Contributor: Arnold Weissler Chief Resident 1958-1959

The happiest day of my life came at 6:30am on a cold and dreary November morning in 1954 when I answered a long distance telephone call. It was a young woman's voice with a distinct southern accent, "Doctor Weissler, you have a call from Dr. John Hickam at Duke."

In a few seconds, Dr. Hickam spoke, "Dr. Weissler, we are offering you a position on the Duke house staff as junior assistant resident for next year, will you accept?"

I immediately responded, "Many thanks, Dr. Hickam, I am delighted to accept." He replied, "Good, we'll see you in late June." This was the realization of a dream.

I first became aware of Duke University in my early teens. Our family was visiting my older brother who was in the Air Force in North Carolina. During a tour of Duke on that occasion, I became captivated by the ambiance of the magnificent campus. I thought then, "Someday, I am going to attend this University." That hidden goal, thereafter, never left my mind. Dr. Hickam's call thus marked the first happiest day of my life.

In early autumn 1957, while on patient rounds as senior assistant resident on the Endocrine service at Duke Hospital, I received a call from Mrs. Bess Cebe.

"Dr. Weissler, Dr. Stead would like to have a brief conversation with you, can you come down?" During the previous three years, I had completed a year of junior residency and two years as a cardiovascular research fellow under Dr. James V. Warren.

Dr. Stead, Dr. Warren and I often discussed our mutual interests in circulation and my research projects. It was a time when I came to know and admire "Bess," as did so many of my contemporaries, as a gentle and wise sister in-aid to the house staff and totally dedicated to the Chief. I sensed some urgency and thus proceeded posthaste to Dr. Stead's office. As I passed her desk, Bess nodded gently, "Go on right in, Arnie" she said, pointing to the open door to the chief's office.

I had no idea what Dr. Stead wished to discuss. However, I had learned that when he requested a brief conversation, it was about a specific idea, question or task that he had in mind; one that would be well conceived and thought out, and generally novel or unconventional. The conversation was indeed brief. I remember the opening words. "Arnie, I have a proposal for you. Harvey Estes is going to leave the VA as Chief of Cardiology section to take on some new responsibilities at Duke."

He then unfolded his plan. He proposed that, when Dr. Estes left, I would take over the chief's position at the VA for the remainder of this academic year and in July, assume the position as chief resident at Duke. He went on to say, "After you finish the chief resident's job, we will put you back as the chief of cardiology at the VA."

It is difficult for me to recall my immediate reaction-surprise, exhilaration, and consummate joy, a realization that I may someday reach my second hidden goal-to be an academician in medicine.

I told Dr. Stead that I was deeply flattered by his proposal and expressed my profound appreciation for his confidence in me. As I floated on a cloud out of his office, I caught a twinkle in Bess' eye and a knowing smile.

This was the second happiest day of my life.

Teaching Rounds Syncope

Soon after my arrival at Duke as a new Junior Assistant Resident in late June, 1954, I encountered many tales related to morning report and bedside rounds with Dr. Stead. Most prominent were stories related to the Stead power to "faint" a house officer or medical student in the course of the presentation of a patient's history and physical findings during teaching rounds. The usual precipitating event was the posing of a pertinent question or comment, wherein Dr. Stead would stare at the presenter in anticipation of a reply.

At morning report during the first week of my rotation, conversation was directed to an episode of teaching rounds syncope. During teaching rounds the previous morning, one of our students presented the history and physical examination of a black woman who was admitted with confusion and severe hypertension. Dr. Stead queried, "What do you think is this patient's problem?"

The student's response was, " I suspect that the patient has severe anxiety and significant hypertension."

Dr. Stead quietly switched on his ophthalmoscope, which by custom he carried with his stethoscope to bedside rounds, and performed a meticulous fundoscopic examination. Upon completion of his examination, Dr. Stead looked up, stared at the student and asked, "What did the eyegrounds show?"

There followed a pause. All eyes then fixed on the presenter who was observed to be ghastly pale, hyperventilating and diaphoretic. He collapsed, falling toward the floor and was rescued from injury by his colleagues. He recovered promptly and was excused from rounds pending his full recovery. The ophthalmoscopic examination revealed grade 4 vascular changes with papilledema. The patient had malignant hypertension.

The student had not performed a fundoscopic examination. Dr. Stead announced that the student would certainly have known about the diagnostic eyeground changes had the housestaff done their teaching job.

After discussion of malignant hypertension, conversation at morning report turned to the nature of the student's collapse. "What do you all think is the mechanism of fainting in a normal young person?" Dr. Stead queried. A profusion of possible explanations was offered by the residents including a sudden fall in arterial pressure, a profound decrease in cerebral perfusion, a marked fall in cardiac output due to vagal induced bradycardia , hyperventilation, venous pooling in the lower extremities and combined circulatory effects.

He then asked, " What do you think precipitated the event?" There was no response. It was so early in the year, the residents could not bring themselves to mention the emotional impact of Dr. Stead's question during clinical teaching rounds.

"Well, I think you all had better read Dr. George Engel's monograph on "fainting." We will resume our discussion after that; let's go on to the next patient."

The 1950 Engel monograph, now a classic, included a discussion of the syncope that occurs in response to sudden intense fear in animals, when the physical reaction of flight or fight is frustrated, a response that Charles Darwin described in 1872. The monograph included a summary of the then limited studies on the circulatory changes in vasodepressor syncope in humans, several of which were reported by Dr. Stead and his colleagues.

The events surrounding this episode of fainting during teaching rounds ignited my continuing interest in the physiologic reactions leading to vasodepressor (vasovagal) syncope in humans. It was the subject of my first publication as a cardiovascular research fellow at Duke, co-authored by James Warren, Harvey Estes, Henry McIntosh and James Leonard.