A Great Conversation With Dr. David Knox

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD A Great Conversation With Dr. David Knox Meagan D. Seay, DO, Rachel Calix, MD, Kathleen B. Digre, MD M eagan Seay (MS): Today, we are talking to Dr. David Knox (Figs. 1 and 2). Dr. Knox graduated from the Baylor College of Medicine in 1955. Dr. Knox is affiliated with the Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center. He has been at Hopkins for nearly all of his career with the exception of ventures including time spent in the Army and terms of practice and education in both Boston and London, England. MS: Dr. Knox, please tell us about where you grew up. David Knox (DK): I was born in Chicago. I grew up in Chicago until age 11 when I moved to Houston, Texas. I lived for 6 months in Brazil at age 5 because my grandfather was a mining engineer and geologist for the world’s largest manganese mine in a little city in Brazil. That helped me to feel that I was different because nobody I knew had lived in Brazil at age 5 for 6 months. MS: How did you become interested in medicine? DK: There was a family friend who was a pediatrician, and when I was 6 or 7 years of age, he made house calls and he would come in and he would talk with me and he would play with my toys and read my books and things like that. My real beginnings, however, began because I was allergic to ragweed mainly living in Illinois, and I sneezed most of the summertime because of ragweed. That made me aware of feeling funny from an external cause. At age 8, I had allergy tests in Chicago where they did scratch skin tests, and they told me I was allergic to grass, ragweed, house dust, and trees. At age 8, I said, “How do I stay away from all of those things?” I’m still trying to make sure what it is that I get around that makes for trouble with me sneezing and things like that. And I’m now 90. MS: What made you choose ophthalmology? DK: When I was a medical student at Baylor, I met a young man named Louis Girard, who had grown up in Houston and attended Rice University and the University of Texas Medical Branch in Galveston. He had done ophthalmology in New York City and then came back to Houston as an enthusiastic person. He took me under his wing. I went with him to his clinics, and I scrubbed with Departments of Ophthalmology and Neurology (MDS, KBD), University of Utah Moran Eye Center, Salt Lake City, Utah; and Departments of Ophthalmology and Neurology (RC), Ochsner Medical Center, Jefferson, Louisiana. The authors report no conflicts of interest. Address correspondence to Meagan D. Seay, DO, 65 Mario Capecchi Dr, Salt Lake City, UT 84132; E-mail: [e-mail] Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 him in surgery. Louis Girard had a long career in ophthalmology. He was a general ophthalmologist. It was Louis who was the one that started me. and I began to wear glasses when I was 6. Kathleen Digre (KD): Did you know you wanted to go to medical school when you were 5 or 6 years old? DK: I had this good pediatrician, and when I was 11, I was at a garden party in Duluth, Minnesota, where my grandmother and grandfather lived, and an older woman said to me, “David, do you know what you want to be when you grow up?” And I said, “Yes, I want to be a doctor.” And it was a straight shot ever after that, and I do remember at the time saying, “If I’m going to be a doctor, I’m going to find out how people live and work and ask questions,” because I thought that that was an important thing for a physician to do. And I’m still digging into people’s lives. MS: That’s terrific. Where did you go to undergraduate school? DK: Rice. My mother and I moved from Chicago to Houston, Texas, when I was 11 and I was much healthier in Houston because there was no ragweed there. Ragweed made me sneeze and drip nose all summer long. Spring, summer, and fall. I was much healthier in Houston. Though I did spend summers in Minnesota with my grandparents and I actually worked on a hay crew and to keep from having the hay in my face, I had cloths around my upper face and then on my nose and then another cloth around my neck so that I could breathe air that had been filtered through the cloths. I worked on a hay baling machine and that was pretty dusty. MS: What was your major in college? DK: Pre-med. I started college in 1948 and at that time we were still under the influence of World War II where people. You didn’t mess around, you just got on with things that were important, and at that time, there were 11 of us who came from either Baylor in Waco, the University of Texas in Austin, or Rice in Houston. And we came to Baylor Medical School, 14 of us who had no college degree, but we were going to medical school and getting on with it. That makes sense? KD: You say you bypassed getting an undergraduate degree and went right to medical school? DK: Right. Rachel Calix (RC): I have a follow-up question for you. DK: Which is? RC: It sounds like you had your mind made up and were pretty determined about the medical field at an early age. e381 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations DK: Yeah, well, there’s no question at age 11. Obviously, I had been thinking about it and when that lady in the garden party in Duluth, Minnesota, said, “What do you want to be when you grow up?” I said, “I want to be a doctor.” It was a straight shot from that point on. RC: Along the way, did anything challenge your decision or pose a major challenge to you getting all the way through? DK: Nothing. Nothing interfered with what I wanted with that track. RC: That’s wonderful. DK: There are some variations in the track, but that’s just part of being a doctor. MS: What made you choose neuro-ophthalmology? DK: Let me give you a little bit of background. I had poor advice in medical school about internships, and I was an unmatched intern, and they gave me a booklet of all the internships in the country which had not filled. I had realized as a medical student at Baylor that private patients were a good way to learn medicine. Now at that time, the best internships went to people with a high level of acute care patients, very, very sick. But I realized when I was a medical student that the private patient was a source of knowledge. Their illnesses, conditions, and the things like that were good ways of learning medicine. I got this little booklet, and in the booklet was a statement that there was an opening in private medicine at the Johns Hopkins. A friend of mine saw an opening for Pediatrics at Johns Hopkins, well, we talked to our faculty and within 12 hours, both of us had jobs at Johns Hopkins. The Ides of March 1955 was a very important day. MS: Sounds like it. DK: Now the next step in this process was when I was a private medicine intern. We had an emergency room, we had bacteriology, we rotated to City Hospital for acute care, and I hung out with the ophthalmologists. Already, the man named Louis Girard, had interested me in ophthalmology, and I hung out with the ophthalmology crowd at the Wilmer Institute when I was a private medicine intern. I’d talked with Ed Maumenee. He had just had a resident drafted out of his program by the Air Force, so he said, “2 people equally qualified, one’s had his military, and then one has not. You know who gets a job?” I said, “Okay.” I applied to the Army and got accepted to go into the Army on July the first, so I could be done in 2 years. At my interview in Fort Sam, Houston, where they sent everybody, they asked “What do you want?” I was going to want to be an ophthalmologist. Would I like an ophthalmology residency in the military? I said, no, I want to try this at a private hospital, but I said to them, I would like it if possible, to be a General Medical Officer near a military hospital. DK: I was single at that time, and I was not making trouble, so they shipped me. They assigned me to a small dispensary in Ascom City in Korea, where there was the 121st Evacuation Hospital. There was a board-certified ophthalmologist there, and I did that job for about 3 to 4 months. They transferred me to a corps headquarters where they had a three-star general, swimming pools, football teams, PX’s, and they also had Red Cross Donut Dollies who had worked in the demilitarized zone. I ran a dispensary, with about 8 soldiers, and I took care of both American soldiers as well as Koreans. DK: A very important thing happened at that time, we realized that a lot of our military patients, which is usual, FIG. 1. Drs. David Knox, Frank Walsh, and Robert Welch at the Wilmer Institute Library in 1975. e382 Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 2. A recent picture of Dr. David Knox. had venereal diseases and gonorrhea was one of them. And one of the most important things was gonorrhea had developed a resistance to antibiotics and I nagged the military people, I said, send the bacteriologic team in here, let’s make science out of this thing that we clinicians are seeing, and they did it, and it helped to establish the science of antibiotic-resistant venereal disease. And I had a good reputation for being somebody who sent patients with serious problems to the 121st evac hospital, or to a mobile army surgery unit, which was 5 miles away, and had a crazy surgeon who was commanding officer. It was one of those goofy guys that liked to operate. So that was an important part of my life at that time. And I came back to Fort Polk in Louisiana, got married and then came to Baltimore in July of 1958, to start a residency. MS: And that’s when you started ophthalmology residency? DK: That’s when I started ophthalmology residency at the Wilmer Institute. MS: Did you have particular mentors who encouraged you to go into neuro-ophthalmology? DK: Well, at that time, Frank Walsh was a very prominent person in the ophthalmology world. His was the third textbook of neuro-ophthalmology. One had been done in 1908, one in German, and one in English. But Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 Frank Walsh had done his first textbook (Walsh FB. Clinical Neuro-Ophthalmology in 1947, which was one of the first textbooks on neuro-ophthalmology. This later of course was revised with William F Hoyt in the third edition), I think he was on his second edition when I got there. It was every Saturday morning, we had neuroophthalmology rounds beginning at 10:30 and lasting until noon. The neurologists were there; the neurosurgeons were there. Frank Ford, who had written the first textbook of pediatric neurology was there on the front row with an unlit cigar, but always asking very pertinent questions. We also had Lawton Smith who was on the house staff, and he was enthusiastic about neuro-ophthalmology. He did a fellowship with David Cogan in Boston, and when it came time for me to finish residency I also went to Boston and worked with David Cogan for a year. MS: Who do you think your biggest mentors were throughout your training? DK: Well, Ed Maumenee was a very good ophthalmologist. He was a good surgeon. He was a likeable fellow. Unfortunate aspect of his life was that the woman he married had had an episode of optic neuritis when she was younger, and she had the progressive form of multiple sclerosis that made her bed ridden, which really upset Ed’s life, seriously. But Ed was always a straight shooter, and I went to Boston to do neuro-ophthalmology, and with David Cogan, who was a physiologist, he was editor of the Archives of Ophthalmology, he was a pathologist, and he ran a good show. DK: When I was there with David Cogan, we had 2 sessions in an afternoon of pathology and neuroophthalmology, and they were great successes. In 1969, when David Cogan came to Baltimore to be the visiting professor, we decided to create the first meeting where ophthalmologists came from around the country to Baltimore and brought with them the pathology of interesting patients that they had seen. It was instant success and became what is now known as the Frank B. Walsh Society, which we have at times meetings with over 600 people. MS: It sounds like quite the beginning back then. DK: The first 3 meetings were in Baltimore, in ’69, ’70, and ’71. We went to Chicago, came back to Baltimore, went to Philadelphia and it’s never been back to Baltimore since. But as you know, the Walsh Society is part of the first day and then NANOS follows up for 3 and a half days. It’s now called the Walsh Society, but it was originally called the Neuro-Ophthalmic Pathology Symposium. It is a core of our academic and it’s going to be by Zoom this year. MS: Would you have imagined, back then, that the Walsh meeting would still be going in 2021? DK: Well, all I knew was we had 29 people the first meeting, and it’s now 600. How do you predict something like that? Other than it was a success. It was success when I did it in Boston. It was success when we had the first ones here and it grew beautifully. e383 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations MS: Do you feel like the cases that are presented at the Walsh have changed over the years? DK: No. Well, I think the key to the Walsh Society is still the pathology of the process. Eye pathology is a struggling sub-specialty. There’s not that many doing it. It’s hard to make a living at it. MS: Let’s go back to your early career. Can you talk about your first job out of training? DK: October 1961, Ed Maumenee called me up and asked if I would come back to Baltimore and be on faculty. I said, “I have to talk with my wife.” She had relatives in Baltimore. We both liked the city and I called Ed Maumenee back and I said, “I’ll see you on July 1st.” MS: What was that experience like for you? DK: Okay. I was seeing consultation patients. I was trying to build a practice. I did some cataract surgery and I was also working with Frank Walsh on cases and also I had an interest in the work of Alan C. Woods, who was working on ocular inflammation. The technology for both neuroophthalmology and uveitis is basically the same. DK: You have to take a full past medical history and system review, and sometimes it’s necessary to put the patient in the hospital and get blood tests, and one of my more dramatic patients was a patient with multiple system diseases. He had episodes of 3–5 days of swelling and pain at one joint. A rheumatologist saw him and said, “That’s palindromic rheumatism.” Now, that rheumatologist walked out of the room, he didn’t look at the chart, but the patient’s white blood count was 15,000, 16,000, 16,500, and we dug, and we dug. Well, he ended up having Whipple’s disease, because he had indigestion, and an upper GI series done by the department chairman did not make the diagnosis, but a gastroenterologist looked at it and said, “Let’s get a jejunal biopsy.” Which we did, and it was classic Whipple’s disease. I wrote it up, it’s in the transactions of the Johns Hopkins School of Medicine as an article (1). That made my name at Hopkins and the patient was presented at Grand Rounds. The resident who presented it said, “David Knox, the ophthalmologist, was the one who continued to dig in this patient and gave us the answer.” DK: We had another patient who had died in 1936 and the Brits wanted to see the pathology, so I sent the man’s pathology to England and it came back after 6 months. I kept it in my office, the box of slides, because the neuropathology department had just sort of fallen into low activity. David Zee called me up one day and he had been reading about eye movement problems for a lecture, and he came across this case that had been written off in 1936, and he said, “David, do you know anything about a patient named Samuel S. Smith?” I said, “No, David.” 20 minutes later I said, “That’s the name of that patient whose box of slides I’ve had in my office for 10 years,” and it became a published case. The name of the article is Cerebral Ocular Whipple’s Disease: A 62-year Odyssey from Death to Diagnosis (2). Oh, was that fun to do. e384 MS: If you could go back and talk to yourself early on in your career, what would you tell yourself? DK: Well, that’s a tough one. When Frank Walsh asked Neil Miller to take over the editorship of Walsh’s text of Neuro-Ophthalmology, Neil came to me and asked, would I like to join him in that effort. At that particular point in time, I was the Chairman of the Admissions Committee to Johns Hopkins Medical School, and I was reviewing 3,000 applications a year before offering people an interview, and I had to say, “Neil, I’ve got this other job to do. I don’t have the time or the energy to get involved. I will help you in anything you ask me to do.” But I did not volunteer, I did not take him up on his offer because I was practicing neuromedical ophthalmology, I was doing the admissions committee job, and I had young children. I have 20 articles of neuro-ophthalmic pathology it’s part of my bibliography. That was my continued academic output. Reviewing 3,000 applications a year, that’s a lot of work. My current department chairman came into the system when I was chairman of the admissions committee. MS: It sounds like a busy time. DK: Well, it was a busy time. I’m flattered that you all are asking me to give you all these comments. There’s another point that I discovered when I was in medical school. I mentioned that a minute ago, is that the involvement with private patients is a superb way of learning medicine. Their stories are simpler than the alcoholic man who has had 3 strokes and is paralyzed, living in an intensive care unit of some kind or another. The private patient is the mechanism for learning medicine, and that was something I learned when I was in medical school, and I will repeat to anybody. That was one reason why I accepted a private medicine internship at Hopkins because I knew that it was a good way of learning medicine. MS: Is there anything about your career that you would go back and change if you could? DK: No, not really, no. I probably should have published more, but I had 3 children and a failed marriage, and I can’t think of anything. Obviously, I should have published more, and a recent colleague said, “David, you haven’t published lately.” At age 84, they told me to stop seeing patients. I’m 90 now. MS: How did that make you feel to be told to stop seeing patients at 84? DK: Okay, what had happened was, the recurrent tactic of doing medicine now is everything goes through the computer and the histories and everything is. I’m clumsy at a keyboard, and I was relieved because the pressures of creating a document, all the stuff that is less important but has to be there because the document wants it, is a problem, and I think it’s wearing people out. A lot of my contemporaries have quit medicine because the demands of the current technology are just too much for them. MS: This is true. What do you consider to be your biggest successes of your career? Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations DK: Okay, I consider my biggest success, the idea and the perpetuation of the Frank B Walsh Society. That to me, I think was the best thing that I did, and it took lots of help from different people who saw the benefits and the wisdom and the learning capacity from that particular methodology. That episode, the 8 hours of the interesting cases every year, it’s just insane. The room is packed with people listening to every word. Have you been to any of those meetings? MS: Yes, I’ve been to the past several. I missed last year also, due to COVID, but we all love them and they’re very interesting. DK: Yeah, I think it was when we were in Southern California. I was the only one that figured out, or I was the only one that asked a question about what it really was. It was a case from Vermont. MS: What was the case? DK: I think it was an astrocytoma, a cerebral astrocytoma, and I guessed it. MS: Are you going to join it on Zoom this year? DK: Yes, yes. I’m learning how to do Zoom. MS: That’s great. So otherwise, how do you spend your free time these days? DK: Eat, read, and sleep. MS: Yeah, sounds good. Do you enjoy it? [chuckle]. DK: Yeah. Well, I read a lot of different things. Medical publishing now is all online, so much of it is online, and so many things are very small print on the computer screen, which makes it hard to read, and it’s not the same as having a journal with articles that are easier to read. It’s changed things. I did not grow up bonded to the computer. MS: Yes, I agree, I like the paper ones better too. DK: I like the paper journal articles much better. It’s what I’m used to, and I don’t know whether the computer writing is any better now than it was on the journal writing. DK: And the diseases are different. MS: How so? DK: We don’t have as many infectious diseases. Trauma doesn’t seem to be as much of a place as it used to be, and it’s a very different world. MS: I can understand that. What advice do you have for those who are currently in their early years of their career? DK: Find a subject that is fascinating and keep it, just always work at it. Find a disease entity that is fascinating, that is interesting, or that you perceive needs help. The help is needed and working at it will help the patients. But find something that is a special interest and work at it. Also, you can’t do it all day, every day, because our world requires that you’ve got to grind out a lot of unimportant things. MS: Right, it’s definitely important to find something that you like though. DK: Yeah, find something that is fascinating to you and make that the thing that you do when you’re driving home and thinking about things. Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 MS: If you were trying to influence someone to go into neuro-ophthalmology, what would you tell them? DK: Spend time with a neuro-ophthalmologist; see the patients that they are seeing and get an introduction to patients with problems. There’s a new technology, which I perceive is in its chief complaint, MRI abnormalities, differential diagnosis of MRI, and you work from there. In contrast to an elaborate medical history and knowing more about the patient, this is one of the styles that has evolved. MS: Yeah, that’s definitely true. DK: Do you agree with me? MS: Yes, these days we rely so heavily on imaging, and a lot of times people forget to talk to the patient. DK: And it is effective, but it also means that there is less time to get a sense of the whole patient and the responsibilities of being involved with the whole patient in both the diagnosis and the continuing care. MS: Is there anything about your career or life that we haven’t talked about that you would like to talk about? DK: One of my things in life was at age 5 I lived in Brazil for 6 months, my grandfather was a mining engineer in charge of the world’s largest Manganese mine, and I lived in Brazil for 6 months, and it always made me feel different that I had had that. DK: And again, my experiences with David Cogan, Frank Walsh, Alan C. Woods, Ed Maumenee, and Lawton Smith. Lawton Smith was an important part of my life because he was a house officer when I was an intern, and he was my head resident at a certain point in time. It was very interesting. Lawton only came to one meeting of the Walsh Society, when it was held in New Orleans, and somebody who had been his fellow was running it, but Lawton did not come to the rest of the meeting, in part because Lawton enjoyed. He liked to be the center of the stage, and at the Walsh meeting, the center of the stage rotates around the people giving the reports. DK: Again, I emphasize the thing I’m most proud of was the idea and the development of the Frank B. Walsh Society. RC: I have one more question. RC: At the beginning, did you mention that you had spent some time in the UK? DK: Yes, here’s the story. About 1963 a fellow named Gerry Crock had been anointed to be the Professor of Ophthalmology in Melbourne. He got his ophthalmology training at High Holborn Hospital branch of Moorfields in London, and Gerry Crock came to Hopkins to learn neuroophthalmology as his long suit to go back and be the authority in Melbourne. But while Gerry Crock was in Baltimore he had some extra time, so he ended up in the retina clinic looking over the shoulders of L. Harrel Pierce and Bob Welch, and he realized that they were doing things for the eye that the people in London, England, had not done at all. Well, it turns out that Gerry Crock wrote back to London and said, “Boys, you are far behind. They’re e385 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations operating and saving eyes that you don’t even operate on,” and that produced a flow of British retina specialists to America. DK: He was followed by a fellow named Dick Galbraith. Galbraith had been at the Moorfields City Road Hospital, before he went back to Melbourne. But they recommended to a fellow named Barry Jones, who was the head of academic ophthalmology in London, that I was teaching things that they were not hearing in London. Barrie Jones invited me to come to London for 6 months where I taught neuro-ophthalmology, and it took me a couple of months to figure out how to do it. At Queen Square, I ended up doing a Friday afternoon, once a fortnight session of teaching neuro-ophthalmology and the young London ophthalmology residents came, and it was a success. One day, I walked into the conference room and sitting on the front row was Roger Bannister, the man who had run the first 4-minute mile and he came to one of my talks. Michael Saunders was there and he was going to come to America and work with Bill Hoyt in San Francisco before he went back to London, which he did. Those 2 men, their exposure to American neuroophthalmology and then retina, helped to change the world a great deal. DK: So that’s an aspect where I taught neuroophthalmology in London for 6 months, and I came back in time to be the head of the Wilmer Residents Association. It was a very good experience. e386 RC: Well, I’m glad we heard about that. That’s an incredible contribution. Thank you for talking about it. DK: Yeah, we had a steady flow of Brits coming to America to learn, mainly, retina and some of them came to do neuro-ophthalmology, but not very many. MS: Well, Dr. Knox, we thank you for joining us today for this Great Conversation. We’re glad to record all of these wonderful contributions you’ve had to the field of neuro-ophthalmology and we’re grateful for all you have done. DK: You’re welcome. Thank you for this opportunity. MS: Bye. Thank you. RC: Thanks Dr. Knox. DK: Bye-bye. ACKNOWLEDGMENTS Drs. Seay and Digre are supported in part by an Unrestricted Grant from Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. REFERENCES 1. Knox DL, Bayless TM, Yardley JH, Charache P. Whipple’s disease presenting with ocular inflammation and minimal intestinal symptoms. Johns Hopkins Med J. 1968;123:175–182. 2. Knox DL, Green WR, Troncoso JC, Yardley JH, Hsu J, Zee DS. Cerebral ocular Whipple’s disease: a 62-year odyssey from death to diagnosis. Neurology. 1995;45:617–625. Seay et al: J Neuro-Ophthalmol 2021; 41: e381-e386 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.