental interference has tended to downgrade the profession of medicine to a commercial business. The rules of the marketplace should not be applied to the medical profession. In the Hippocratic oath the doctor
239
swears - by whatever he holds most sacred to lead his life and practice his art in uprightness and honor and that in whatever house he enters, it shall be for the good of the sick to the utmost of his power. When all ophthalmologists abide by that oath, ophthalmology will again become known as the Queen of the Specialties.
Reprint address: Robert Shaffer, Street, San Francisco, CA 94 102.
M.D., 490 Post
