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Robert B. Daroff, MD Pioneer of Ocular Motor Research

Trobe, Jonathan D MD

Journal of Neuro-Ophthalmology: December 2009 - Volume 29 - Issue 4 - p 342-353
doi: 10.1097/WNO.0b013e3181b14889

Robert B. Daroff, MD was born in New York City and, except for a 2-year hiatus at military school in Georgia, attended public school there. He left high school early to start undergraduate education at the University of Chicago, but transferred to the University of Pennsylvania, where he served as editor-in-chief of The Daily Pennsylvanian, the college newspaper.

He entered the University of Pennsylvania Medical School bound for psychiatry, but a fascination with internal medicine and an exposure to potent role models in neurology guided him toward neurology. A chance encounter with David Cogan's little masterpiece, The Neurology of the Ocular Muscles, led to his becoming the local expert on eye movements while he was a resident in neurology at Yale University. To further his knowledge in this field, he undertook a 3-month elective rotation with J. Lawton Smith, MD which gave him exposure to the talented cadre of neuro-ophthalmologists at the University of Miami and sealed his decision to become a neuro-ophthalmologist.

After serving a 2-year stint as a neurologist in the United States Army, he became a neuro-ophthalmology fellow under the direction of William F. Hoyt, MD at the University of California-San Francisco and later joined the faculty at the University of Miami. There he began to document the trajectories of normal and abnormal eye movements with Louis Dell'Osso, PhD and other systems control wizards. He left Miami in 1980 to become chair of the neurology department at Case Western Reserve University in Cleveland. His strong support of ocular motor research led to the establishment of the Daroff-Dell'Osso Ocular Motor Laboratory at Case, from which seminal contributions to the understanding of eye movements continue to emerge.

From 1987 to 1997, he served as editor-in-chief of Neurology, the official journal of the American Academy of Neurology. An authority on the management of headache, he has looked after members of the royal families in Saudi Arabia and other Persian Gulf states. After he stepped down from the chair position, he served as chief of staff of University Hospitals-Cleveland and is currently Associate Dean for Development at the medical school.

He has held virtually every leadership position and received every honor in American neurology and neuro-ophthalmology. He is one of the founders of the Rocky Mountain Neuro-Ophthalmology Society, the predecessor of the North American Neuro-Ophthalmology Society (NANOS). Recognizing the value of applying engineering principles to the analysis of eye movements, he has trained many of the ocular motor investigators at major university centers around the world.

This interview took place at Lake Tahoe, Nevada, on February 23, 2009.

JDT: I know you were born in New York City, but I found it odd that you left elementary school to go away to military school…

RBD: Yes, I went to Riverside Military Academy in Gainesville, Georgia, when I was 10 years old.

JDT: Why military school?

RBD: My family thought it was best that I get some discipline.

JDT: You didn't have discipline?

RBD: I thought I did, but I got a whole lot more in military school. When I got back to school in New York, I remember the teacher calling off the roll, and everyone would answer “Yeah,” but when she came to me, I said “Yes, ma'am.” The class laughed. I still say “Yes, ma'am” and “Yes, sir.”

JDT: And in spite of this stiff training, you chose later to go to college at the ultra-liberal University of Chicago. Why?

RBD: There was a study to see how high school kids would do if they came to college early. Four colleges participated: Harvard, Yale, Columbia, and the University of Chicago. You would get a scholarship if you passed the entrance exam, which I took in my sophomore year. I didn't make it, but the University of Chicago agreed to take me if I would pay the tuition. I wanted to go, so my parents agreed and I enrolled at age 16.

JDT: Why would you go off to college at such a young age? Had you outgrown high school?

RBD: I was ambitious. I was accepted to college. Why not go?

JDT: What was it like to go to college so young?

RBD: The summer before I started, I taught myself to smoke. I thought it was a “mature thing.” I worked as a beach boy at the (New) Jersey shore, and every evening I would go out on the dock and inhale and cough. It wasn't easy, but I was becoming a man.

JDT: Why the Jersey shore?

RBD: My father, Charlie Daroff, was one of four brothers who owned H. Daroff and Sons, a well-known Philadelphia company that made Botany 500 clothes. We lived in New York only because my father ran the New York office. Every summer the family got together in southern New Jersey-at Ventnor or Margate, on the beach.

JDT: How did the year at the University of Chicago turn out?

RBD: It was fantastic academically, and I developed all sorts of interests in things like transcendentalism, Hemingway, Hawthorne. But when I would come home for breaks, I wasn't really communicating with my parents or their friends. I honestly felt that this college education was not preparing me for my family's circle of friends. When they got together, it wasn't existentialism that they talked about. I felt out of touch. Also, there was the girl situation. I was a 16-year-old kid without a car in Chicago. I decided I wanted to be around the family in Philadelphia, so I transferred to Penn (the University of Pennsylvania).

JDT: Did Penn give you credit for the courses at the University of Chicago?

RBD: Not really. They accepted me as a freshman, provided I took one more course. So I took a social studies course at the summer school of the University of Chicago. My roommate happened to be Carl Sagan.

JDT: Before he became the Carl Sagan…

RBD: Yes, of course. I knew he was the smartest person I'd ever met but who knew he'd go on to be Carl Sagan. Besides being smarter, he was a year older and more mature than I was. The other thing that happened that summer was that I got into Freud, especially his book Civilization and Its Discontents. It explained why I was unhappy. The way I interpreted this book was that we are sexual creatures and the only way to get rid of this strong sexual desire is sublimation, which was not really adequate. So we were destined to be unhappy.

JDT: Did this incline you toward psychiatry?

RBD: I was hooked on being a psychoanalyst. But I started a regular college life at Penn, with fraternities and girls-all the things I hadn't had in Chicago.

JDT: What do you recall of those undergraduate years?

RBD: Fraternity life was vital. The fraternities had lists of all the students at Penn, and next to each name was either the letter P, C, or H-Protestant, Catholic, or Hebrew. This was 1953. There were gentile fraternities and Jewish fraternities. Some gentile fraternities-the highfalutin ones-did not take Catholics. There were absolutely no Jews in the gentile fraternities. The Jews were in the 13 Jewish fraternities. There was only one black student in my class (he became a successful orchestral conductor) and he was in a Jewish fraternity.

JDT: You pledged?

RBD: Yes, at Sigma Alpha Mu, in my freshman year. They told me that to be admitted, I had to go out for an activity. I told them I was pre-med and didn't have time for other activities. They said you have to do something. I wasn't a good enough jock, so I decided to go out for the newspaper-The Daily Pennsylvanian. Trying out was called “heeling.” I was forced to heel. But I made it on to the newspaper. And I became editor-in-chief in my senior year, an experience that became very important for my later life.

JDT: What did you do forThe Daily Pennsylvanian?

RBD: I put the paper to bed every fifth night, copyediting. I organized. I commissioned stories. I wrote stories. I covered a story about an important skull being discovered in Africa that had anthropologic significance. I called up Loren Eiseley, a big professor at Penn, and he invited me over to his office and explained for 2 hours why this was such an important finding. I also remember interviewing Lewis Mumford, the writer and city planner, about why we should give up nuclear weapons. He asked if he could see my article before it was published. I said “Yes, sir.” He rewrote it completely. It appeared under my byline-the best thing I have ever written! Mumford discovered Melville's Moby Dick. It was just a whaling story until he analyzed it. Fantastic. After that experience, I took a graduate course that he taught.

JDT: How did you do academically at Penn?

RBD: Not well. I settled for Cs. I never studied. I spent all my time either at the newspaper or playing Hearts at the fraternity.

JDT: And after graduation?

RBD: I was accepted to Penn Medical School. With my crummy grades, it was only the newspaper editorship that got me in.

JDT: What happened at Penn Medical School?

RBD: It was complicated. From being a big man on campus, and an American Civilization major, I was suddenly among science majors who were smarter than I was. I didn't do well in the first year. That Fall my father died and I got depressed. I consulted the student health psychiatrist and found the sessions helpful. I wanted to continue, so they recommended full psychoanalysis. I wound up as a patient of Aaron T. Beck (father of Roy Beck, MD, PhD and later winner of the Lasker Award). What luck that was! He was getting disenchanted with psychoanalysis and shifting into cognitive therapy. I was there for the transition.

JDT: Weren't you also doing research in psychiatry at the time?

RBD: Yes, a Penn professor thought that essential hypertension was due to inverted hostility: you were really angry, but you didn't let it out, and therefore you became hypertensive. He thought you could prove this by analyzing the dreams of hypertensive patients, which should be hostile. I went around to hospitals and clinics collecting dream information and scoring it for hostility. The theory turned out to be wrong. Beck wondered whether depressed people were hostile in their dreams, a prediction of psychoanalytic theory. Much to his surprise, it turned out that they were as depressed in their dreams as in their waking life. I think it was this finding that finally took Beck out of psychoanalysis.

JDT: You have told me that an accidental event in medical school had a major effect on your life….

RBD: Yes, meeting Jane. She had transferred to Penn from Vanderbilt University in her junior year. She was standing outside a phone booth with my lab partner, who was waiting for me to finish a phone call. I came out of the booth and Jane went in to make a call. I asked my lab partner later if he was interested in her and he said sure, but he found out that she belonged to a Jewish sorority. He said that his Catholic mother would kill him if he brought home a Jewish girl. So I said, “Well, that is not my problem.” We dated but my understanding was that you do not get married while you are in psychoanalysis. I eventually mentioned it to Beck and he said, “Where is that written?” He had met her and he thought she would be great for me-beautiful, smart, calm, likeable. We got married in my junior year in medical school. In December of 2009, we will have been married 50 years. By the way, I still keep up with Beck.

JDT: If you were bent on psychiatry, how did you get sidetracked to neurology?

RBD: Another accident. When I rotated through internal medicine as a third year medical student, I found that this stuff was really good. I realized I couldn't give it up. Then I ran into some wonderful role models in my neurology rotation and that did it-away from psychiatry and into neurology.

JDT: Who were these role models?

RBD: Jim Toole, later neurology chair at Bowman Gray, John Bevilacqua, Gabe Schwarz, and Abraham Ornstein. After I finished my neurology rotation, I spent a month cutting brains in the mornings-learning neuroanatomy-and the afternoons in Toole's office seeing patients with him.

JDT: Who taught you how to cut the brain?

RBD: Nobody. You cut vertically or you cut horizontally. I used an atlas.

JDT: So internal medicine plus psychiatry yielded neurology for you.

RBD: Yes, every patient with chronic neurologic disease has psychiatric problems.

JDT: What was neurology like when you started?

RBD: I started in 1962. There wasn't any imaging-CT came in 1972 and MRI in 1982. There wasn't much treatment either. We had phenytoin and phenobarbital and mysoline for epilepsy and ergotamines for headache. Making the diagnosis-the thought process-that is what turned me on.

JDT: You went to Yale for neurology residency. How come?

RBD: Penn neurology was in transition. Jefferson was a great program, but Alpers, the chair, would make rounds at 5:30 in the morning. That may have satisfied Norman Schatz, who took his residency there, but not me. Harvard required another year of medicine. I did not want to live in New York. So that left Yale, a terrific program.

JDT: Who influenced you at Yale?

RBD: Gil Glaser, the neurology chair, and Lew Levy at the VA were very impressive. But it was during my internship at Philadelphia General Hospital that another accident occurred that altered the course of my life….

JDT: And that was….

RBD: One of Jane's friends had married an ophthalmology resident at Penn. One night we went to visit them, and he had Cogan's book, The Neurology of the Ocular Muscles, lying open on his desk. I asked if that was a good book, and he said yes. So I bought a copy. A year later, as a first-year neurology resident, I was making rounds at the VA at Yale with Levy and we had a patient with supranuclear ophthalmoplegia. Lew said, “I don't really understand this. One of you guys is going to have to read about eye movements and present it to the group.” It fell to me to be the one. So, for the entire 3-month rotation, I read Cogan, Kestenbaum, Holmes, and Bender. Then I wrote a paper for the group on eye movement control. There I was, knowing more about eye movements than anyone else at Yale. There was no one doing neuro-ophthalmology at the time.

JDT: Where did it go from there?

RBD: I decided I had better study under someone who really knew about eye movements. I wrote Walsh. He replied that he was sorry, but neuro-ophthalmology was a subspecialty of ophthalmology. Marvin Sears, the ophthalmology chair, suggested I contact a former co-resident of his from Wilmer-Lawton Smith. And Lawton said “Yeah. Come.” So I spent 3 months of my second neurology residency year with him in Miami.

JDT: How was the time with Lawton Smith?

RBD: Wonderful. I realized that I did know something about eye movements, but I learned more. I decided to become a neuro-ophthalmologist.

JDT: But first you had to serve your military duty.

RBD: Yes, I spent 6 months as a U.S. Army neurologist at Fort Knox, Kentucky. Then I was sent to Vietnam for a year as the first and only Army neurologist in the country. I was supporting a psychiatric unit. We were sent to a hospital in the jungle. Why the jungle? If you take a psychiatric casualty and put him in a nice clean hospital with good food far away from the fighting, he is not going to want to get better. Put him in our jungle hospital-with snakes and rats and giant spiders and awful food and danger-and he will want to get right back in action.

JDT: What could a neurologist like you possibly contribute?

RBD: I took care of 18 soldiers with cerebral malaria. And kids who had fits, faints, and headaches. That part was not so different from a stateside neurology practice.

JDT: And then back home to the States….

RBD: …to Letterman General Hospital in San Francisco, to serve out my last months of army duty. There I met a young physiatry resident named John Susac. He rotated on neurology with me and decided to become a neurologist. Later, when I was editor of Neurology, I asked him to write a paper on his syndrome of retinal, cochlear, and cerebral manifestations. I insisted he call it “Susac syndrome” and he did.

JDT: And then you moved across town to spend a year's fellowship in neuro-ophthalmology with Bill Hoyt at the University of California, San Francisco. What of that?

RBD: Hoyt is to neuro-ophthalmology what Boswell was to Samuel Johnson.

JDT: A scribe?

RBD: Yes. For every patient we saw, he had a card. Hoyt knew everything. His neuro-ophthalmology was different from Smith's. Smith's was an office practice. Hoyt's was basically rounds on the inpatient neurology and neurosurgery services. We had permission to examine without formal consultation any patient on those services. As the senior fellow, I would go around every afternoon and decide which patients we would present the next day to Hoyt. I would call him at home late in the evening. After only one ring, he would always answer: “Hoyt here!” He often dismissed as uninteresting the patients I suggested. Rounds began at 7:30 in the morning. If you were late, it was a disaster. To avoid being late, I met him for breakfast every morning at 7. He had dug into his reprint file and brought reprints on the patients we were going to discuss. But he never let go of those reprints! You had to get your own version.

JDT: Was there any downside to the experience?

RBD: We did not have control of our patients. I did not like just giving opinions-what I call “service neuro-ophthalmology.” I wanted to go to a place where they had neuro-ophthalmologists doing that, so I could do general neurology and specialize in eye movements. And where was such a place? The University of Miami. Ed Norton had been a neuro-ophthalmologist. Smith was there with John McCrary, Joel Glaser, and Nobby (Noble) David. My referrals came from them.

JDT: When did you get there?

RBD: I arrived in 1968 with a joint appointment in neurology and in ophthalmology at the Bascom Palmer (Eye Institute). Nobby David needed help in neurology at the Miami VA, so I went there. But another important accident happened before I got there.

JDT: What was that?

RBD: Peritz Scheinberg, then the neurology chair at Miami, wrote me a letter before I arrived asking me to spell out the systematic research I was going to do when I joined the faculty. I wrote back to say “Neuro-ophthalmologists are phenomenologists. We don't do systematic research. We observe and write down what we see.” At that point, I had already written 13 papers, only one of which was an actual research paper. Scheinberg wrote back: “Everybody in my department has to do systematic research. Find something.”

JDT: So what did you do?

RBD: Someone had written a paper showing that eye movements could predict phenytoin blood levels. But no recordings. I decided I would quantitate that phenomenon with DC oculography.

JDT: How did you know about DC oculography?

RBD: I forget. But somehow I knew enough to write a proposal. Then Nobby David wrote me that the VA had research money and I could have it, but I had to spend it before the year ended or we would lose it. I was advised to buy a Beckman 8-channel DC oculography machine. My first study was a recording of saccades in normal subjects simultaneously from each eye separately, which no one had ever done. That was a simple study. If I was to go further, I needed someone who really understood the machinery. That was Lou Dell'Osso. He had spent time studying eye movements with Larry Stark at the School of Optometry at Berkeley. Lou had written his PhD thesis in biomedical engineering on his own congenital nystagmus. He had been recruited by the biomedical engineering department at Miami, but they had no eye movement equipment. Here I was with equipment but no knowledge. So we became a team. We have collaborated for 40 years. He enabled me to be more than a dilettante.

JDT: That collaboration was to become the Daroff-Dell'Osso Ocular Motor Laboratory, first in Miami and later in Cleveland.

RBD: Right. We studied normal and abnormal eye movements. We were part of the training grant in neuro-ophthalmology that supported the Glaser fellows for 11 years. Nearly all our fellows wrote papers with us. Todd Troost, a neurologist trained by Hoyt in neuro-ophthalmology, joined us as a full-time fellow for two years and later joined our faculty. Larry Abel and other PhD engineers came on to do postdoctoral training, and it became a thriving lab.

JDT: What did you discover?

RBD: The metrics of normal eye movements. The waveforms that distinguish congenital, vestibular, and gaze-paretic nystagmus based on the slope of the slow phase. We studied latent nystagmus and coined the term “saccadic intrusions” and catalogued the various forms. In our normal saccade study, we found that with large saccades, one eye would land on target, the other eye would fall short-and drift or slide into the target. “Glissade” is the skiing and ballet term for sliding. Ron Weber, my collaborator, was a musician, so he suggested we apply it. I think we became famous for that!

JDT: How did your work compare with what was being done at other ocular motor laboratories?

RBD: We established the linkage between the engineer and the clinician in eye movement analysis. David Robinson and David Zee and others did similar work later.

JDT: After 12 years in Miami, you left to go to Case Western Reserve in Cleveland….

RBD: I wanted to be a chairman of a neurology department.

JDT: What happened to the ocular motor research when you moved to Cleveland?

RBD: We were even more productive. As department chair, I was able to support it. John Leigh and Mark Walker, two terrific people, later joined us.

JDT: You were the Gilbert Humphrey Professor and chair of the department of neurology at Case for 13 years. Was it fun?

RBD: It was initially-recruiting and building a department from a division of medicine. Joe Foley, a great neurologist, had left the division head position 3 years before I came, and by the time I arrived, there was practically no one on the faculty. As a division, it was impossible to recruit anyone of substance. Also, the residency was on probation. Fortunately, we became a department when I arrived and got off probation within a year. I managed to build up a good group or residents and faculty, but we were losing money. I began to tire of always thinking about money. When you come as a new chair, you are at the trough-you get help from the dean. Ten years later, you are far away from the trough. Then it is time to bring in someone new to be a favorite son.

JDT: Is it impossible for a neurology department to make money?

RBD: Yes, unless neurology gets paid for downstream income to the medical center. I would spend an hour making a brain tumor diagnosis and hundreds of dollars would wind up in neuroradiology and thousands in neurosurgery. That phenomenon is being increasingly recognized, even at Case, where we have a neurologic institute that shares revenue.

JDT: During your chairmanship, you were editor of Neurology-the “green journal.” Let us talk about that.

RBD: Russell DeJong founded the journal in 1948 and stayed on as editor for 23 years. Then the editorship became a 10-year term. Lewis Rowland followed DeJong, and I became the third editor. My appointment came from another accident.

JDT: This would be accident number 5, but who is counting….

RBD: OK. When I was Hoyt's fellow, Fred Plum, then chair of neurology at Cornell, got delayed in San Francisco on a flight to Japan. He decided he would spend the day making rounds at UCSF. Our neuro-ophthalmology bunch was the only group making rounds. We decided to present a woman with encephalitis. Her husband at first refused to have us come in. So Plum imperiously barges in and tells the husband that he-Plum-has been summoned from New York to render a special opinion which will improve her care. The husband starts to cry and says certainly. Years later, when Plum was a visiting professor in Miami, I reminded him of that. We must have developed a relationship, because, as editor, he appointed me to the editorial board of the Archives of Neurology, then the official journal of the American Neurological Association, but published by the American Medical Association. Some years later, Plum became angry at the AMA for interfering with his editorial decisions. So he and the entire editorial board quit, and we started our own journal, the Annals of Neurology. When he later became head of the search committee for the next editor of Neurology, he came up to me at a meeting in Germany, grabbed my arm, and said “Daroff, how'd you like to be editor of Neurology?” But aren't there qualified candidates in the search, I asked. Plum replied, “Look Daroff, this is what is good for American neurology. They aren't. You are. Do you want the job?” I meekly said yes.

JDT: How did you change the journal?

RBD: I inherited a great journal from Rowland. We quadrupled the number of published manuscripts, condensed them, shortened the delay from submission to publication from a year to about 4 months. I compulsively copyedited-my experience at The Daily Pennsylvanian. I still get cross over a split infinitive. Some of that I attribute to Hoyt, who was a very tough language critic and wrote well himself.

JDT: Of all the honors and awards you have received, which one stands out?

RBD: President of the American Neurological Association, the senior society of neurologists in the United States. Founded in 1875, it is the oldest neurologic association in the world.

JDT: Are you one of the founders of the Rocky Mountain Neuro-Ophthalmology Society, which later became the North American Neuro-Ophthalmology Society (NANOS)?

RBD: Yes. Tom Carlow was a neuro-ophthalmology fellow with my colleague Joel Glaser at Miami. Tom moved to New Mexico. He and Joe Bicknell, who liked to ski, started the annual meeting at a ski resort. Carlow, Bicknell, Glaser, Hoyt, and I were the original faculty.

JDT: Besides being a neuro-ophthalmologist, aren't you something of a headache specialist?

RBD: Yes, that came from another accident. In Miami, Peritz Scheinberg considered all headaches that did not have structural causes to be psychogenic. Nobby told all his headache patients that he solved his own headaches with a thimble full of Scotch. A lot of headache patients were being sent to ophthalmologists at Bascom Palmer because people thought the eyes had something to do with headache, which they rarely do. Those patients were referred to me. Besides, I was well trained in headache because Lou Levy at Yale had been trained by Harold Wolff. I liked treating headaches. Later, when I was in Cleveland, I got a call from Neil Raskin, a headache specialist at UCSF, who was looking for more academic rigor in that field. He asked me to take a leadership role in the American Headache Society, which I did.

JDT: You have also taken your headache skills abroad….

RBD: Yes, a daughter of the head of state in United Arab Emirates had bad headaches and had been seen by several neurologists around the world. They finally found me. She had severe migraine. I flew over with some DHE 45 and she got better. The sheikh's personal physician began inviting me back. One day he notified me that I would be getting a call from the head of the Bahrainian medical society and that I should accept their invitation to take care of the queen. I did. And then I got on the Saudi bandwagon and have made over 20 trips to take care of various members of the royal family. The neurologic problems expanded, and I would take over other experts-a movement disorders person, a cardiologist-whatever I needed.

JDT: You are arguably most famous to young neurologists and otolaryngologists for the Brandt-Daroff positioning exercises. How did those come about?

RBD: Thomas Brandt finished his neurology residency at the University of Freiburg in the early 1970s under the legendary Professor Richard Jung. Thomas was interested in the vestibular system and published excellent papers during his residency. Thomas developed a contact with Bill Hoyt who recommended that he visit me at our Miami VA laboratory. He came and we bonded personally and professionally, as did our wives and children, over the ensuing years. Thomas discussed the treatment he had developed for benign paroxysmal positional vertigo, and I encouraged him to get more data prior to publishing.

We ultimately published it together in 1980 with Thomas as first author. It was his idea and study; I was merely an encouraging facilitator and scribe. The Brandt-Daroff exercise was the first and only treatment for over a decade, until Semont and Epley separately published their maneuvers, which have the distinct advantage of being a single “liberation” in the office, rather than our repetitive home exercises. But if the Epley and Semont maneuvers fail, the only alternative is the Brandt-Daroff exercise, which is then usually successful.

JDT: When you left the neurology chairmanship, it was for another administrative role?

RBD: As chief of staff at University Hospitals, Case Medical System. It was a good job, although a bit frustrating. There was tension between the administration of the hospital system and the doctors. I had to mediate between them. The administration paid my salary and wanted me to be their person. But because I am a doctor, the medical staff thought I should be their person. It was hard on me. Eventually, new administrators were hired and they decided they wanted an MBA person in my job, so I moved on to become vice dean for education at the medical school.

JDT: And now?

RBD: I am the associate dean for development at the medical school, which means that I advise the fundraisers-I tell them who could be the benefactors.

JDT: Looking back on this interesting and productive professional life, what are you most proud of?

RBD: I trained a lot of very bright people. I hope it will be said that I was a good teacher.

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