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Journal of Neuro-Ophthalmology:
Legacy

Thomas R. Hedges, Jr: Witness to the Birth of Modern Neuro-Ophthalmology

Volpe, Nicholas J. MD; Balcer, Laura J. MD, MSCE

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Division of Neuro-Ophthalmology, Departments of Ophthalmology and Neurology, University of Pennsylvania School of Medicine, Scheie Eye Institute, Philadelphia, Pennsylvania.

As the first fellow in neuro-ophthalmology under Frank B. Walsh, MD, at the Wilmer Institute in Baltimore, Maryland, Thomas R. Hedges, Jr, MD, was present at the dawn of neuro-ophthalmology as a subspecialty. Through his relationships with many of the field’s greatest figures, he has gained unique insights and personal perspectives on the development of the field. The author of 90 original manuscripts, he is the co-founder of the International Neuro-Ophthalmology Society (INOS) and a charter member of the Frank B. Walsh Society. Now Professor Emeritus of Ophthalmology at the University of Pennsylvania School of Medicine and Emeritus Chief of the Ophthalmology Section at Pennsylvania Hospital in Philadelphia, he has been a mentor to countless students, residents, fellows, and faculty at Penn. This interview took place at his home on January 28, 2003.

NJV: Where did it all start?

TRH: I was born in Cleveland, Ohio in 1923, and I grew up in Sandusky, Ohio. I lived my whole younger life there with the exception of summers with my uncle on his dairy farm in Kent, Ohio. We had horses to pull the wagon into town when we took the grain to be sold. Every morning we fed the cows at 5 AM and every evening we drove them back from the pasture to the barn for milking.

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NJV: How did you become interested in ophthalmology?

TRH: My father’s career as an optometrist probably had a great deal to do with it. He graduated from the Optometry School at Ohio State University in Columbus, a school that is still among the best of the American optometry schools. He studied under Charles Sheard, MA, PhD, ScD, who wrote the standard text of the time on physiological optics entitled Selected Writings in Visual and Ophthalmic Optics.

NJV: What about your undergraduate life?

TRH: I was on the championship swim team at Ohio State and qualified for the Olympics as part of a medley relay team. But that was 1939, and the 1940 Olympics were to be held in Tokyo. The events of World War II led to the cancellation of those games.

By this time, most of my friends were in the service. When I went to enlist, a navy lieutenant recruiter said, “I see here you are accepted at medical school. We need you for that. Get out of here and get on with it. We’ll need you more when you get to be a doctor.” I knew that I wanted to go to medical school, so that was it.

NJV: Why did you go to Cornell for medical school?

TRH: I had been accepted at the medical schools of Harvard and Cornell. I visited Harvard first, but I was put off by my student guide who was less than enthusiastic. When I asked about the anatomy course, he replied, “Why would you care about that? It’s so basic we try to avoid it.”

After I saw Cornell and New York Hospital, I just fell in love with the place and the people. I thought the faculty was impressive in the basic sciences and clinical medicine. Physiology and anatomy were taught by Professors Eugene F. DuBois (Physiology), George Papanicolaou (Anatomy and Histology), and Vincent du Vigneaud (Biochemistry). John McLean, MD, in ophthalmology and Harold Wolff, MD, in neurology stand out since they played such an important role in my future.

When I entered Cornell Medical School in January 1944, I was assigned to a room on the fifth floor of the old Nurses’ Residence, which was made into a dormitory for men. We lived in little cubicles that were no bigger than closets. The guy next door to me was quiet, unassuming, and very serious. His name was Ed Norton (later to become chair of ophthalmology at the Bascom Palmer Eye Institute, Miami).

World War II was well underway at this time so we were all in uniform. Ed and I were midshipmen in the Navy V-12. One of our memories was marching around the hospital once or twice a week. We agreed that we had fought the “Battle of 68th and York,” (referring to the address of Cornell Medical School and New York Hospital).

During this time, I saw a lot of Ed Norton. I was drawn to him by his consuming interest in medicine and his wonderful personality. Through our exposure to Harold Wolff, Ed and I realized that we had a great interest in neurology. In 1945, Wolff had written the first textbook on headache, called Headache and Other Head Pain. This book had a great influence on both of us. In that year, I found another book in the Cornell library that influenced me. It was Neuro-Ophthalmology by Donald J. Lyle, MD, of the University of Cincinnati. I showed it to Norton.

My wife Ann and I were married in 1946. I told her about my interest in Lyle’s book. She found it at a medical bookstore and gave it to me as a Christmas present.

Norton and I attended lectures given by another neurologist, Louis Houseman, MD. We told him that we thought neuroanatomy was poorly taught. He said we ought to build a brain, and he promised to show us how. So Norton and I each built a brain out of clay and wire on a wood cut-out frame. We spent about 100 hours on that project. That model meant so much to me that I carried it with me wherever I went. The thing finally fell apart in the heat of the attic in the first house we had in New Jersey.

NJV: What were your earliest formal exposures to ophthalmology?

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TRH: The lectures of McLean at Cornell. They made ophthalmology an engrossing and challenging subject. After the first lecture, I remember walking up to him and telling him of my interest in his material. He later offered me a residency in ophthalmology.

NJV: But you didn’t accept the offer…

TRH: Because it came during my rotating internship at St. Luke’s Hospital in Cleveland, where I had become fascinated with neurology. I had met Jack Nichols, MD, a neurologist at Western Reserve University. Nichols often made rounds late at night, and somehow I’d find a way to go on those rounds. He arranged for me to do a fellowship in neurology at the Cleveland Clinic.

The neurology-psychiatry section at the Cleveland Clinic was run by Louis Karnosh, MD, a true intellectual with an interest in everything from bookbinding to making paper to wood cut illustrations. Most importantly, he wrote a book that dealt with psychiatry almost as an art form, called Engrammes of Psychiatry.

I also met Otto Glaser, MD, who had written the first textbook of neurophysiology. I told him that I wanted to learn more neuroanatomy. He said, “Fine, we will spend evenings doing an orange stick dissection of the fixed brain.” We concentrated on the visual pathways and the venous sinuses because Glaser had told me that the venous sinuses have a lot to do with brain swelling.

I had realized that I was not cut out for psychiatry or neurosurgery, so I was in a quandary between ophthalmology and neurology in that spring of 1949.

NJV: How did you resolve the quandary?

TRH: I went back to Cornell to see if I could obtain a residency position in ophthalmology from McLean. He said that he had two ophthalmology residents—Ed Norton and Paul Wetzig—and didn’t have room for anyone else. But he said that Walsh was interested in taking on a young man with a background in neurology. He asked if I knew how to do visual fields. I had done finger waving, but I hadn’t actually done formal fields. He gave me Walsh’s phone number and said he would recommend me.

I left the office and went to the first phone I could find and called Walsh. He was interested in my background and asked me if I could get to Baltimore. I went down on the train the next day and he accepted me as his first fellow.

NJV: What was it like to work with Walsh?

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TRH: It changed my whole life. He was a tall, good-looking man, completely personable, with the kindly manner and the grace of a true gentleman. He was straight in bearing and quick in step. He had been one of the first chief residents at Wilmer in 1933, and had started early in gathering material for the first volume of his book. By the time I joined him, he was on the staff at Wilmer and in part-time private practice with Charles M. Iliff, MD. He was about 54 years old, but in no way did I think of him as an “older” man. His scientific curiosity and verve were the peak of anything I had encountered in any of my professors. He had a remarkable single-mindedness.

His offices were at 12 West Reed Street, near the Washington Monument in Baltimore, an older building suitable for his practice of general ophthalmology and neuro-ophthalmology. He wanted me to work with him there and at his Wilmer clinic. We spent afternoons at the Wilmer and evenings in his office writing. Our association was a model, I think, for the fellowships which were beginning to shape the future of neuro-ophthalmology.

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NJV: Were you examining patients with Walsh in his office—cataracts and all?

TRH: Yes, and I will never forget a woman with headaches who came to be examined by the “great Dr. Walsh.” I didn’t find anything wrong and told Walsh. In his very stately way, he said “Madam, everything appears to be all right.” As he began to usher the patient by the elbow to the door, she turned to him and protested, “But doctor, I came in because I cannot read. I think I need reading glasses.” “Oh,” he replied. He picked up the prescription pad, wrote down the number +2.50, handed it to her, and told her that that would do the trick. He disliked refractions and had very little patience with routine eye exams.

NJV: How did Walsh get you started in research?

TRH: He sent me to the brilliant Jonas Friedenwald, MD, PhD, who ran the Ophthalmic Pathology Laboratory at Wilmer. We read slides together twice a week. I told him that I was interested in the optic nerve. The lab had many specimens of posterior segments of the eye obtained at autopsy with clinical records that went back to the time of the great neurosurgeon Harvey Cushing, MD.

Friedenwald walked over to a green file cabinet and said, “Here are the 300 to 400 files of optic nerve sheath hemorrhage that I have collected all these years. Go through them and see what you can find out.”

Walsh had suggested that a good project would be to find out how many hemorrhages and papilledema they had. In the end, we restricted our research to aneurysm patients. In 1951, Walsh and I wrote the paper that became the Jackson Lecture that year (1).

Looking back on it now, I only wish I had had a copy machine to save the clinical data, which included notes from Cushing and Walter Dandy, MD (then professor of neurosurgery at Johns Hopkins University). I had gone back through Cushing’s and Dandy’s records, including Cushing’s drawings of all the operative findings. I had them all in front of me with details of each patient’s course. The most fascinating patients were those who had had ruptured aneurysms.

NJV: Which patients had had optic nerve sheath hemorrhages?

TRH: All the patients had optic nerve sheath hemorrhage, many due to birth injury, accidents, or trauma. The most interesting case was of tetralogy of Fallot in a 38-year-old woman who had received a fatal injection of Diodrast and had died of acute massive increase in intracranial pressure. At autopsy she had only petechial hemorrhages in the brain and no intracranial subarachnoid hemorrhage. There were, however, massive subhyaloid hemorrhages in the eyes, large optic nerve sheaths, and many orbital hemorrhages.

Up until then, it was always thought that the hemorrhages might have gone through the optic canal. We concluded that the origin of these subhyaloid and vitreous hemorrhages—Terson syndrome—was a massive increase in intracranial and venous pressure. To try to prove that the sheath space in the optic canal was such a minute microscopic opening, and that blood could never go through there, I went to the morgue one Sunday afternoon and injected India ink under high pressure into the subarachnoid space of a cadaver. I could not get it to go through.

One day, late in my fellowship year, I got a call from the technician at the Hopkins morgue. A young girl who had been rehearsing her senior high school year play had dropped dead. I was allowed to do the dissection from the chiasm to the posterior segment of the eye. I found hemorrhages in the chiasm, third cranial nerve intracranially, orbit, optic nerve sheath, and vitreous, again illustrating the explanation for Terson syndrome. These pathologic findings had their origin in the sudden rise of intracranial pressure with a concomitant increase in venous pressure transmitted to the orbit.

NJV: What had laid the groundwork for neuro-ophthalmology as a subspecialty?

TRH: There were two major advances. First, there were the early textbooks by Lyle in 1945, followed in the same year by Cogan’s Neurology of the Ocular Muscles. In 1946, Kestenbaum published Clinical Methods of the Neuro-ophthalmology Examination, and, most important, there was Walsh’s Clinical Neuro-Ophthalmology, which came out in 1947. Walsh’s text was as complete as could be at that time. He had written 1,500 pages followed by as in-depth an index as anyone had compiled to date. He said that the index was the most important part of the book—any book. Luckily he had an assistant who made it so accurate and complete that the volume was completely usable by the clinician.

The second and the most important development was the fact that teaching centers were setting up neuro-ophthalmology fellowships.

NJV: How did you transition into an ophthalmology residency?

TRH: One day during my time with Walsh in the spring of 1950, he said to me, “Doctor, you are going to go see Dr. Alan Woods (then the chair of Ophthalmology at Wilmer) for a residency interview today.” That evening, I came back from interviewing for residency with Dr. Woods. It had not gone well. Later that evening, as Walsh and I were working on the second edition of the book, he suddenly looked up at me and said, “And how did things go with Dr. Woods?” Seeing the hard expression on my face, he said, “I figured.” He knew that I had failed the “Woods course.”

Walsh picked up the telephone and called Francis H. Adler, MD, professor and chair of Ophthalmology at the University of Pennsylvania. I remember his saying “I have a young man who needs a residency in ophthalmology. Would you look at him?” I went up to Philadelphia where I had the interview with Harold G. Scheie, MD, because Adler had gone back to the Marine Biological Laboratory in Woods Hole, Massachusetts to finish writing his book on ocular physiology. Adler and Scheie offered me a residency to start in ophthalmology in July 1950.

NJV: What do you recall of your ophthalmology residency?

TRH: Scheie, who ran the residency, was a great clinician but a hard taskmaster. One of my fellow residents called him “The Sabre.” He ran that residency as he must have run his group in the army. Morning rounds started at 7:30 am—not 7:31 or 7:29, but 7:30—and if you were late, God forbid. One morning, I presented a headache patient to him. He made no comments, walked over to the patient, pulled the hair back and exposed herpes vesicles, and said, “Herpes zoster, Doctor. If you open your eyes and look, you may eventually be a clinician!”

NJV: What events followed your residency?

TRH: In 1952, the Korean conflict was on everybody’s mind. I felt I should volunteer.

I was assigned to William Beaumont Hospital in El Paso, Texas—the only ophthalmologist at a hospital that took care of the huge Army base at Fort Bliss, the White Sands Missile Proving Grounds, Biggs Air Force Base, and the air base at Alamagordo. I had a 60-bed eye unit in the hospital. I saw general ophthalmology patients and patients with MS and strokes.

NJV: What happened when your military service was over in 1954?

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TRH: Adler asked me to come back to Penn. William C. Frayer, MD, and I covered Scheie’s office and various clinics associated with Penn, which included the University Hospital, the old Philadelphia General Hospital, the Veterans Hospital, and the Children’s Hospital of Philadelphia. I started seeing all of the neuro-ophthalmology cases at those affiliated hospitals. During this time, I befriended Francis C. Grant, MD, who was professor and chief of Neurosurgery at Penn. He suggested that I work on meningiomas. Eventually, Grant and I wrote a paper on tuberculum sellae meningiomas. (2)

NJV: What was your time at Wills Eye Hospital like?

TRH: Irving H. Leopold, MD, ophthalmologist-in-chief at Wills, and a professor of ophthalmology at Penn, asked me to come to Wills in 1959 to work in his office and do neuro-ophthalmology with Nathan M. Schlezinger, MD, professor of Neurology at Jefferson Medical College and chief of neuro-ophthalmology at Wills. I also helped the residents with retinal detachments, corneal transplants, and things I had never done in my life. Two or three years later, a position opened up at Pennsylvania Hospital. I was very eager to become part of that historic hospital.

NJV: What were your most important interests and activities at Pennsylvania Hospital?

TRH: During my time at Wills, I had started to develop an interest in the ophthalmic manifestations of increased intracranial pressure. I told this to Lewis Coriell, MD, PhD, who had founded the South Jersey Medical Research Institute, now the Coriell Institute for Research. He did much of his research on Rhesus monkeys and suggested that if I came over to his lab, I could use his monkeys for my research.

I had worked on intracranial pressure for about three years when Thomas Langfitt, MD, chief of Neurosurgery at Pennsylvania Hospital, and Jim Weinstein and Neal Kassell, who were Penn medical students, and I transferred the monkeys to Pennsylvania Hospital, where we continued to develop our techniques. We simulated brain tumors using balloons inserted into the intracranial vault. Kassell designed a screwbolt that fit in the head through which we could continuously measure intracranial pressure. We carried out that work together for almost 10 years. A fairly large series of papers came out of that research, including one on the importance of hydrostatic or vascular mechanisms in the production of the ocular signs, especially papilledema, with acute increase of intracranial pressure (3). We believed that in the pathogenesis of papilledema, elevation of venous pressure played an important role in the ocular signs, especially with acute increases in intracranial pressure. I do not think that axoplasmic stasis alone can explain these ocular signs.

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NJV: Was it around this time that neurologists began to enter the field of neuro-ophthalmology?

TRH: Yes, in the early 1960s. Walsh had said, “They [neurologists] cannot do refractions. You cannot evaluate a patient with vision loss unless you can do a refraction.” Of course, even he did not like refraction! By then, however, William F. Hoyt, MD (then Chief of Neuro-Ophthalmology at the University of California, San Francisco) had started his fellowship program. Robert B. Daroff, MD, a neurologist, came as a fellow to Hoyt in 1957. Bob was so bright that he paved the way for bringing neurologists into neuro-ophthalmology.

NJV: You ran the neuro-ophthalmology course at the American Academy of Ophthalmology Annual Meeting for a number of years. How did that start?

TRH: There had been no courses in neuro-ophthalmology at that meeting until Walsh started one in 1960. Our course grew out of a meeting in a small room at the Palmer House in Chicago in 1962 that included Walsh, Lyle, Smith, John W. Henderson, MD (Ann Arbor, MI), and me. Walsh ran the course in the beginning. Henderson took it over for about five years and then I took it over. I ran it for about 20 years, and it gradually grew into a three-day course.

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NJV: You were also instrumental in founding the International Neuro-Ophthalmology Society (INOS). Tell us about that…

TRH: In 1975, I was at a meeting in Dallas of the American Academy of Ophthalmology. In the breakfast line, I ran into an old friend, Alfred Huber, MD, professor of ophthalmology at the University of Zurich, and a leader in European ophthalmology. He had written an authoritative book entitled Eye Symptoms in Brain Tumors.

Huber and I were determined to start an international society. My wife Ann reminded me that the University of Pennsylvania was a trustee for the fourteenth century Chateau de La Napoule, near Cannes. After a hundred phone calls, it became the site for our first meeting. In 1976, 58 people gathered from all over the world (Fig. 8A and B). Walsh was the honorary chair.

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The meeting was a great success. I remember that the EMI (“Emmy”) scan, now known as the CT scan, was the promising new diagnostic tool. All were impressed that the Beatles and English Music Incorporated (EMI) had donated money to help develop the technology.

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INOS really took off at the second meeting, held in Warrington, Virginia at the Airlie House in 1978. David G. Cogan, MD, and Melvin G. Alper (Chevy Chase, MD) arranged that meeting, to which over 100 people came. INOS has met every other year for the past 26 years. The number of attendees has doubled to about 200.

NJV: Walsh died in 1978. What events do you remember from that time?

TRH: We were attending the second INOS meeting in 1978. Walsh got into my car in Baltimore and I saw that he didn’t look well. At the meeting, Hoyt’s first fellow, Richard L. Sogg, MD (Palo Alto, CA), a concert pianist, was playing the piano after dinner. Walsh said it was worth coming to the meeting just to hear Dick play the piano. But his breathing was not good, so the next day Richard C. Lindenbergh, MD (formerly professor of neuropathology at Johns Hopkins University), got him into the car and took him back to Baltimore. Later that day, Lindenbergh called to say that Walsh had oat cell carcinoma of the lung. On the way back to Philadelphia, I stopped at the hospital to see him. He said he was sorry to have missed part of the meeting.

He died six months later. I saw him in the hospital just before that. His last words to me, now in a weak voice, were “Tom, you will be glad to know that Miller (Neil R. Miller, MD, Baltimore, MD) has agreed to write the next edition of the book.”

NJV: What legacy do you want to leave to neuro-ophthalmology?

TRH: I am most proud of the fact that I was part of the beginning of modern neuro-ophthalmology, and of the fact that my son Tom went into neuro-ophthalmology. From the beginning of my career, I have taken great pleasure in teaching students, residents, and fellows who have come to work with me. Hopefully, this effort, along with my clinical research in the field, has contributed to the development of neuro-ophthalmology over the years.

I am proud of the fact that, together with Huber, I founded INOS, which has done much to bring neuro-ophthalmologists internationally closer together. I am especially grateful to have been a part of the highly talented and thoughtful University of Pennsylvania neuro-ophthalmology group. I am fortunate to have had my many mentors, students, and, most of all, my wonderful wife Ann to support me through both the good and the difficult times.

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REFERENCES

1. Walsh FB, Hedges TR Jr. Optic nerve sheath hemorrhage [The Jackson Memorial Lecture]. Am J Ophthalmol 1951;34:509–26.

2. Grant FC, Hedges TR Jr. Ocular findings in meningiomas of the tuberculum sellae. Arch Ophthalmol 1956;56:165–70.

3. Hedges TR, Weinstein JD. The hydrostatic mechanism of papilledema. Trans Am Acad Ophthalmol Otolaryngol 1968;72:741–50.

© 2004 Lippincott Williams & Wilkins, Inc.

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