In the last quarter of this century, following the Supreme Court decision in the case of Roe v. Wade (1973), the social and surgical management of pregnancy termination took on a new face. It became yet another ethical enigma for physicians and surgeons, a major change in the ethical awareness of our era. It has touched all people, especially women, and all surgeons and physicians. From the viewpoint of gynecologists and obstetricians, who so often witnessed the tragic disasters associated with self-induced abortion and abortion parlors, the relocation of this surgical procedure to the realm of hospital care with sterile precautions seems to be such a tremendous improvement that it has outweighed other considerations. Saving lives and ending misery is not a new concern. Gynecology was an integral part of our department. If a department of a hospital is put in the position of providing this service, then it should be done right, both surgically and ethically.
It is important for everyone, including the opposition, to realize that few women ever really want an abortion. A woman may need one and ask for one. But she does not really want it. Certainly not the young girl embarrassed by her life-changing fix. Or the mother of five who feels she just can’t carry another pregnancy or afford that sixth child. Neither wants to abort her own offspring. She may even have been through the experience before but still does not want it. In many instances, religious
zealots overrate the importance of their ideological bias and seek to force on everyone a policy that fits their own personal needs. They are not the only ones who do not want an abortion.
During our medical school days and in the early years of my surgical work, pregnancy terminations were of the utmost rarity in hospitals, being done only to save lives in critical emergencies such as when the mother had tuberculosis, a heart attack, or epilepsy. And then, often in the second or third trimester. By contrast, we saw many disasters of illegal abortions, especially overwhelming pelvic infection (infection around the uterus) due to septic abortions. Such infection was always destructive, if not lethal, always resulting in infertility.
One Saturday morning, a few years after Roe v. Wade, Somers Sturgis and I were walking into the operating room and looking at the day’s schedule. Pregnancy terminations were carried out on Saturdays. There were six of them that morning. At larger hospitals there might be even more. Of course we knew this was going on, but nonetheless we looked at each other in wonder and amazement. We just couldn’t believe how widely accepted surgical abortion had become. Nurses and other hospital staff who did not wish to participate in these procedures were never required to do so, nor were they questioned about their reasons. It is important that most of those patients did not fit the customary image of the college girl in trouble or the high-school girl who drank too much. Instead, they were apt to be mothers who wanted to do some family planning but were about 3 months too late. Now that the liberalizing (yes, liberal) view of enabling abortion has been expressed and endorsed as widely as it has been in this country, crossing all political, regional, ethnic, and religious barriers, no political forces of repression or restriction seems likely to hold it back. Better to keep it legal and make it safe. I have no objection to social safeguards such as parental permission for minors and a waiting period with, under specified circumstances, spousal consent.
Through these troublesome years I have gained respect for the view that we should not take young lives, but let us not make those lives in the first place. Let us pursue birth control and improve education for young people. Let us brave the scorn of a younger generation by talking out loud about these issues. Let us encourage personal devotion, commitment, and love as necessary accompaniments of sex. We favor marriage
over informal cohabitation. These are important solutions, each of them only a partial one, to the problem of illegitimate pregnancy, unwanted children, and abortion.
The taking of life is not the only issue in abortion. Rather, it is the avoidance of a life not validated by love and care. Other countries do it differently. Far better legal abortion in the United States than septic abortion here or female infanticide in the Far East. In India, female children are sold out to prostitution or enforced marriage. Better than either are love, caring, and commitment as an integral part of sex.
The case of an illegal abortion gives an idea of where such convictions come from for our generation of surgeons. Cases like this help explain my advocacy of legal, clean, safe surgical abortion as a right of choice for American women.
The patient was a 23-year-old woman who had been divorced. During her marriage she had borne four children. Since then she had been pregnant on two additional occasions, both pregnancies being terminated by illegal abortion. The year was 1964, 9 years before Roe v. Wade. Now, in the fourth or fifth month of her seventh pregnancy, she went to an abortion parlor. At that time a frequent method of inducing abortion in the underworld was the infusion of Lysol or soapsuds into the vagina. Upon her request, a pressurized soapsuds douche was administered. As might be expected, no sterile precautions of any sort were taken.
The next day the patient began to have chills and abdominal pain and was admitted to the Brigham on March 5, 1964. Her blood pressure was low, her pulse rapid, and she had ceased to make urine. On pelvic examination, the uterus was large and extremely tender, with the feeling of crepitus. Crepitus is the sensation you get by running your hand over something filled with a lot of small bubbles. (During World War I, the feeling of crepitus under the skin of a wounded man indicated that bubbles of gas were forming within the tissues in the region of the wound. This was gas gangrene, a common occurrence in that war, less frequent now. Ominous, often lethal.)
As is typical of septic shock, her blood pressure was low (80/40).
Her temperature was low rather than high, a dangerous sign indicating that the patient’s resistance to infection was fading. Her white blood cell count should have been very high but was very low (another bad sign), and she was anemic. Waste products were accumulating in her blood because her kidneys were not working. That she already had lung trouble was evidenced by a low oxygen tension in her blood. She was panting and trying to breathe, air hungry. Pelvic examination had confirmed that she did indeed have an infection of the type produced by the Welch bacillus, Clostridium perfringens, the gas bacillus. X-ray showed bubbles of gas in the uterus. The blood culture was positive, meaning that these anaerobic organisms grew directly from her blood on culture. Given this overwhelming and deep-seated anaerobic gas bacillus infection with kidney failure, a fatal outcome seemed inevitable.
One of our residents at that time, Robert H. Bartlett, was taking care of her. He consulted with experts in obstetrics and in infectious diseases and sought the use of the new high-pressure oxygen chamber at the Children’s Hospital Medical Center next door. She was given penicillin, streptomycin, and antitoxin against tetanus and gas bacillus infection. An emergency operation was performed in which her damaged uterus was removed. As soon as the operation was completed she was taken to the hyperbaric oxygen chamber.
About 20% of the air we breathe is oxygen. High-pressure oxygen chambers employ 100% oxygen at 2 atmospheres pressure. This means that the partial pressure of oxygen within the chamber is almost 10 times higher than it is in the air we breathe. High oxygen tensions are toxic to anaerobic bacteria. The term anaerobic means that the bacteria are able to live without oxygen; oxygen is poisonous to them. After the oxygen treatment, she was prepared for dialysis on the artificial kidney because of her kidney failure. This remarkable combination of aggressive steps in treatment led to her recovery. On the 12th postoperative day her kidneys started to work again, and on the 40th postoperative day, after a long convalescence, she went home, well and healthy.
My only role in the care of this patient was in encouraging Bob Bartlett and the staff to take the necessary steps and for him to follow his own remarkable insights. That the patient recovered so beautifully was
entirely due to his vision, imagination, and aggressive care. He is now Professor of Surgery at the University of Michigan.
That this young woman had such a terrible, life-endangering episode was due in part to the fact that legal abortions were not yet available. But this crisis was also traceable to the fact that her emotional life was out of control, with repeated pregnancies and repeated abortions. She was an exploited, confused, struggling orphan of our social controls long before she had this abortion. Although we sought the advice of psychiatrists and social workers while she was with us, they did not hold out much hope of redesigning her life.
It has been said that the quality of a society is measured by the care it gives to its least fortunate members. We gave this unfortunate young woman care that returned her to life. We could only hope that she would lead her life better in the future than she had in the past. While the statistics were against rehabilitation, she surely would never become pregnant again.
A case like this makes us stand in awe of the complex and fateful ramifications of reproduction in our society. And it shows again, as do several of the other cases described in this book, how medicine and science, for all their high-tech complexity, can help humble, low-tech people in distress. And how clean surgery to terminate pregnancy is to be much preferred over the filthy manipulation of illegal abortion.
At the other end of life there has also been a change during our years of surgery. But this has been a change more in the thinking of the public than in the ethical awareness of physicians and surgeons who have embraced these problems and tried to help solve them for many years.
Doctors of our generation are not newcomers to this question. Going back to my internship days, I can remember many patients in pain, sometimes in coma or delirious, with late, hopeless cancer. For many of them we wrote an order for heavy medication to be given regularly by the nurses. Morphine by the clock. We were assisting with a softer exit from this world. Nurses helped willingly. This was not talked about openly, and little was written about it. It was essential, not controversial.
According to the press, another reason this problem has become so urgent now is that with such measures as assisted respiration, assisted heartbeat, and an artificial kidney, we are able to keep people alive long after they otherwise would have died. These patients, some of whom have long since lost their desire to live, have attracted lawsuits and court actions and have brought headlines on this matter to the public view.
It is my conviction that although such patients on complex life-support systems have focused attention on the matter, they are but a tiny fraction of the total population for whom this matter of preserving unacceptable existence becomes urgent and urgently demands a solution. Many patients who want surcease from life are not being kept alive, either by machines or by the machinations of physicians or family. They have managed to survive too far into the progress of disease by dint of their own efforts, better hygiene, and nutrition. While doctors may not have been guilty of keeping them here, they need guidance on helping them leave.
Another concept that has brought this problem into focus has been the definition of brain death, that is, defining death as having occurred when the brain no longer shows any activity. This definition of death was established by the Commission headed by Henry Beecher in 1966. The group was asked to define death legally, morally, and biologically—not only to clarify the answer to the medical-legal question “When is a person actually dead?” but also to decide at what point the human body could become available for the donation of its precious anatomical resources to give other people a better life. This definition of brain death was primarily based on prolonged, irreversible coma. It stated, in essence, that if the brain was long dead, the person was also dead.
Soon this reality was extended to include people who might have been in coma for only a few minutes but who had suffered irreversible and irreparable physical destruction of the brain by a bullet or blunt injury, as in a shooting or an auto crash. I believe it is a tribute to the level of education of the public both here and in Western Europe that the concept of brain death was widely accepted within a decade.
Going back to Chapter 1, where we saw the human body as a dwelling place for a person’s mind and soul, the concept of “brain death” helps move our thinking along. As soon as you understand the meaning
of brain death, you begin to appreciate the converse meaning of “brain life.” The brain can be alive in a suffering person, while the rest of the dwelling place itself is in such wreckage and is the source of such anguish that the person should be allowed to leave that dwelling place by achieving brain death. No human being should be required to remain very long in the terrible situation of fearing death and at the same time wanting it to come as soon as possible: a living mind seeking brain death.
This matter has now reached the stage where all physicians should declare their credo, at least to themselves. It is my credo that assisting people to leave the dwelling place of their body when it is no longer habitable is becoming an obligation of the medical profession. It is part of the doctor’s job. This new job for the physician is being defined against a rapidly moving backdrop of changing images that include doctors doing this publicly and possibly illegally; new laws being proposed in some states and nations making it legal, acceptable, and possible; families who want to pull the plug or remove the tube; and anguish over the suitability of physicians’ behavior in helping soul leave body. Inevitably, both society and the law will come to accept a variety of solutions. Broader ranges of acceptability will develop in a decade or two.
It is best to approach a struggle with clear views of the obstacles ahead. As this matter moves closer to practical reality, we can be sure of two things. First, that many will be bitterly opposed to any social and legal acceptance of the physician caring for patients in death, assisting them to leave their bodies by achieving brain death. This will become as emotional an issue as pregnancy termination and rather similar to it in pitting personal choice against unremitting life preservation. It will involve a similar struggle between available choice and stand-pat bias. There will be strong feelings and deep human awareness of potential abuse and misuse. While we can expect headlines about doctors undoing a tradition that goes back to Hippocrates, there will be a strong public awareness that such a step is often essential to the doctor’s historic mission of care and caring for human life, its quality as well as its duration. Events have broadened the physician’s responsibilities. Now we must often hurt before we can heal. In the future we will be called upon to heal by declaring the dwelling place uninhabitable.
Second, we can be sure from the very outset that when physi-
cians’ care in death becomes either commonplace or publicly accepted, this privilege will occasionally be abused.
The best way to bring the problem into focus is to describe two patients whom I cared for in the later years of my clinical work who exemplify the many problems of this genre. The basic human understanding that went into their care and the thinking of those near them have a strong bearing on this problem of the ethics, ways and means of care, in death. Experiences like these have been weathered by many families, physicians, and surgeons of our era. These two epitomize many similar challenges in my surgical years.
The patient, formerly a nurse, had sustained a fractured pelvis in an automobile accident. A few days later her lungs seemed to fill up with a process that at first was called pneumonia, but soon other causes became more likely. She stopped making urine and her heart began to act up with dangerous rhythm disturbances. Her blood pressure began to fall. She was transferred to our hospital, to the Bartlett Unit.
On admission she was only intermittently conscious and became unable to oxygenate her blood adequately. An endotracheal tube was placed for assisted breathing, and with machine assistance she achieved higher oxygen tensions in her blood. With a slow, low-volume transfusion, her blood pressure picked up. She was placed on dialysis for renal failure. She improved but was neither fully conscious nor aware.
The mystery of what was going on in her lungs was hard to solve. In people with fractures of the pelvis, bone marrow fat sometimes leaks out into the circulation and produces a disorder called fat embolism. Because she might also have had some such transport of fat to her lungs, she was placed on an anticoagulant, despite its hazards. This helped her. But as her breathing began to improve, her heart rhythm became more erratic and she lapsed into deeper coma. An electrical pacemaker was placed, running from a vein in her neck down into the heart. With the help of this device, she was able to maintain a strong regular heartbeat.
So there she was: in coma, on dialysis every couple of days for kidney failure, intubated, on machine breathing, heartbeat maintained with
an electrical device. Being kept alive with all those high-tech machines. Since she was on the Bartlett Unit where I made rounds every day, I was well aware of her precarious status.
One day after rounds I was in my office talking to one of the residents. There was a knock at the door. My secretary said that two relatives of a patient on the Bartlett Unit wanted to see me. I asked her to show them in. Because I had glimpsed them over the last few days, and many of the staff had talked with them at length, I recognized one of them as the husband of our patient, the other as one of her sons.
They sat down with me, looking sad and gloomy. As well they might. They told me that their wife and mother was obviously going to die, that she did not want to die this kind of a death while being maintained by machines. She was a nurse and had told her family that she never wanted this kind of terrible death in the remoteness of a hospital intensive care ward away from her family. Death with dignity, at home if possible, had been her wish.
I told them that while I respected their view, we should all be aware of the fact that she did not have cancer or some other malignant condition. There was nothing intrinsically lethal about her situation. It was precarious. It was dangerous. It was unpleasant. But not necessarily fatal. She did not have severe vascular disease, by which I meant anything resembling a stroke or a heart attack. The disturbed heart rhythm for which she had received a pacemaker was one that often returned to normal, leaving no trace. The sort of kidney failure she had was just the kind for which the artificial kidney was most effective. Many such patients recover their kidney function and a year later have perfectly normal kidneys. Such lungs as hers could also recover completely.
I did not want her family to think I was going to force things on them or could guarantee recovery. They wanted to have her care discontinued, the plug pulled, although they did not use those exact words. They wanted to have all those artificial devices disconnected and let her die in peace and without pain.
I listened attentively, shook their hands, and told them that we did not feel death was imminent and, in fact, she might well recover completely. For the moment at least, we should hang in there. I asked
them if they would stick with us for a few more days and invited them to call me or come see me again as often as they wished.
While possibly a bit reassured, they were disappointed. Here was the head surgeon seemingly determined to keep everybody alive, no matter what, just as they had read in popular magazine articles about those misguided doctors. I tried to tell them such was not my philosophy. But you cannot review all of ethical philosophy in a few tense moments. I just said, “Let’s give her some more time.” Somewhat more content, but still unhappy, they thanked me and left.
About 3 days later her kidneys began to open up. Over the next week, slowly but surely, the patient dug herself out of her troubles. Our diagnosis of fat embolism to the lung was never substantiated by a lung biopsy or by any of the meddlesome methods one might use. In any event, the lungs cleared up just the way fat embolism does. Anticoagulants were stopped. She no longer needed the machine to breathe, and the endotracheal tube was taken out.
When patients start to get very sick, they often seem to fall apart all at once. Everything stops working: a syndrome known as multisystem organ failure. The reverse is also true. When dreadfully sick patients start to get well, suddenly everything starts to pull together at once like an eight-oared crew that has suddenly got it all together with a good coxswain: multisystem organ recovery.
Within a few days the patient’s pacemaker could be removed, and she awoke from her coma, albeit a bit fuzzy. She could not remember anything that had happened over the previous weeks. She left the hospital and went home with her family.
I did not happen to see the husband and son again up on the Bartlett Unit, and I didn’t even give it much thought, because I knew of course that they were pleased. The younger staff kept in close daily touch with the family. About 6 months later I was again in my office, on a day when I was seeing patients. So it was not unusual when a woman and her husband and son walked in. My secretary asked them if they wanted an appointment. They said yes, they did, but they weren’t really patients anymore. They just wanted to see me. To talk.
Doris Lewis, my secretary, was intuitive. She sensed that this was something very meaningful to these people. She vaguely recalled their
first visit. So when a gap opened up in the office schedule she told me over the intercom that a woman, husband, and son wished to see me for a few minutes. Somehow I had a flash association and thought of that patient.
The door opened and in walked a gloriously fit woman with her snappy new dress and a large picture hat. She was prancing, almost waltzing. Showing off. The husband was feeling good and smiling. The son trailed in, proud to be with his parents.
They introduced themselves and after some cheery words of appreciation, the father and son asked to speak to me alone. They had planned this. The wife and mother—the patient—went out and sat in the waiting room.
As soon as the door closed, both men became tearful. They didn’t quite know what they wanted to say and couldn’t really say it. All that came out was, “We want you to know how wrong we were...” and “We’re so glad that you did what you thought was right.” I knew what they were thinking. No explanations were needed.
I thanked them for their thought and told them again how much confidence I had had in the recovery of their wife and mother. I gave them a few minutes to collect themselves. They left the office quietly, joined her, and departed.
There is a lesson here for everybody. The lesson is so obvious and has such a timely message for all of us that I won’t even repeat it. Res ipsa loquitur. The facts speak for themselves. Assisting people to leave this life requires strong judgment and long experience to avoid its misuse. It is always a clinical decision, not an ethical, legal, or religious decision, despite the importance of those aspects in getting there.
The second patient whose case is relevant here was an elderly lady whose hair caught fire while she was smoking. Elderly women are especially prone to bad burns when they live alone, if they smoke, and especially if they drink and try to operate an electrical appliance. Although we never got the story straight, she had put some sort of liquid or hair tonic on her hair and while smoking had also tried to dry it or blow it with an
electric hair dryer. It was not clear just what the source of ignition had been. Maybe a spark. She arrived at the hospital with a deep burn involving her face and the upper part of her chest, the very area that might be exposed in a woman wearing a nightie. Only 15% of her body surface was burned, but a very critical area it was. She was 85.
She had been a sprightly woman, well educated. She was not an alcoholic. She was admitted directly to the Bartlett Unit, and we gave her the usual resuscitation.
From career-long experience I knew that a burn even of this small size including the face and the upper airway (nose and throat) in a woman of this age would surely be fatal. But if my own personal experience was not enough to go on, several statistical and probabilistic analyses had recently been done in which percentage of burn and patient age along with other variables were taken into consideration. Young infants are highly vulnerable to burning. Tiny babies with a burn of only 15 or 20% of their body surface are apt to die. It is for them that heroic removal of the burned skin and replacement with skin grafts from parents may sometimes be life-saving. And at the other extreme of age, as in this patient, small burns are lethal. Even though the patient’s heart, lungs, and kidneys seemed to be working pretty well day to day, because of her age they lacked the reserve required to deal with the added burden of such a severe injury.
We had not yet formulated a specific plan for this patient, but we had talked about the options. And we had talked with the nurses. Nurses are of immense importance to any consideration of what should be done for patients with a life-threatening illness. The nurses have a deep sense of what is right and wrong with patients. They know the families. I have had nurses warn me not to pay attention to a family because they were interested in their inheritance rather than their mother’s welfare. While that was not the case here, it is an example of why it is important to consult with nurses in such critical situations.
As a remarkable coincidence there was a seminar going on at that time on medical ethics, given by the wife of an official of our university. She was interested in ethics in general as well as the ethics of medical care. The seminar course was given at Harvard College, but upon my invitation she brought some of the participants over to the hospital from time to
time to have discussions with physicians. A day or two after our patient was admitted, she asked me if I had any sort of an ethical problem that I could bring up for discussion. I said yes. So, when the patient had been in the hospital about 3 or 4 days, the time was right for me to bring this case up for discussion by these bright-eyed young students.
I described the case of this 85-year-old woman who had a small burn, but one that would surely kill her, a very painful death. Part of the skin of her face and neck would slough off, and she would require skin grafts if she lived long enough. I told them she would probably die in a week or two of kidney failure. At the time I was presenting this case (in the previous 12 hours) her urine output had begun to decline—the first sign of kidney failure.
After I told the students about this agonizing situation, I asked their opinion. Some thought morphine by the clock was the way out. Others were violently opposed to this course and said it would be murder if we didn’t do everything conceivably possible to keep the old lady alive as long as possible. Every minute we could. Even in pain. At 85.
No vote was taken. If somebody had suggested a vote, I would have been opposed to polarizing their opinions. After the discussion I made a remark that was, in retrospect, a serious mistake.
I said, “I’ll take the word back to the nurses about her and we will talk about it some more before we decide.” I did not think twice about making this simple, matter-of-fact statement.
The response was immediate and totally unforeseen, at least by me. The instructor, the ethics expert, and the students were shocked.
“You mean this is a real patient?”
“You mean this is a patient there in the hospital right now?”
I said, “Yes... I thought it would be most important for us to deal with some ethical problems the way they arise in real life.”
The ethics class was shocked. I will not record the rest of the conversation except to say that the teacher of ethics was not accustomed to having her prejudices challenged by reality. She wanted make-believe, fantasy, on which to drape her gossamer of theory. I will admit to pique and a flush of anger at her seemingly self-serving desire for simplistic ethical fantasy rather than real-life cases. Why weave fantasies when reality is so fascinating and challenging? Truth is both stranger and more
important than fiction. So we did not exactly part happily. Later, we had a chance to talk it over and we remain friends.
In any event, I went back to the ward and met with the nurses. We didn’t say or discuss anything new. I made no mention of the ethics class. I did reassure the nurses that it was a good policy always to start out by treating the patient vigorously, as we had done. In this way the patient’s family would not worry that we just wanted to let go. In time, the family themselves would come to recognize futility. The nurses were often among the first to sense this.
Curiously, it was some of the younger nurses who were the most aggressive. They were the ones who wanted to continue treatment and start skin grafting right away (she would not have survived a general anesthetic). It was the older, calmer nurses who thought that we should somehow let her go if we could do it mercifully and with the blessing of the family.
Should we ask the patient herself? Febrile, in and out of coma, under drugs, often in pain, hallucinating and disoriented, it would be a cruel mockery of informed consent to ask her if she wanted to stay alive.
Here, as occurs all too often in the elderly, family members were few and far between. Her husband had died some years before. A daughter living in California, age 65, had been unable to afford travel to see her mother for the past several years. Only a grandson in New York could be reached by telephone. He had come up to visit once when she was first admitted, but he fled when he saw her and washed his hands of the whole affair. Since he was the nearest relative, I called him up and told him I thought his grandmother probably wasn’t going to make it and would he suggest any other members of the family to talk with. He just said, “No. Do whatever you feel is right.”
So, about a day or two later, when she was making little or no urine, her lungs were filling up with fluid because of heart failure and she was suffering terribly, we began to back off on her treatment. When she complained of pain, we gave her plenty of morphine. A great plenty. By the clock.
Soon, she died quietly and not in pain.
Neither in this instance nor in the cases of many other terribly sick patients we have helped along to an easy end have I been the least bit disturbed about the ethical problem now termed euthanasia. Maybe I have been too slow and too conservative. Too unfeeling? Don’t think so. I hope not.
For patients dying of cancer, I do not believe there is any insurmountable problem if they are in severe pain or in coma, near the end. As the responsible physician, you had better move ahead and do what you would want done for you. And don’t discuss it with the world—or any ethics classes—first. Maybe just one member of the family. The doctor should do his duty, which is to give the patient the best possible chance for good minutes, hours, days, but avoid prolonging agony.
The problem becomes far more difficult when the patient does not have cancer, a bad burn, or any other clearly terminal condition. Or when helping a patient leave this world would involve doing something drastic even though the patient is fully conscious and seeking death, with weeks or months ahead, as for some patients with acquired immune deficiency syndrome (AIDS). When patients are in pain or anguished by the necessity of invasive treatment (such as breathing or feeding tubes), they often seek a way out even though they have a good chance of recovery. In such cases, morphine by the clock is definitely not the answer.
The solution to this problem is just as much a part of the physician’s charge as is the care of the newborn or the elderly. It is becoming part of our responsibility to help patients safely and painlessly out of this life. I do not know just what form our social understanding of this problem will take. What ways we will find acceptable are still unclear. It will probably not be as simple as assisted suicide. Nor morphine by the clock. Nor pulling the plug, because for most such patients (as pointed out earlier) there is no plug to pull. It must involve legal safeguards. It will involve the family, so long as they can be trusted.
The clergy would like to be involved. I believe that many ministers of the gospel have an insight into such matters, but their importance is limited entirely to those patients who, before they were sick, were personally close to a rector, a priest, or a rabbi and for whom religion was an
integral part of their lives. While I welcome the clergy into the sanctum of those who must make these ethical decisions, I am not convinced that any class of people gains a special depth of human insight just because they deliver a sermon every Sunday. It is the patient’s relationship to them, rather than any pipeline to revealed truth, that gives the clergy their authority. The clergy should demonstrate through the patient’s affection and confidence that they have earned a place in this decision.
Now is the time for guidelines to be drawn and the public to accept some way for desperate patients—those in pain, anguished, or hopeless—who have good enough reason to want to leave their bodily dwelling place to do so. They need social approbation and the assistance of merciful science via their physician to acquire the ways and means of care in death.
Do not forget that most critically ill patients are emotionally upset, often mixed up, sometimes hallucinating, often heavily medicated, rarely getting things straight. If you follow the advice of such a disoriented patient just to console yourself about consent, you may be doing the patient a disservice.
Responsible physicians should join forces with the public to write a new chapter in medical education that places care in death in its proper context. It is tricky. It is dangerous. We need it and people are ready for it. It will relieve more suffering than did the discovery of anesthesia 150 years ago. Physicians today should help lead the public to understanding the nature of this problem and the need for a new solution.
It was the spring of 1972. I was meeting with Bob Ebert, the Dean, about several matters. So I thought I would spring it on him. After all, he would need several months for his committee to come up with a nominee.
“Bob, in July 1973 I will have been head of my department for 25 years,” I said.
“Quite a while,” he sparred, wondering what I was driving at.
“I have always said that no major department of a university should be under the thumb of the same person for more than a quarter of a century.” I was trying to get on with the matter.
“But you’re still doing a great job!” he said, wondering if I was just fishing for some words of praise.
“Thanks,” I said. “But I think it’s time we got a younger man to run the department.” This caught him a little bit off guard. So, he sparred some more, for time.
“When is your Harvard retirement age?”
“June 30, 1981,” I shot back. Obviously I had looked up the matter and checked with University Hall. Harvard retirement ages come in different sorts and sizes, and I was one of the older appointees, since my first faculty appointment had been in 1943. So retirement came on the June 30th after my 67th birthday.
“That’s great! Another 9 years as professor,” he said.
“Yes.” Now I wanted to drive home the point. “I would like to retire as head of the department next July.”
There it was. On the table. He became visibly upset. He seemed surprisingly concerned about it. Somehow I didn’t think that I, merely one of his 20 or 30 department heads, would loom very large on his list of worries. He tapped out his pipe. Filled it with new tobacco and tamped it down, slowly. Lit it up. Puffed. Swung around in his chair. This was a ballet Bob Ebert went through whenever he was stalling for time. It was such familiar body language that the students had lampooned it several times in the annual student burlesque. It said, “Give me a moment to think this one over.”
“You can’t retire now,” he said.
“Why not?” I shot back.
“Because I’m going to retire.”
I was stunned. In the one-upmanship of conversational poker, he had a royal straight flush! This was totally unexpected. I had thought I was surprising him, but he won.
Bob Ebert had been appointed dean by President Pusey in 1965. He had done a great job, particularly in shepherding the medical school through those difficult years of the late 1960s and early 1970s, years of student uprisings about the Vietnam War and public opposition to the new hospital. He had started up a large health maintenance organization (HMO), or prepaid care plan, known as the Harvard Community Health Plan (in 1969). This was one of the first and most successful of the university-based HMOs. He had had some differences with President Pusey, particularly when students occupied the main offices in University Hall in 1969. Bob Ebert, along with the deans of two or three other graduate schools, had counseled strongly against calling in the police or making any sort of a public nuisance out of this student action, which certainly bordered on violent trespass. Nate Pusey had apparently rejected his deans’ advice and called the police anyway. What happened thereafter is one of the darker chapters in Harvard’s history: the police threw out the students with considerable violence. There were some cracked heads. Our son Chip was a freshman at Harvard at that time. He and most of the uninvolved students thought that it was not a student riot at all, but a
police riot, that the police simply ran amok and took it out on all those rich boys.
I had enjoyed working with Bob Ebert and saw no need to cross him on this point. My plan had been to resign as department head in 1973. Now that was postponed to 1976, still 5 years before my Harvard retirement in 1981.
So it all worked out, and about 4 years after that talk with Bob Ebert I was able to struggle out of some of the responsibility I had accepted so excitedly on July 1, 1948. Laurie and I were much freer to do things together. I welcomed John Mannick, my successor as Moseley Professor, on that same day. He moved into the old Cushing-Cutler-Moore office. I yielded also my precious laboratories next door, which would be as convenient for him as they had been for me.
In 1977 Derek Bok appointed Daniel Tosteson as the new Dean of the Harvard Medical School and in 1978 he took over from Bob Ebert.
The retirement neurosis is basically a fear of not having anything to do. It affects busy people who are suddenly unoccupied. It also contains a germ of deflated ego. Having a lot of responsibility for many years makes a person feel important. Part of the retirement neurosis comes from a loss of that sense of being a cog in some important piece of machinery.
I was lucky on both scores. I would stay busy by helping raise funds to build the new hospital for which I had been busily working for so many years, taking on new national responsibilities with NASA, becoming the book review editor of The New England Journal of Medicine, and chairing the Massachusetts Health Data Consortium (MHDC). President Ford was kind to give me an assist when he asked me to become a member of the Board of Regents of the new federal medical school in Washington, the Uniformed Services University of the Health Sciences (Chapter 27). The MHDC is a free-standing organization based on collaboration of the Massachusetts hospitals to pool their clinical data using a standard method and terminology. This work fitted in with my longstanding interest in national health policy. So I had plenty to do!
The university-hospital committee again went on the prowl for a new Moseley Professor and Surgeon-in-Chief. In 1976 John Mannick was appointed my successor as the sixth Moseley Professor of Surgery at Harvard and the fourth chief surgeon at the Brigham. He was a graduate of the Harvard Medical School, likewise interned at the Massachusetts General Hospital, had been a staff member under one of our Brigham stars, David Hume, then Professor of Surgery in Richmond, Virginia. Mannick was brought to Harvard from Boston University. He was Moseley Professor at Harvard as well as Surgeon-in-Chief at the Brigham until he retired on June 30, 1994. Identification of the next surgeon to fill the Moseley chair did not have to wait too long, as we now welcome Michael Zinner as John’s successor. Considering the Brigham tradition, it is fitting that Zinner is a Hopkins trainee but in addition brings us fresh ideas from UCLA, where he pursued his surgical work before coming to the Moseley chair and the Brigham department.
Thus, the tradition of the Moseley Professorship of Surgery at Harvard carries on with flying colors and will soon celebrate the 100th year of its endowment. An important 200th anniversary was celebrated in 1982, because it was in 1782 that John Warren was appointed Professor of Anatomy and Surgery at Harvard. It was also in 1982 that the Harvard Medical School celebrated its bicentennial, and I was thrilled to be the recipient of an honorary doctorate. In 1990 a new surgical chair was endowed at Harvard University, named in my honor. This endowment came from the generosity of hundreds of friends, colleagues, and patients. This professor is to work with the Moseley Professor. In 1992 Nicholas Tilney was appointed the first Francis D. Moore Professor.
To have been one link in this chain of Harvard surgical leadership and to live to celebrate its 200th birthday was a unique privilege for me, as it would have been for any surgeon.
In 1976 the Dean gave me an office on the fourth floor of the Countway Library. It is perfect. Not much bigger than the cabin of a boat, but with a secretary’s office next door. I am grateful for this privilege. Imagine in retirement having an office right in the midst of the library and right next to the hospital where you could visit patients and old friends, and then, into the bargain, to have it just one story below the
Journal where you were going to work as Book Review Editor for 12 years.
On several occasions over the course of 50 years, I have been for a time a member of the editorial board of The New England Journal of Medicine. The term was usually 3 or 4 years. I served under a succession of distinguished editors including Robert Nye, Joseph Garland, Franz Ingelfinger, Arnold Relman, and now (appointed in 1992) Jerome Kassirer. The Journal enjoys a large circulation, something close to 300,000—a larger paid circulation than any other medical journal in the United States. Although the Journal of the American Medical Association (JAMA) has a larger circulation, The New England Journal of Medicine has entirely a paid circulation.
I went up to see Bud Relman one day in 1981, feeling underemployed, only to have him offer me the job of editing the book review section. I happened to hit the day he was ready to make such a change. A perfect job for a job-vacant retiree. Lucky again.
I accepted this task, worked at it for about 12 years, and enjoyed it immensely. The Journal receives 3,000 to 4,000 books annually. My job was to pick the approximately 500 to 550 books to be reviewed each year. And then find other people to review them.
Over the years I had reviewed a good many books and continue to review a few each year. As Book Review Editor it was my job to assign most of the reviews to other desks, and we rarely had a turn-down. We often asked distinguished senior scientists, physicians, pediatricians, and surgeons to review important new monographs in their field. For some of the other books we sought reviews from young people just starting out who were already making a mark in science or teaching.
The conduct of this book review section brought me a small income, always welcome when you are suffering from acute and chronic retirement. It also put me in touch with doctors of all stripes and many scientists over the country and over the world. After 12 years of this enjoyable job, I began to think that maybe they needed a younger man. I
am very proud of the fact that Robert Schwartz succeeded me as Book Review Editor of the Journal—the same Dr. Schwartz referred to in Chapter 20 who coauthored with Dr. Dameshek that key paper describing for the first time the immunosuppressive potency of 6-mercaptopurine.
As Book Review Editor I was impressed with the large number of medical books published every year. It became my conviction that most of them should be interred in some library soon after birth and spend the rest of their natural lifetimes or, rather, deathtimes there. I became disillusioned with the torrent of books in medicine. So here I am adding a ripple to that torrent.
When our youngest son FDM, Jr. (Chip), had finished college and medical school and was married (in 1976), our life, like that of all married couples, underwent a radical change. With the fledglings flown from the nest, our house was quiet. Empty. We rattled around. We moved to a much smaller house. But even there the house seemed vacant.
Despite this (and after 41 years of marriage), the pleasures we enjoyed together never abated. We went together on medical trips. Many visits to England, France, Italy, Scandinavia, Australia, New Zealand, and finally around the world via Australia, Bangkok, and New Delhi. Some years later we had a wonderfully interesting trip to China. Nice to have a wife who knew a bit of Chinese history.
On July 25, 1988, in a sudden, black, summer thunderstorm and thundersquall like the one we had driven through at the start of our honeymoon 53 years before, Laurie’s life was ended in a moment of terrible encounter. I was working in my office at the time; the great black cloud from which came the fatal thundersquall could be seen in Boston, coming in from the northwest. I looked at it and still remember a sense of foreboding. She was driving home from Carlisle, northwest of Boston, near Concord. Because of the darkness and the torrential downpour she could not see the fully loaded gravel truck bearing down on her tiny car.
The service in her memory was a simple one, held at the First Parish Church across the street from our home in Brookline. I had asked several young women, close friends of Laurie, if they would help as ushers at the service. Diana Phillips, niece of Rebecca Lewis, one of our closest friends, had become an ordained Episcopal minister. She had also been the chaplain at our hospital and had presided at the wedding of our youngest son, Chip, to Carla Dateo 3 years before. Diana's remarks, the service filled with music, the church filled to overflowing, marked a milestone in our family’s life but not an ending for Laurie. A believer in the soul of mankind, I have no trouble with the thought that her memory and her living legacy to her children and grandchildren constitute an eternal life for her as it does for any mother taken away in her prime.
A couple of weeks after Laurie’s service, our youngest grandchild was born. One of Laurie’s Bartlett family names going back to colonial days of New Hampshire was Colcord. He was named Francis Colcord Daniels Moore. His father is Chip. This young man, who never saw his grandmother, is known as Cord.
A month or so later, Laurie’s ashes were put into the earth on the hill above Grafton, Vermont, the village that was the home of my great-grandfather Francis Daniels and his son (my grandfather) Francis Barrett Daniels, and where my daughter Sally Moore Warren and her family now live. My father and mother, who died in 1966 and 1972, are buried in that same small Grafton cemetery. Laurie’s father had been buried in Peoria, Illinois, and her mother in Granville, Ohio. Laurie had told us that if anything happened, she wanted to be buried up on the Daniels hill, there, in the old Vermont cemetery. We had then been married for 53 years; she had been part of my life for at least 58 years.
After Laurie’s death came a new form of loneliness. Some men simply cannot get along alone. This might be especially true of men who married young, men who have had a happy marriage for many years.
Kathie Saltonstall and her husband William, formerly principal of Phillips Exeter Academy in New Hampshire, had been friends of ours for many years. In 1944, through my friendship with his brother Henry Saltonstall, a classmate, a surgeon of Exeter, New Hampshire, I had been asked to operate on their older son Bill, Jr., for appendicitis. Then, over the years, the acquaintance of the two families had become closer, and in
the last 15 years before Laurie’s death, Katharyn and Laura were intimate friends. Over the last 10 years, with her husband’s progressive sickness, our lives involved many parallel activities in Marion, Massachusetts, especially trying to help with Bill and taking him sailing, despite his illness. On other days Laurie was the crew for Katharyn in races that Katharyn often won, and Laurie could bask in reflected glory.
Katharyn’s husband was quite ill and bedridden at the time of Laurie’s death. We both had tried to help as best we could with Bill’s care. Laurie and I had been worried about Katharyn’s stress and fatigue during those hard years of his illness. Katharyn’s husband died December 18, 1989, about 18 months after Laurie. Kathie and Bill had been married 58 years.
Katharyn Watson Saltonstall and I were married about 6 months later, on May 13, 1990. We tried to explain to people that although we were newlyweds, we were embarking on our 111th year of happy marriage.
Like Laurie and me, Katharyn and Bill had five children. They had 16 grandchildren, we had 17. Katharyn has two great-grandchildren; a ways ahead of me. Katharyn’s younger son, Sam, had worked with us one summer helping to look after our youngest son Chip, who was about 10 at the time. Katharyn is a successful author. Small Bridges to One World (1986) is the story of the years she and Bill spent in Nigeria when he was the Peace Corps representative (1963 to 1965), supervising the work and tending to the well-being of almost 750 Peace Corps volunteers there.
The instinctive need for prayer usually arises from fear of the future, of the unknown. But it also arises from gratitude. Prayers of thanksgiving are deeply ingrained in the Christian tradition and have a secure place in American secular culture as epitomized by the celebration of Thanksgiving Day.
Since Laurie’s death and my marriage to Katharyn, I seem to have become a more religious person. Katharyn and I attend church fairly regularly, though not quite as steadily as we should. As I enter that Marion church—where we were married in 1990—I have the sensation, and I think Kathie shares it, that we are entering a place where, among other things, we can give thanks to some higher power for our marriage, for finding an end to our loneliness, and for our large and wonderful
families. Our Pastor, Bob Duebber, by his kindness and concern has added immeasurably to these feelings of reverence. It is said that older people acquire religion because they need it.
One might offer thanks to God (in the conventional sense of the Christian Church), to chance, to the forces of nature, or to the combined coincidence of our two families. When I hear of men who have lost their wives, or wives who have lost their husbands, I could never wish for them a happier outcome after loneliness and grief than a marriage such as ours.
Early to the hospital, late home. Sunday morning rounds. In times of despair our children referred to their parents as workaholics. In their more thoughtful moments they could hardly hold to such a view, and Laurie stoutly held up for our side. After all, we had sailed together in Buzzards Bay, ridden horseback in Wyoming, skied, fished, hunted, traveled, and sang with the best of them. We tried to broaden the experience of our children to realms beyond Boston, away from home, following the tradition initiated by our parents years before. Now, all five of our offspring are workaholics in their own way. Each of them attacks the particular problem at hand with fierce determination. While all have found satisfaction in their careers, each family has developed its own pattern of release.
Our hobbies boiled down to sailing and music.
While many summers of my youth were spent wielding a lasso or riding a horse on roundups up and down mountains, I had done some sailing as a youth. About 1947 we began to spend some summers at the seashore on Buzzards Bay and became addicted to sailing. Laura, likewise a middlewestern landlubber, also took to the salt water and enjoyed sail-
ing, being crew for Katharyn in the ladies’ races, also being the chief cook and bottle-washer on our cruising boat. She was keen of eye and ear. Navigating at night or through the fog, she was the most reliable in getting us where we should go, spotting the lights, hearing the groaners. In addition, she could take the helm and steer a compass course along with the best of them despite winds or tide. Our children took up racing and won their share of trophies.
Many of the hobbies of Americans are complex and demanding, something you have to work hard at. Sailing is an example. Sometimes sailing is beatific in brisk wind on bright water (as in the beer ads), but it can also be grungy work. On one occasion there was a clogged valve (probably valvular stenosis) in the carburetor of our engine. You could only get at it by taking apart the whole afterpart of the boat, exposing the bilge, which could be at times a bit oily, even smelly, and not as clean as we would have liked. It was a very hot day. I was stripped to the waist. Dripping sweat. Leaning down and reaching around in this filthy bilge water trying to locate the valve. Swearing softly to myself. Somebody peered down the hatch and said, “Hi Franny, whatta’ya doin’?”
In a moment of inspiration I replied:
“Yachting.”
The Moores and the Delands were the co-owners of a 40-foot Bermuda yawl, Angelique. Over the course of 12 or 15 years we did a good deal of ocean racing. As skipper, I conducted Angelique to Bermuda, on the Whaler’s Race at Block Island, and several times to Halifax. The Halifax Race became our specialty. Most of the time you can’t see anything because of the fog. One time we had a major northeast gale. But it was on the Halifax Race that we came closest to some sort of glory. In our class of 40-footers, we were second. Halifax is 365 miles from the start at Marblehead. We were only 38 seconds behind Ted Hood, a yacht designer and genuine pro. We are proud of our silver bowl. It is used to serve potato chips.
There is something especially serene about sailing at night, as you do on long ocean races. It is dark. Maybe a few stars. You are in your bunk up forward. As skipper you are apt to have a small compass there and a flashlight so you can secretly check on the helmsman. But more likely, you are drifting off to sleep on the off watch. There is only an inch
of mahogany between your ear and the entire ocean, which gurgles soporifically along the hull. Looking aft you can see up the companionway where there is the dim red glow of the binnacle light on the compass. And around it faces of family or friends, having a good discussion or argument, laughing, and enjoying themselves immensely as they guide the boat through the night sea. Sailing in the Gulf Stream on the way to Bermuda, flying fish are attracted into the cockpit by the binnacle light, flopping around in that strange place until they are assisted back to their element.
Then there are the storms, the crashes (we were hit full-on by another boat in one race), or the encounters with geology (once we hit a rock during a gale in outer Marion Harbor within sight of our house). If you do a lot of sailing, such things are bound to happen.
While there are many delightful moments in the world of cruising, few surpass the “happy hour.” It has been a long day in the wind and sun. Now you are in a secure anchorage. The hook is down. She is swinging kindly. It is the time for some snacks and a few drinks, on deck. The gulls are shrieking around, hoping for a handout, or geese are honking and hoping for their bit of a Triscuit with cheese. And maybe you can see an osprey gliding off to its evening hunt. As the sun sets, small lights go on in the cabins of other yachts around you. If you have been clever, you have fixed the main halyards so they won’t slap against the mast. And unless there is somebody on board who snores too loudly for kind words, you are in for a good night’s sleep.
Surprisingly, there are actually people who dislike yachting. I remember one horseman who said, “Why should I sleep in a narrow hallway with a toilet at one end and a smelly gasoline engine at the other?” I thought for a little while and said, “Well, you have different functions at the two ends of a horse.”
Music provides some of the same kinesthetic sensations and aesthetic joys as sailing. There is a sheer physical, muscular, pleasure in playing the piano, in the exercise of arms and hands, in hearing nice sounds come out. It does require a fair amount of work. We were
pleased that all our children at one time or another played two-piano or instrumental music with me. Some of them clung to their music more than others, but music did become a part of their lives: Peter playing the guitar, Sally as a choral singer in Vermont, Caroline with her two-piano music.
Music began for me at a young age when somebody thought I might be good at playing the piano. I never had any sense of practicing very much. While I was never disciplined or forced to practice, I played at the piano a good deal. During high school and college I was involved in various public performances: musical shows, concerts. Probably only a few of the musical sounds that an amateur makes are very pleasurable to others.
It was in college that I became involved with writing the music for two musical comedies at the Hasty Pudding (Chapter 6). And then later on, both in medical school and afterward, I continued to write some musical comedies. Those various musical comedies were often more comical than humorous. At medical school, John Rock was one of the pioneers in birth control. He was one of our teachers. So one of the jazzy songs of the medical school show in 1938 was Rock, Rhythm, and Romance. Here the word “rhythm” had an unusual double entendre: hot jazz and the female fertility cycle. And “Rock” meant Professor John, not a form of swing. In fact, the term “rock” for any sort of music had not yet been coined.
In composing later musical shows I enjoyed the coauthorship and collaboration of several talented people, including David McCord, who wrote the book and lyrics for one of our shows. It was based on the fanciful concept of a hospital that was losing too much money and a bank that was making too much money. Since the hospital needed money and the bank needed a built-in deduction, they merged. The name of the show was Futures and Sutures, or the Urge to Merge.
While the tunes for these ventures could hardly be referred to as serious music, they sometimes took the form of more conscientious pieces in the nature of trios or quartets. My musical philosophy defends the concept that all music is joyous, written to provide joy to the listener. True, there are exceptions, such as the requiems. And some of the passionate parts of the oratorios and masses, for example, the tragic Crucifixus
from Bach’s B Minor Mass. Possibly it would be an injustice to Bach, Mozart, Fauré, and Brahms to say that these requiems are intended to give joy to the listener. Maybe it would be better to say that all music provides the listener with an aesthetic experience, usually a pleasurable one. There is no fundamental difference between the music of Bach, Handel, Haydn, Mozart, and Beethoven and that of Gershwin, Porter, Berlin, Copland, or Bernstein. Some are greater composers than others, but all music has the same message of joy in performance and, if well performed, for the listener.
As I grew older, my sailing did not improve any. In fact, it deteriorated. I became very good at losing races. But my music seemed to improve.
About 1975, several of us got together (faculty and students) and formed the Harvard Medical School Music Society, or HMSMS. It was our intention to make the most of the musical talent in the medical school, students and faculty. One of our surgical residents had taught piano in Cleveland for some years and had performed all the Beethoven piano concertos with the Cleveland Orchestra. Another student had been first clarinetist in a symphony orchestra. Still another medical student, a violinist, was the sister of Yo-Yo Ma and, like her talented brother, a delightful performer. At HMSMS we could hear unusual duets and arrangements that the students themselves found and performed. We gave two concerts a year. I used to play piano in some of these concerts, usually playing one of two pianos, or else accompanying students. The performers came entirely from within the Harvard medical family. Now HMSMS is guided by a faculty wife, Annette Benacerraf. I have not played in the concerts so much recently.
“Hey Doc, whatta’ya do in your spare time?” is a question that every doctor (or his wife) is frequently asked. About a month or two before Christmas. Be careful what answer you give. I have a great many recordings piled up from past Christmases, and I have received quite a few life preservers. The former are most enjoyable. I am not sure the latter are much of a tribute to my nautical abilities.
This book should end with sparkling memories ofyouth. I especially enjoyed the brightness of those Wyoming years, living for a time each year in a part of the world quintessentially American. A part of the West claimed by the white man only since the Battle of the Little Bighorn, 50 years before we first arrived in 1927 and 50 miles away in southern Montana.
From high school years until entering medical school I enjoyed a drastic change of scene every summer. This Wyoming cattle ranch, by name the Horseshoe, had been put together from homesteads around 1890, as were many ranches in that part of Wyoming. In its early years it was a horse ranch providing remounts for the United States Cavalry. Range mares were bred to the remount stallions placed in that country by the army to improve the breed. Buyers sent out by the cavalry then came to pick up the product.
The circumstances of our summers there arose from the rental of the ranch house by my parents for a summer vacation of family and friends in 1927 and again in 1928, followed by their purchase of the place in 1929. They operated it for the next 17 years, and our summers were spent there. Our honeymoon was spent there. It was a bright and shining
aspect of our lives until the time when war, medical school, graduate studies, jobs, and a growing family of young children prevented our going there. We last went there for a vacation just before the war in 1941.
The Horseshoe Ranche (the terminal e a holdover, it was said, from the Spanish spelling) comprised 5,000 acres on the eastern edge of the Bighorn National Forest near Dayton, Wyoming. The western border of the ranch was the eastern border of the forest. It was also a distinct geologic borderline. To the west the heavily timbered mountains rose abruptly. From this border eastward lay the flat open plains of eastern Wyoming, stretching across the Powder River Divide, the land of the great cattle ranches of the 1880s (a small town there, Ucross, is named after one of those cattle brands), finally bounded by the forests of the Black Hills 150 miles away. This open land is marked by colorful buttes and mesas, pine-bordered rimrock, deep red cliffs, and shale. Rivers come down out of the mountains from melting snow, through limestone canyons, and change to a slower flow. They are lined with huge cottonwoods, making places of coolness and damp shade, of quiet pools for trout. A welcome contrast to the broiling summer heat on the plains. The grateful shade.
The hay and grain raised on these dry plains must be on meadows under ditch. The irrigation system consists of ditches leading from the streams as they emerge from the mountain canyons. Alfalfa is grown on the hay meadows, the standard hay crop of the area, stacked in huge haystacks (10 to 20 tons each), never kept in barns or silos as in New England.
Just west of the ranch, the land abruptly rose almost 5,000 feet in just a mile or so. The altitude at the ranch house was about 3,800 feet. The tops of foothills immediately to the west were at about 8,600 feet. Then, a limestone plateau extended westward for several miles, in the center of which was the granite uplift of the snow-covered Bighorn chain, culminating in a few peaks at 12,000 to 13,000 feet.
Riding on the lower ranch to the east you were on open plains. Immediately to the west we started up trails in the steep mountain canyons. As teenagers, we worked in the hayfields, driving teams, mowers,
stackers, and buck-rakes. Hard work in the hot sun, a volunteer effort for the family project. All the heavy machinery was pulled by four-legged horsepower. We raised Belgian draft horses to do this work. Driving these marvelous beasts was a powerful experience.
The wild animals we encountered (always called “game”) were intriguing. The bighorn sheep were there no more, although we found their sunbaked white skulls, curled horns intact, in the deep canyons. Buffalo were long gone; we found many of those skulls also. The sheep and buffalo must have been driven into the canyons to escape the predations of the Indians, who in turn were escaping the predations of the white man. Elk, deer, black bear, and coyotes were there in abundance. In the early morning when we left the corrals to enter the pastures along the mountain front to wrangle the horses, we would often surprise these wild animals as we tried to find where the horses had wandered, grazing during the night.
Although there were roads up the mountains, the landscape that we saw still looked much as it must have in the time of Lewis and Clark. Certainly there were fences every few miles. There might be an occasional ranch building. But the general lay of the land—the mountains, forests, buttes, mesas—and the crystal-clear limestone-alkaline mountain water with plenty of trout gave a special charm to this part of the West.
The cattle business at that time was heading into a severe depression. The great drought of the early 1930s, as evidenced by the Okie dustbowl and Steinbeck’s The Grapes of Wrath, dry farmers gone broke and leaving Oklahoma for California, was reflected in Wyoming by severe drought and an almost biblical plague of huge grasshoppers that lasted for several years. Beef prices were low. Hay prices were high. A bad combination. The 1930s were not good years for cattle ranchers. The economic success of a ranch depended on water rights, irrigation, and a mountain-grazing permit obtained from the U.S. government (which involved a fair amount of politicking) that enabled the rancher to graze his cattle in the national forest during the summer and feed them homegrown hay in the winter. After the roundup in the fall, the steers, dry cows, and old bulls (“baloney bulls”) were shipped by railroad to Chicago where they were resold, the prime steers going to the corn-feeding farms of the middle west, the old bulls to the sausage factory.
The cattle in those days were uniformly the white-faced Hereford. On the mountain grazing-ranges, cattle of many owners and from different ranches roamed over large areas of the mountains with no fences. For this reason all ranchers in an association had to agree to purchase bulls of about the same quality.
Much of this has now changed. Huge trucks are used to take the cattle from the ranches directly to the Iowa feedlots without passing through Chicago at all. The Chicago stockyards have disappeared. Overgrazing on both plain and mountain pasture produced loss of ground cover, erosion, and degradation of grass in the mountain meadows. The number of cattle grazing on national forest land (on government mountain permits) has been sharply reduced. Angus, black or red, have partly replaced the white-faced Hereford.
For trips into the mountains we did everything ourselves: tossing the diamond hitch to pack the horses, picketing them at night, hunting for the lost ones the next morning, catching trout for breakfast, cooking, making the paniers of equal weight for balance on the two sides of the packsaddles. Or, in haying time, mowing the hay, sulky-rake, buck-rake, and horse-drawn stacker. The men with whom we worked were never hurried or harried. They got the job done, rested the horses at noon, fed them, ate their box of sandwiches in a cool cottonwood grove by the stream, and taught us how to pace ourselves.
As to the particular crafts of the western ranch hand, his ability to rope horses or cattle at a high gallop is certainly legendary. But of all the things the cowboy could do, there was nothing quite like rolling your own at a full gallop in a high wind. This was an operation carried out under difficulty, with impressive skill, an elegant technique in a learned handicraft. Surgical.
The prevailing form of tobacco for ranchers at that time was a dry, brown, powdery substance called Bull Durham, a reference to Durham, North Carolina, although the residents of that beautiful college town may possibly wish to deny it. The tobacco itself was disparagingly referred to by the locals as the “sweepings from the Lucky Strike factory.”
That little cotton sack of tobacco (old print of a Red Bull on the label) was kept in the left upper front pocket of the cowboy’s vest (if he was right-handed). A small, yellow cardboard tag was hitched to the drawstring of the tobacco bag, hanging out. Then, at a high gallop in a high wind (left hand for the horse at all times), the procedure was as follows: the bag of Bull Durham was removed and one tiny, fluttering piece of flimsy cigarette paper was withdrawn from the attached paper-packet, shaped like a little trough or gutter in the left hand (also holding the reins) by curling it delicately with the thumb and third finger around the extended index finger. Then, with the horse still at a gallop, still in the wind, tobacco was poured into the cigarette paper by gently agitating the open bag. By seizing the tag-end of the tobacco pack-string in the teeth, it was possible with one hand to close the bag by pulling on the other end and to put it back in the upper left-hand vest pocket. Then the cigarette was rolled dry between the fingers using two hands but guiding the horse around boulders or over streams the while. Finally, when a small, cylindrical object that vaguely resembled a store-bought cigarette had been produced, it was passed across the tongue. Such was the nature of this paper that when moistened it would stick to itself. One end was then squinched together between the fingers, the whole rolled again, and the other end placed between the lips for smoking.
Now came the hard part. A match was taken from the right-hand side pants pocket and struck by scraping it across the slot in a little screwhead that is always found in the central part of the horn, or pommel, of a western saddle. This requires some skill, even when one is standing quietly in the barn. The paper is still wet. Hard to ignite. Once the match is struck and lit, held in one hand, it must be shielded by curling the fingers around it with only minor burns, protecting the flame from the wind. The burning match is brought up to the cigarette, the cigarette lit, and a contented puff taken. This whole operation requires only a short time, possibly 2 or 3 minutes. There are at most six puffs and only a few more minutes left in the smoke. This western horseback ballet, while a routine matter-of-course to the rider (the smoker), could not help but arouse astonishment and admiration on the part of an observant young companion galloping alongside.
Many young men from back East have tried to repeat this them-
selves, after only a few rehearsals on a horse galloping around in the corral, only to find that this is an art to be neither taken lightly nor mastered quickly. Even standing still on the ground with no wind, there is frustration. You have to keep spitting out the little bits of tobacco that get into your mouth.
Years later we learned that those heavy-smoking ranchers had a high incidence of lung cancer. It took a lot of work to get even a few short puffs out of Bull Durham. Think of the lives it saved.
Everyone is entitled to enshrine one setting as the place that holds the most cherished memories of youth, of the years when everything seemed possible and the present looked good.
Laurie’s family were very liberal in letting her visit my family each summer in the early 1930s. She was a good rider. Mother gave her a spunky little mare called Babe, a cross between an Arab and a Shetland. Small, peppery, lots of energy, very intelligent, never panicked. She was perfect for a small lady. We rode every day either to do ranch work or just for pleasure after supper on long summer evenings. Usually we went with friends. But sometimes alone, getting off and sitting on a pine-needle carpet on some hilltop looking out for miles over a limestone rimrock. It was there we made our plan to get married.
Then we came out a few more summers before medical work occupied 12 months a year. In 1937 we brought Nancy out there as a baby. One or two more brief visits. Then, during the war, mother and father aging, the family moved away, the ranch was sold. Better the book to be closed.
We visit Wyoming only occasionally, these days. Usually for fishing or, like Conrad, in quest of our youth. As you look over the pool and the brush, taking your eye off the fly at precisely the wrong moment, the country ahead is unchanged from our first visit almost 70 years ago. Or when Custer (only a few miles to the north) made that fatal decision in 1876 to send Major Benteen off toward the Bighorn Mountains with his Gatling guns. There were 15,000 Sioux waiting for Custer. They knew