Dr. David PecoraBorn: October 2, 1916

Died: July 24, 2014

Married: Dorothy Beavers Pecora, on July 22, 1944

Children: Michele Pecora and Ann Diamond

David V. Pecora, M.D., graduated from Columbia University in 1937 and from Yale School of Medicine in 1941. He was a World War II veteran; as an Army surgeon, he served in the European Theatre from 1943 to 1945. After the war, Dr. Pecora completed his residency, and then became Chief of Surgery at Ray Brook State Hospital. He developed several surgical procedures, including transtracheal aspiration. The Surgical Intensive Care Unit he created at Ray Brook was among the first in the U.S. He was widely published and considered to be an expert in the surgical treatment of TB.

Adirondack Daily Enterprise, August 5, 2014

David V. Pecora, M.D., born October 2, 1916, died at his home in McLean, VA, at the age of 97 on Thursday, July 24, 2014. He and his wife, Dorothy Beavers Pecora, celebrated their 70th wedding anniversary on July 22. He is survived by his wife, Dorothy; daughters, Michele Pecora of McLean, VA and Ann Diamond of New Haven, CT. He also had two granddaughters both of San Francisco, CA: Vanessa Lindlaw and Melanie Loftus. In addition, his only great-granddaughter, Katherine Blake Lindlaw, lives in San Francisco. Of Dr. Pecora's four siblings, two remain: Mena Beasdlsley and Louise Williams of Yonkers, New York. He was predeceased by his brother, Peter Pecora and his sister, Tullia Ricci.

Dr. Pecora was born in Yonkers, New York to Tullia Muzi and Michael Pecora, both Italian immigrants from Agropoli near Naples. He graduated from Columbia University in 1937 and from Yale School of Medicine in 1941. He joined, as a surgeon, the surgical service of the Army during WWII, where he met and married Dorothy Beavers, an Army nurse. He served from 1943 to 1945 in the European Theater. Upon leaving the Army, as a captain, he returned to New Haven and Uncas-on-the-Thames to complete his residency in general and thoracic surgery. He was a founding member of the American College of Thoracic Surgery and a diplomat in both general and thoracic surgery. Much of his research and work were done in the field of tuberculosis while he was Chief of Surgery at the State Hospital at Ray Brook, New York in the Adirondacks. Among his achievements was his development of several surgical procedures, including transtrachael aspiration. While at Ray Brook he created a Surgical Intensive Care Unit for his patients, which was among the first in the country. He is widely published and considered to be an expert in the surgical treatment of TB.

After Ray Brook closed, Dr. Pecora continued to work and to do research in the Veterans Administration in PA, VA, and DE. Eventually, he concluded his career by going into private practice in Wilmington, Delaware where he specialized in trauma and vascular surgery. In 1998 he published an autobiography, entitled Between the Raindrops, which discusses not only his career, but his and Dorothy's wartime experiences. In 2007 he and Dorothy moved to McLean, VA, to be near their daughter Michele and her family. His hobbies consisted of fixing cars, clocks and other mechanical devices.

His daughter, Ann Diamond, writes:

I'll tell you one story:  They used to prepare the little pond for skating.  During the school hours the patients used it; but after school we kids would go down to skate.  There was a log cabin with a fireplace we used to change skates in and they had a speaker set up to play skating music.  One time we all were playing crack the whip.  I was at the end of the line and got cracked.--and as it turned out, so did my ankle. 

One of the groundsmen came by and picked me up.  He literally carried me into my father's office, where my father was working behind a desk piled so high with in papers we couldn't actually see him.  The man told him what happened.  My father didn't get up from the desk;  we heard his voice behind the barrier of papers say, "Take her to x-ray."  I was carried down the hall to the x-ray suite where my ankle was x-rayed immediately and it was determined I had only sprained my ankle.  It was a long time before I realized that everyone didn't have their own x-ray machines and that the kind of health care I was accustomed to was unique.

Chapter XX of David Pecora's Between the Raindrops, Vantage, July 1998.  Courtesy of Michele Pecora

Forever Wild

As we mapped our trip we noticed that the hospital, named Ray Brook, was situated in the heart of the Adirondack State Park, between Lake Placid and Saranac Lake, the same Saranac Lake with which I had been threatened as a child to induce me to eat my meals. I remembered hearing of people who were sent there and never came back, and I had determined that I would never go there.

The State Park, established in 1894 when Teddy Roosevelt was Governor, included 2.8 million acres. Many people referred to the area as God's Country. I couldn't discern why. Did they mean only God could live there, or did they mean that only God could create a place so beautiful? Anyway, we decided to stop by on our way home from Ohio.

The narrow winding road from Watertown pierced the mountain wilderness. There were many swamps and lakes in the forest which blanketed the area. We encountered few dwellings and the occasional villages were very tiny. It was early morning and patches of mist hid many of the low lying gullies. We silently and quickly passed through the almost deserted streets of the town of Saranac Lake and, after traveling a couple of more miles, turned right at a sign pointing to Ray Brook. We drove down a narrow drive flanked by tall pines and birches and suddenly found ourselves at a mirror like pond on which swam a white swan. Before us were a group of buildings. The largest one, to the right, consisted of an interconnected series of wings, in the center of which was the main entrance, a multilevel combination of porches and curved stairways. On the left was a large modern brick building identified as the Infirmary, which we were later told housed the surgical service. In front of it lay a miniature nine hole golf course. A drive leading up a hill behind the main building led to a number of houses which were staff residences.

We climbed the main staircase and entered a large hall in the center of which stood a bubbling fountain. The furnishings were early American. Nearby a tall clock monotonously ticked away the seconds. We were met by Mrs. Laura Ward, an elegant matron with a friendly smile and graceful bearing, who identified herself as secretary to the Director, Dr. Fred Beck. Soon the Housekeeper, dressed in a spotless white starched uniform, appeared and conducted us on a tour. She explained that the interior decorator responsible for the elegance was Mrs. Trudeau, the wife of the son of the famous founder of the Trudeau Sanitarium. [See Note below.] The first building was authorized by a law signed by Governor Teddy Roosevelt in 1903 and constructed on a parcel of land consisting of 516 acres. The institution had always been a show place of the New York State Health Department. Its erection followed by only six years the passage of an ordinance by the New York City Board of Health declaring tuberculosis to be an infectious disease, and requiring mandatory reporting by physicians. The walls of the main dining room were covered with 18th century scenes. After seeing the main hospital we visited the chief surgeon's office which had been elaborately paneled in wood, Georgian style, by resident master cabinet makers. Finally we visited the house reserved for the chief surgeon, which was beautifully decorated, having been designed by the wife of last occupant, Dr. Joseph Gordon, a distinguished thoracic surgeon. Locally it was appropriately called the "doll house". As we toured the place, my daughters suddenly came alive and rushed to explore every room. They immediately chose bedrooms and demanded that I take the job. This was unsettling because I had just decided that the place was too isolated.

After our tour we were ushered to Dr. Beck's office. He was tall and impressive in appearance and seemed to know all about me. I learned that he had graduated from Yale, both premedical and medical schools, After preliminaries he reviewed the history of the hospital. Dr. Max Chamberlain, a famous thoracic surgeon in New York City and Dr. Joseph Gordon had served as Surgical Directors (Principal Thoracic Surgeons). Dr Edward Welles and Dr. Warriner Woodruff of Saranac Lake, both pioneers, were consultants. The former had served in the British Army during World War I and was the first thoracic surgeon to come to the area. Dr. Archibald in nearby Montreal had done the first thoracoplasty for tuberculosis in North America. Dr. Norman Bethune whose rib shears almost everyone used had been at Ray Brook before volunteering for service in the Spanish Civil War and later with the Communists in China. Dr. Alfred Blalock of Johns Hopkins had been a patient at Ray Brook. Dr. George Thorn, Chairman of the Department of Medicine at Harvard, had done research there. Dr. David T. Smith, Professor of Bacteriology and Medicine at Duke had investigated fusospirochetal and fungal infections at Ray Brook. Dr, Hugh Burke had done monumental work on silicosis in local iron miners. Dr. Harry E. Rose had left Ray Brook to become Chairman of Microbiology at Columbia. In 1938 Ray Brook staffers had reported the first well documented outbreak of histoplasmosis. The Ray Brook microbiology laboratory was one of the best in the field of tuberculosis. There were a number of other renowned hospitals in the area including the Trudeau Sanitarium and Laboratory, Will Rogers and Sunmount Veterans. An animal laboratory and the resources of the New York State Health Department were available for research. The hospital was loosely affiliated with Albany Medical College and was used by the University of Vermont for clinical teaching. The local schools were reported to be top notch; and opportunities for recreation were innumerable. They had all of the winter sports. Nearby Lake Placid had an Olympic Stadium, ski jumps and slopes and a bob sled run. In summer the lakes and streams were available for sailing, swimming and fishing. Of course there was also hunting, which did not interest me. My salary would be increased slightly. There were many perks such as maid service, use of an automobile for official trips, low rent and wholesale food prices. The chief surgeon would be second in command to the Director. It would be an opportunity to spend time with my family as all of my work would be on the grounds. As we drove back to Providence Dorothy and I discussed pros and cons. By the time we arrived home we had decided to take the job.

My friends at the Providence Veterans Hospital were convinced I had made a mistake. The folks in Yonkers concurred. They jokingly said that we were going to the North Pole. Actually there was an area on White Face Mountain named North Pole, where the kids could meet Santa and Mrs. Claus and the elves. Anyway, we wound up our affairs and went on our way.

As we approached our new home I began to wonder if my friends and relatives might have been right. Certainly, I was not moving towards my goal of becoming a cardiac surgeon. On the other hand, our social status was changing from low middle class to country gentry.

On arrival at Ray Brook I met my physician associates, nurses and other staff. We were welcomed like members of the family and assured of everyone's cooperation. I soon learned that the personnel were exceptionally competent, what many people would call overqualified. They were reliable, industrious and took great pride in their work. Most had been former patients who had left skilled positions to "cure" and had stayed on as employees. The Chief of Microbiology, Dr. Diran Yegian, was formerly a veterinary surgeon. One of his technicians was a prize winning photographer. The Surgical secretary, Sophie Philipowicz, was a whiz, who would have been worth her weight in diamonds in the private sector. I never had to give her instructions more than once. She worked rapidly and never made a serious error, almost always completing assignments ahead of time. The Ray Brook staff worked as a team and as a result were able to achieve excellent results.

My first few operations were carefully observed by Drs. Welles and Woodruff, until they were satisfied that I was competent. To assist me I had a Surgical Resident and a Fellow. In addition we had well qualified consultants in various specialties. In time I was able to develop a strong affiliation with the Upstate Medical Center of the State University of New York at Syracuse, where Dr. C. Barber Mueller was Chairman of the Department of Surgery. He had been trained by Dr Evarts Graham at Washington University in St. Louis. Thereafter, Surgical Residents from Syracuse rotated through Ray Brook regularly. Our affiliation proved to be exceptionally fruitful, as Dr Mueller was an excellent educator.

Governor Averell Harriman was a frequent visitor to the area as had been his progenitors. When he made rounds with me the day after I performed an arduous and fortunately successful operation, I was surprised by his profound knowledge of pulmonary disease until I later learned that his son-in-law was a pulmonologist. We had many other distinguished visitors, mostly physicians responsible for tuberculosis control in foreign countries. I entertained many of them at home, which gave our daughters an unusual opportunity to become acquainted with other cultures. I also learned of the tremendous accomplishments they sometimes achieved with limited equipment.

Ray Brook lay between the villages of Lake Placid and Saranac Lake. The former, the site of a Winter Olympics, was dedicated to vacationing and sports, especially for the wealthy. The latter developed as a tuberculosis treatment center. In the past the two villages had little in common and were often at odds. Dr. Francis Livingston Trudeau [sic: Edward] originally came to Saranac Lake to die in pleasant surroundings after contracting tuberculosis while caring for his brother. Being a naturalist he had himself carried to a hunting camp belonging to a guide named Paul Smith. To everyone's surprise he recovered to become one of the early advocates of fresh air and sunshine in the treatment of tuberculosis. In 1885 he built the Little Red, his first treatment cottage. Almost simultaneously he added a laboratory as he was one of the first to accept Koch's discovery of the infectious nature of tuberculosis. Gradually the area attracted additional physicians and patients including many notables. Later the Veterans Administration built a large hospital and research center in nearby Tupper Lake.

Treasure Island was one of my favorite stories, and Robert Lewis Stevenson a favorite author. Never imagining that we would cross paths I was surprised to learn that he had lived in both Bournemouth, England and Saranac Lake where he took the cure for tuberculosis. His cottage was now a museum. A memorial tablet quoted him. "I was walking in the verandah of a small house in which I lived, outside the hamlet of Saranac. It was winter; the night was very dark; the air extraordinary clear and cold, and sweet with the purity of the forests. From a good way below, the river was to be heard contending with the ice and boulders: a few lights appeared, scattered unevenly among the darkness, but so far away as not to lessen the sense of isolation. For the making of a story here were fine conditions..."

Farther to the east beyond Lake Placid was another museum in the former home of John Brown, whose body lay a smoldering in a nearby grave. Unknown to many he had engaged in abolitionist activities there before going to Harper's Ferry.

The area surrounding Saranac Lake attracted many outstanding physicians and became a teaching center for pulmonary diseases. They held many symposia, the best known being the annual Trudeau Symposium on Pulmonary Disease, the General Practice Symposium on Pulmonary Disease and the Sunmount Conference sponsored by the Armed Forces and Veterans Administration. New York State also had inter-hospital conferences. We at Ray Brook were privileged to be contributors of faculty and clinical material in these endeavors.

One of our frequent visitors during various symposia was Dr. John Strieder from Boston University. He surprised me by commenting that we were able to obtain better results than they could in large centers because I "specialed" my patients. He said that it was the diligent perioperative care that made the difference and this was not possible in large institutions. Perhaps the greatest proof of our success was the preference of our staff to be treated and have surgery at their own institution.

The well staffed Will Rogers Hospital was reserved for members of the performing arts guilds. They hosted a steady stream of famous entertainers, the most popular being Helen Kane (Betty Boop). Many villages, including Saranac Lake, held winter carnivals to interrupt the monotony of the long winters. The festivities, featuring notables, including Sachmo Armstrong, Sonia Heinie [sic] and Arthur Godfrey, offered opportunities for our young people to perform on stage and to skate in the Olympic Arena. We learned to tolerate temperatures as low as 40 to 60 below zero Fahrenheit and never became bored. Now we were sure that it was God's country because He had made it so beautiful. I could understand why former patients hated to leave. The serenity helped us to concentrate on our tasks and to strive for solutions to the many medical problems we faced.

Perhaps I was the only person in the area who had come strictly for professional reasons. In time I learned its rich history. Before the advent of the whites the natives had never settled in the mountains. Excavations had revealed nothing of archeological interest. Jacques Cartier laid claim to the area for Francis I of France after he founded Montreal in 1536. In 1609 Samuel de Champlain explored the area but the mountains did not seem suitable for settlement. John Jacob Astor became rich on the pelts of local animals. Others exploited the timber and iron ore. Many famous people visited and vanished including Viscount Chateaubriand, Joseph Bonaparte, Ralph Waldo Emerson, James Russell Lowell, James Fennimore Cooper, Mark Twain, and Presidents Theodore Roosevelt, Calvin Coolidge and Grover Cleveland. In addition there were Winslow Homer, Rockwell Kent, George Gershwin, Grace Moore, Arthur Rudinsky, Harry Lauder, Al Joleson [sic] and many others. It seemed that almost everyone had been there.

Ray Brook received problem cases from everywhere in the State, and indirectly Puerto Rico. Since surgery was just one mode of treatment, non emergency management decisions were made by the combined staff physicians at periodic conferences. Because treatment was prolonged patients and physicians became well acquainted with each other. Our large surgical waiting list gave the patients time to become familiar with their options, especially when decisions regarding the use of new drugs had to be made.

One of the first things I did on arrival was to establish a pulmonary physiology laboratory and to continue gathering information to supplement my previous research. I ordered a new machine featuring Clark/Severinghouse electrodes which could translate blood carbon dioxide and oxygen tensions into electrical currents. Much to my surprise the apparatus was not approved after one of our consultants, a leading pulmonary physiologist, declared that the apparatus was nothing but a black box. This forced us to follow our patients clinically, since the usually used van Slyke technique was too time consuming to be of value when results were needed most. I also ordered a new anesthesia machine equipped with a mechanical respirator to be sure that patients would be properly ventilated during anesthesia since the recent literature had shown that older manual methods were inadequate. A newly designed portable cuirass type ventilator was acquired to be used postoperatively.

To minimize the need for blood transfusions which were causing immunological reactions and transmitting diseases such as hepatitis I developed a meticulous hemostatic technique using the high frequency coagulator developed by Dr. Harvey Cushing and his associate Mr. Bovie. As a result we were able to do about half of the lobectomies and a fifth of the total pneumonectomies without having to transfuse the patient (1). Much to my surprise, many surgeons criticized our technique claiming that the coagulating device predisposed to infections. In time they were proved to be wrong, but for awhile they made us uncomfortable.

One of the problems encountered by thoracic surgeons was the question of the ability of the patient to physiologically tolerate a planned procedure. To determine the answer one had to know the patient's preoperative status and also the effects of each type of operation. Although a number of ventilatory tests were being used to evaluate pulmonary function accurate standards had not been established. There was even less information regarding the effects of various operations on pulmonary function. Since joining Dr. Kelley at Uncas I had kept detailed records on almost every patient upon which we operated providing an extensive data base which we now attempted to refine. As I reviewed the data I found I was able to solve the problem of comparing different individuals of different sex and stature by reducing the postoperative values to a percentages of their preoperative values. Surprisingly this simple mathematical maneuver allowed us to compare the data of all patients with each other. We then found that all patients behaved simililarly to a statistically significant degree. We discovered that merely opening the chest produced a deficit in ventilation which took about six weeks to return to preoperative values (thoracotomy effect), that removal of up to 70 percent of a lung produced no measurable ventilatory effect on a patient with relatively normal lungs(2), that operations on the chest wall were better tolerated than operations on the lung, and that it took a lot of fluid or air in the pleural space to seriously affect lung function. We were able to measure the effects of various operative complications (3), learning that open thoracic operations were the most, upper abdominal operations less and lower abdominal operations the least depressing to ventilation. Operations on the perineum, neck and extremities had little effect on breathing (4). When a prominent surgeon claimed that bilateral lung operations were better tolerated when done simultaneously than separately, we were able to prove that he was wrong (5). We found that diaphragmatic hernias had to be very large before they affected ventilation (6). By measuring pressure in the pulmonary veins and arteries we were able to establish that the real risk of dying from surgery was from right heart failure secondary to increased pulmonary vascular resistance. After we made all of these determinations we were able to accurately predict risks and almost all mortality (7). We also found that we could successfully operate on many patients heretofore thought to be too risky(8). We developed improved methods of diagnosis(9) to limit resections to diseased portions while sparing a maximum amount of functioning lung.

As the whole field of pulmonology was rapidly evolving there always appeared more questions than answers. Each break through created more problems than it solved. New drugs were being introduced and the methods of administering older drugs improved. Surgically, our foremost problem was always how to control tuberculous operative complications (10). We cultured both the patients expectorations and the resected tissues and were able to establish the fact that available first line drugs could sterilize the lung. It was easier to do this if there were no cavities. We were able to establish a correlation between duration of therapy and the culturability of the organisms in the tissues. For awhile there was a question of the viability of organisms which could not be grown in the laboratory. However we showed that they behaved clinically as though dead. After determining the behavior of various lesions we were able to adapt our surgery to remove only threatening infectious cavitary areas, thus preserving function (11).

Many patients microorganisms developed resistance to our most effective drugs. To determine the effectiveness of newer or less potent older medications we developed protocols keeping very detailed records of results and complications (12). Although patients were fully informed regarding toxicity and possible risks we never lacked volunteers. Fortunately our results were usually good.

Although pulmonary resection was now common there was no consensus regarding the proper treatment of the residual pleural space after removing a whole lung. Some surgeons prophylacticly collapsed part of the chest (thoracoplasty) in the hope that they could prevent postoperative air spaces from occurring. We proved that such procedures were ineffectual. Persistent spaces tended to become infected. Anecdotally it was thought that mediastinal displacement interfered with cardiac function. Many surgeons performed postoperative thoracoplasties to prevent this from happening. Unfortunately thoracoplasty adversely affected pulmonary function. We proved that we could fill the spaces by actually encouraging mediastinal displacement and that the latter had no ill effect.. As a result we rarely found it necessary to perform disfiguring thoracoplasties for such purposes.

Another theory held by many surgeons was that lung distention caused emphysematous disease. Over the years we were able to prove that this too was not so. We were also able to prove that pulmonary vascular resistance was unaffected by the usually encountered degree of postoperative distention of the remaining lung (13).

We treated patients with fungus diseases and atypical mycobacterial infections as well as common suppurative infections, cancer and bronchial diseases (14).

Many of our patients had obstructive pulmonary disease with asthmatic like symptoms. When we studied them we found that the bronchial obstruction was due to both inflammation and spasm (15). We learned to treat each component, often improving the condition of borderline patients sufficiently to permit them to tolerate surgery.

As we cultured lung specimens routinely we learned that almost all patients with tuberculosis or cancer did not harbor organisms found in the mouth. We learned that contrary to the common belief the healthy lung was sterile (16). Since expectorations were contaminated as they passed through the mouth we developed a method of obtaining specimens directly from the lower respiratory tract by inserting a small catheter into the trachea with a needle (17). This method was widely adopted especially in research and was also useful in detecting cancer (18). We also determined that commercial catheters which supposedly retrieved uncontaminated lower respiratory tract specimens were not reliable (19).

We saw many patients with chronic empyemas(20), infections of the pleural space, and determined that most of the mixed tuberculous and pyogenic infections were the result of contamination during medical and surgical treatments. We found that we could cure tuberculous infections with antimicobacterial therapy alone even if other microorganisms were present. Then we could handle any residual infection in standard fashion. Above all, early treatment avoided chronicity.

Wound infections in thoracic surgery had always been a serious problem, often enough to shut down operating rooms (21). As a result we monitored our activities very carefully. We redesigned the operating room, installing air conditioning which introduced filtered outside air at a slightly positive pressure to prevent contaminated hospital air from entering by other routes. We sampled operating room air under various conditions testing the validity of accepted recommendations. We found that shoes and clothing were not carriers of contaminants. We tested masks and tested and designed one of the first "space suits". We proved wrong the prevalent practice of not having patients wear masks because of the belief that they were immune to their own microorganisms. We demonstrated that the exhaust gases from anesthesia machines were at times contaminated. Our most important finding was that the skin of room occupants was the chief source of wound infection, the risk increasing with the number of occupants and their length of stay. On the other hand we found that talking was not an important factor. A very surprising finding was that antibiotics given postoperatively did little to prevent wound infection even though the offending microorganisms were susceptible to them. Future research would show that antibiotics had to be given preoperatively to achieve an effective tissue level during the procedure.

It was commonly believed that the normal skin harbored microorganisms in sweat and other glands. Dr. William Halsted had devised the epithelial stitch for animals because he did not wish to puncture infected hair follicles with his needles. When we tried to verify this concept we were surprised to learn that the follicles and glands of the normal skin were sterile (22), and simple methods could be used to sterilize the skin of the operative field. Cumbersome commercial barrier drapes were costly and usually not necessary. Once more we proved that much that is accepted in Medicine is unfounded.

At times patients with neck and chest wounds would occasionally develop huge collections of air in their tissues, a condition known as subcutaneous and mediastinal emphysema. Though usually frightening to behold the condition rarely threatened life unless accompanied by lung collapse. Many believed that patients with neck wounds could suck air into their tissues. As there was considerable uncertainty regarding proper treatment. we took the problem to our animal laboratory and proved that air could not be sucked in from a neck wound and were able to propose for the condition a simple treatment which in our hands worked very well (23). A surprise finding was that air embolism, the introduction of air into the circulation, could be caused by increasing the pressure of inspired air (barotrauma).

To minimize postoperative pain and disability we developed an incision which was small and injured muscles minimally (24). The procedure was so successful that many patients requested it preoperatively and proudly exhibited their small scars postoperatively. One such patient, returning for a visit, said that her physician had told her that he didn't believe she had a lobectomy because her scar was too small and her x-rays looked normal. Years later the procedure found its way into the surgical literature as a new discovery attributed to others (25). We also did studies of the effects of suturing techniques on bronchial healing (26).

At one time it was believed that people with pulmonary tuberculosis were less likely than others to develop lung cancer. We showed that the opposite was true and called attention to methods of separately diagnosing the coexisting diseases. Later we confirmed that there was a relationship between scarring and malignancy (27).

We did not forget the esophagus. and were able to show that both tuberculous lesions and severe scarring due to reflux, with or without perforation, could be managed without sacrificing the organ (28). For many years I disagreed with the popular practice of removing the organ for benign disease because it was thought too dangerous to treat otherwise. Perhaps I was influenced by a patient I had seen in the Army who had been shot in the chest. When first seen he had a bullet in his esophagus. While we were performing diagnostic tests he swallowed the bullet and later passed it. Except for penicillin he needed no other treatment and recovered fully. We continued to study gastroesophageal reflux, encountering many patients with related pulmonary symptoms. Unfortunately many physicians would not believe that esophageal reflux could cause pulmonary complaints. We noted that the usual radiological methods of diagnosing hiatal hernia were inaccurate and developed a balloon tube and other methods of improving diagnosis (29).

We were so busy with other more pressing problems that I had to postpone my intravenous feeding studies. I never forgot that Bill Abbott at Western Reserve had showed that operative mortality was proportionate to preoperative weight loss and did my best to maintain our patients' nutrition, gavage feeding many who could not eat enough with a specially prepared highly nutritious formula prepared by our dietitians.

Ever since I was a medical student I was concerned about ways of cataloguing important medical information and being able to retrieve it. My first solution was to summarize everything on 3x5 inch index cards. I developed a simple index system based upon anatomy, pathology and physiology. Later I developed home made punch cards. Unfortunately, the process was dependent upon my personal perceptions and I could not delegate the tasks to others including my secretary or residents. I also used mechanical calculators, slide rules and other devices as they became available. When I joined the New York State Health Department I took advantage of the opportunity to utilize their facilities for handling statistics, which were first rate. I sent follow-up letters to all discharged patients and their physicians and recorded their replies. All of this required many hours of extra work, which was not apparent to the casual observer. I recall one instance when a physician happened to see me working with punch cards and seemed very interested in my activities remarking that he thought I had a simple system. Several weeks later I observed one of his associates working with punch cards. The associate explained that his group had decided to write a paper the easy way like I did. Several months later when I asked him if the paper had been published he replied that they couldn't finish the paper because they had never realized it was so much work. Fortunately he did not succumb to the temptation to fudge results as was common. Personal computers, when they arrived, made work much easier but did not eliminate it.

My past experiences had impressed me with the value and necessity of the honor system in medicine and research. I was convinced that almost all physicians were honorable. Unfortunately, I had a rude awakening, which was a prelude to my eventual realization that plagiarism was rather common. Of course, I knew it occurred frequently in industry and I had learned that Dorothy's ancestor, Benjamin Russell Hanby, had found it necessary to sue his publishers to prevent theft of the songs he created, but I thought Medicine was different, that is, until Dr. Beck returned from a meeting in an unhappy mood. He announced that a surgeon whom we knew had read a paper almost identical to one I was preparing for publication and had presented to several small groups for editorial criticism. When I suggested to Dr. Beck that the truth would eventually become evident he disagreed. After obtaining an apology from the culprit we thought we had corrected the matter until we realized that he never acknowledged my authorship publicly. Subsequently, others have appropriated my materials without acknowledging the source. Our transtracheal procedure leaked prematurely and found its way into the literature. Fortunately our purpose in developing the procedure remained a secret until we published it. I once asked a medical student eager to do research to study the effects of external pressure on the lower esophageal sphincter using an apparatus I designed. He did not complete the project and went to another center. Several months later my apparatus, attributed to someone else, appeared in the literature. Several procedures I developed and taught to residents but did not publish were later presented at meetings as the creation of others (30).

Particularly vexing to the careful investigator are publications which are not meticulously done or intentionally falsified. Although subsequent experience tends to expose their errors the perpetrators enjoy temporary undeserved acclaim. Unfortunately reliable investigators must waste valuable time correcting these errors. Medical literature is replete with great claims which are never substantiated. Few ever publish retractions. Another disturbing practice has been the tendency to list large numbers of authors to papers, many more than could have made significant contributions. This practice is an obvious ploy to permit many individuals to list the same limited number of papers in their bibliographies to create the false impression of great productivity. Rarely should a paper have more than three names on it. Minor contributions can be recognized in other ways. A more recent tendency in medicine, especially in surgery, has been the employment of the media, often enlisting free lance writers, newspapers, radio and television to glamorize accomplishments of questionable value. Obviously, such publicity is as reliable as advertising for consumers products.

We have never had to retract any of our publications since we have worked carefully. Professional honesty is the very foundation of research and should not be abused. Unfortunately, our present culture supports dishonesty. Professor Casey knew all about the problem.

With increasing productivity scientific journals did not have sufficient space for much valuable information. Moreover the limited space that existed was inefficiently utilized by many editors, who often paid more attention to circulation than quality. Also journals tended to restrict their material to specialized fields. Delays in publishing undoubtedly facilitated a number of well publicized instances of plagiarism by reviewers who subsequently published under their own names articles they had rejected. My solution to the problem was to establish electronic libraries and journals with unlimited capacities to remove the middle men and effect rapid dissemination of information (31). The concept would take over 20 years to be accepted--not soon enough to help me.

Sequestered in the Adirondaks I lost track of outside events. Senator Joseph McCarthy was condemned by the Senate. Germany, allowed to rearm, joined NATO. Once more there was talk of war with the Soviets, who countered with the Warsaw mutual defense pact of communist nations. The Supreme Court desegregated schools. In 1956 Egypt seized the Suez canal precipitating an international crisis. The first transatlantic telephone cable was initiated into use. Israel invaded the Sinai. In 1957 Britain set off their hydrogen bomb in the Pacific. The Soviets launched the first man made satellite, Sputnik I, which worried Americans over our apparent scientific inferiority. In 1958 we launched our first satellite, Explorer I. The first transatlantic jet air service was initiated.

Note: On May 24, 2019, Ann Pecora Diamond wrote that the décor at the Ray Brook Hospital was designed by Annie G. Dewey of the Lake Placid Club, not by Mrs. Trudeau, Jr. Her source was "Woodland Whispers," a patient newsletter at the Ray Brook san. Mrs. Dewey was well-known in the field of home economics.