Our medical school courses were arranged so logically that it was difficult, 15 years later, to become enthusiastic about the massive changes in the teaching of medical students introduced after World War II. We had started out with anatomy, both gross (i.e., dissection, anatomy as viewed by the unaided eye) and microscopic (histology). Then came biological chemistry, physiology, pharmacology, pathology. What could be more logical? Or simpler? Each of these was a major course arranged by a professor and department head who gave most of the lectures and whose personality was strongly impressed upon us. It is said that no two people can agree on how to mix a martini. Certainly it is true that no two decades of faculty opinion can agree on how to mix a medical curriculum. Even in our day, medical education in the United States seemed a radical departure compared with that in the British Commonwealth.

We spent 4 months in anatomy. Seemed long at the time. In Great Britain, that would have been regarded as too short—a mere dab—since medical students there spent the entire first year in anatomy and, in New Zealand, most of the first 2 years. In United States medical schools, the emphasis on chemistry and physiology was much stronger than in the Old World. Maybe it was not surprising when, after World War II and the great revolution of applying physiology and biochemistry to patient care, it was America that led the way.

When the next change came, about 1960, our generation (speaking for myself, at least) was a bit shocked at the complete restructuring of the medical curriculum—the so-called “omelettization” of medical education.We were probably being typical and stuffy older conservatives. Pathology was now chopped up into small pieces and mixed in with physiology and biochemistry. Pharmacology

disappeared in the Curriculart mixer. The basic preclinical sciences were not presented as disciplines but rather in conjunction with some organ or system of the body (e.g., kidney, brain, liver) or one set of diseases (e.g., injury, infections, tumors). Twenty years later, the takeover by molecular genetics made further changes essential. Do the students emerge better prepared than we were for their hospital work and careers in practice? I would answer “No.” But they know about a lot of things we never heard of.

Possibly all students look back on the way they were taught as being the best and most logical foundation on which all education should rest. Any change seems unnecessary, radical, meddlesome, and undesirable. Moral: Never let the alumni run an educational institution.

Professor Bobby Green’s version of the quotation from Terence—Nihil humanum mihi alienum est... nihil anatomicum—may not have been perfect, but the idea he wished to convey was crystal clear. I am indebted to James Learmonth, a teacher in the British school system, for correcting this back to the original line by Terence (Heauton Timorumenos, Act I), with amendment: Homo sum: humani nil a me alienum puto... [nec anatomici] (“I am a man, and nothing human is foreign to me ... [nor anything anatomical]”).

Reference is made in the text to the “Fabrica” of Andreas Vesalius and the concept of anatomy as being the fabric of the human body. The complete reference:

Vesalius, A. 1543. De Humani Corporis Fabrica, Libri Septem. Basel.

What is now known as the Harvard Medical School was started up in 1782 as the Medical Faculty of Harvard College. The lectures were open to the public and were given in Holden Chapel. Articles and books on the history of Harvard Medical School include the following:

Harrington, T.H. 1905. The Harvard Medical School. A History, Narrative, and Documentary, 1782-1905. Mumford J.G. (ed), New York: Lewis.

Harvard Medical School Faculty of Medicine. 1906. The Harvard Medical School, 1782-1906. Boston, private printing.

Beecher, H.K., and M.D. Altschule. 1977. Medicine at Harvard: The First 300 Years. Hanover, NH: University Press of New England.

Benison, S., A.C. Barger, and E. Wolfe. 1987. Walter B. Cannon: The Life and Times of a Young Scientist. Cambridge, MA: Belknap Press (of Harvard University Press).

The Nobel lecture of John Enders is important in Harvard history because of its significance in the global conquest of a costly and lethal disease.

Enders, J. F., F. D. Robbins, and T. H. Weller. 1954. The Cultivation of the Poliomyelitis Viruses in Tissue Culture. Les Prix Nobel en 1954. Stockholm, The Nobel Foundation.

Two of our teachers wrote autobiographies:

Irving, F. 1942. Safe Deliverance. Boston: Houghton & Mifflin.

Zinsser, H. 1937. As I Remember Him. The Biography of R.S. Boston: Little, Brown.

Zinsser, H. 1945. Rats, Lice and History. A Study in Biography. Boston: Little, Brown.

President Eliot’s reforms began early in his Harvard presidency. Richard Wolfe, Curator of Rare Books and Manuscripts at the Countway Library, supplies this account:

At the time of the U.S. bicentennial in 1976, I contributed a history of American surgery to the Bicentennial Volume published by the Josiah Macy, Jr., Foundation:

Moore, F.D. 1976. Surgery, pp. 614-684. In Advances in American Medicine: Essays at the Bicentennial, J.Z. Bowers and E.F. Purcell (eds). New York: Macy Foundation.

Six years later, in 1982, there was a celebration of the Harvard Medical School bicentennial:

Moore, F.D. 1982. In medicina, veritas. The birth and turbulent youth of the Faculty of Medicine at Harvard College. N. Engl. J. Med. 307:917-925.

The name Hubbard Woods, assigned to a station on the Chicago and Northwestern Railroad just north of Winnetka, Illinois, was a reference to Gurdon Saltonstall Hubbard, a New England pioneer of lower Lake Michigan and its

environs. In his book he tells of coming to the Chicago area in 1818 as a 16-year-old hunter and trapper, trading with the Indians for valuable pelts of beaver, otter, and mink. This was only 6 years after the Fort Dearborn massacre (1812). He lived to become a leader of commerce and banking and a patriarch of the region. The Hubbard Trail is named after him. His life epitomizes the short span of time that changed this area on the southwest shore of Lake Michigan from a swampy wilderness to a great metropolis and railroad center. Two books tell of Hubbard’s adventurous career:

Hubbard, G.S. 1911. The Autobiography of Gurdon Saltonstall Hubbard: Pa-Pa-Ma-Ta-Be (The Swift Walker). Chicago: Lakeside Press.

Hubbard, M.A.: 1912. Family Memories. Chicago: Donnelly Printers, Chicago Historical Society.

Frederick Christopher was the surgeon in Winnetka who had pictured my fractured knee in his Textbook of Minor Surgery. This textbook (the leader in its time) later went through many editions and was finally succeeded by the huge Textbook of Surgery currently edited by David Sabiston, Professor of Surgery at Duke. Christopher was an engaging person, Head of the Department of Surgery at the Evanston Hospital. My contacts as a patient of his were unquestionably part of my drive toward surgery.

His brief autobiography:

Christopher, F. 1957. One Surgeon’s Practice. Philadelphia: W.B. Saunders Co.

Christopher’s textbook legacy:

Christopher, F. 1937. Minor Surgery, 3rd ed. Philadelphia: W.B. Saunders Co.

Sabiston, D.C., Jr. (ed). 1981. Davis-Christopher Textbook of Surgery. The Biological Basis of Modern Surgical Practice, 12th ed. Philadelphia: W.B. Saunders Co.

Sabiston, D.C., Jr. (ed). 1991. Textbook of Surgery. The Biological Basis of Modern Surgical Practice, 14th ed. Philadelphia: W.B. Saunders Co.

The Pullman Company of the 1920s was a vast corporation. With Grandfather as escort, we visited the city of Pullman. Here, red iron ore—the raw material used to build the railroad cars—was brought, freshly mined from the Mesabi Range, by the ore boats docked alongside the huge blast furnaces. The finished product, standing on the tracks a mile or so away, was the “Pullman Palace Car,” with its painted Victorian finery and woven tapestry, complete and ready to roll. Even to catch glimpses of this heroic industrial sequence was

unforgettable for a third-grader. In 1969, operations in Pullman ceased. At that time a glory, the Pullman manufacturing process is now becoming a relict in the rust belt. Has Boeing taken its place?

In our childhood we were subject to certain health fads espoused by our parents’ generation. All who pursue the diet and exercise fads of today, such as “designer” foods or workout machines, will enjoy perspectives from similar activities of 75 years ago.

As mentioned in the text, children were supposed to sleep outdoors on “sleeping porches,” no matter what the weather. Sleeping outdoors was healthy. Suburban dwellings built between 1890 and 1940 shared this structural spinoff of a health fad now long gone, and largely forgotten. Many homes had a sleeping porch, maybe even two or three, on the second floor. Plenty of room for everybody. Good ventilation. Fresh air. Like jogging and cholesterol-free, high-fiber foods, this was a health fad exclusively indulged in by those who could afford it, those whose education included warnings of the hazards of doing otherwise (i.e., sleeping indoors).

This physical culture craze centered on the cult of a muscled hero named Bernarr Macfadden. His largely nude figure, muscles clenched and bulging, was on the cover of his books. As little boys we mocked his poses and showed off our muscle-clenching for anyone who had a Brownie camera handy. I am indebted to Diane Forti of Dedham, Massachusetts, for drawing my attention to the fact that it was in Macfadden’s book that outdoor sleeping was raised to the status of a health mandate in 1904. It is refreshing today to view some of the chapter titles: “Building Vital Power With Long Walks,” “Vast Importance of Water,” “How a Powerful Stomach May be Acquired,” “Developing Great Lung Power,” and “Perfect Ventilation,” the last being best achieved, of course, by sleeping outdoors. Many architects, builders, lumber companies, and blanket manufacturers owed Macfadden a debt of gratitude:

Macfadden, B. 1904. Building of Vital Power. Deep Breathing and a Complete System for Strengthening the Heart, Lungs, Stomach and All the Great Vital Organs. New York and Chesham, England: Physical Culture Publishing Co.

Quite a few couples from among the students at North Shore Country Day School later became husband and wife. Laurie and I were not the first. In 1983, about 50 years after graduation, the two of us were given the Stanton Award as outstanding alumni of the school. Never mind honorary degrees or such like matters of high prestige; this was the honor we most enjoyed. They said we won it together.

Our first 2 years at Harvard College were under the presidency of Abbott Lawrence Lowell. At the start of our junior year (1933) James B. Conant was appointed President of Harvard. He had four careers: chemist, university president, High Commissioner to Germany, and educational reformer. A recent biography by Hershberg, an extensive (900-page) review of Conant’s life and times, paints him as a rather stern, uncompromising person who made little of human or family relationships.

My picture of Conant was based on his visits to the Lampoon while I was president and his attendance at some of our club dinners. When I was appointed Moseley Professor, I met with him in his office to discuss new horizons for the medical school; new undertakings in medicine, surgery, and science; the Moseley Professorship; and my forthcoming salary. Conant attended the faculty meetings of the medical school quite regularly, the only President in my experience to do so. This biography, which I would characterize as unjustifiably and unnecessarily negative, deals only with Conant’s later years:

Hershberg, J.G. 1993. James B. Conant; Harvard to Hiroshima and the Making of the Nuclear Age. New York: Alfred A. Knopf.

Our text in organic chemistry:

Conant, J.B. 1933. The Chemistry of Organic Compounds. A Year’s Course in Organic Chemistry. New York: Macmillan.

Conant’s successor as President in 1953 was Nathan Pusey (class of 1928); Pusey was followed by Derek Bok in 1971, who resigned in 1992, and finally by Neil Rudenstine. My most abundant and always pleasurable contacts were with Conant and Pusey.

The department of my concentration, anthropology, was still a unified one in the 1930s. Physical anthropology, paleontology, human evolution, ethnology, ethnography, and even some of what would now be called social anthropology were all in one department. Alfred Tozzer was chair. His daughter, Joan, later married one of our classmates, William Lincoln, and became a close friend. Ernest A. Hooton was in charge of teaching human evolution and physical anthropology. His textbook was an entertaining departure from the usual sober-sided text:

Hooton, E.A. 1931. Up From the Ape. New York: Macmillan.

Another work on anthropological philosophy:

Hooton, E.A. 1937. Apes, Men, and Morons. New York: G.P. Putnam’s Sons.

Hooton acquired some fame among the students because on the lecture stage

he imitated the posture and gait of the anthropoid apes. His imitation of a gibbon loping along, arms upraised, grasping for a branch to leap onto, was memorable.

In 1984 we staged a 50th reunion of our 1934 Hasty Pudding Show Hades! The Ladies! as the entr’acte in the annual club show at the clubhouse in Cambridge. Alistair Cooke came up to Boston from New York for the occasion. As the curtain opened, he could be seen sitting in his wing chair, fingers clasped in his characteristic pose, saying, “Good Evening. I’m Alistair Cooke.” This was the way in which he began each television program of Masterpiece Theatre. This moment alone made the entire re-staging of a few scenes from our 50-year-old show worthwhile. Some of our singers were still quite operatic, especially Frank Johnson, who sang “Don’t Wait for Roses in The Spring,” a song I had written for him 50 years before as a sentimental spoof. Our show presented parodies of some of the Tin Pan Alley music and lyrics still current but possibly most notable in the 1920s: the June-moon-soon, love-dove-above, gal-pal-Sal school of lyrics. This waltz was one such. While the Hasty Pudding Show of 1984 was somewhat more grandiose than its predecessor of 50 years before, it had few personalities to match that of Cooke and few marvelous lyric tenor voices to match that of Johnson.

Insider accounts of the surgical residency experience at American teaching hospitals are rare, at least in published form. Out of a desire to remedy this, we asked our former residents at the Brigham Hospital to help us summarize their experiences, criticisms, and career outcomes. These notes and letters were set forth in a privately printed summary in 1980:

Moore, F.D. 1980. Three Surgical Decades. Brigham Surgery and the Residency Program. Boston, private printing.

Here, in these Notes and References, I have not listed all the interns, residents, and surgical scientists who worked in our department between 1948 and 1981, often as close collaborators and always contributing immensely to the productivity of those Brigham years. Some appear here as coauthors of publications. Others whose work was largely in daily clinical care made our surgical care of thousands of patients both effective and safe. All of us on the staff owed these young surgeons and scientists a deep debt of gratitude.

The Cocoanut Grove fire acquires historical importance not because of the

number killed (490) but because of the research carried out and lessons learned, especially with respect to the pulmonary (lung) injury incurred with burns.

Experiences with the patients injured in the Cocoanut Grove fire occurred at a curiously critical moment in my own surgical career because I had just returned from a fellowship year in research and was going straight on toward the chief residency. I had already completed some research on burns, and this accident offered the massive challenge of putting what I had learned to work, as well as laying the foundation for a lifelong interest in the care of burned patients. I was only a junior resident, 29 years old at the time of the fire, and working under the tutelage of Oliver Cope. One of the major contributions of his productive career was to focus attention on the pulmonary injuries observed in burned patients and to guide their treatment.

The fire also occurred at a remarkably critical moment in the development of wound surgery, i.e., the surgical care of injured, burned, fractured, or otherwise traumatized patients. It was nearly one year after Pearl Harbor, just before the massive engagements of American troops in North Africa, Europe, and the Pacific. Here was an opportunity for a civilian hospital to demonstrate an aggressive approach to seriously injured patients, combining the ancient traditions of emergency surgery with the finest of academic work in surgery: research applicable to the care of the sick.

It is to the everlasting credit of Edward Churchill that he saw this opportunity and led the effort to minimize the loss and suffering from this disaster on the one hand, while making of it a lesson for military surgery on the other. The fruits of his foresight are set forth in the Annals of Surgery issue cited below, which was devoted entirely to these patients. Shortly after the fire, he left Boston to become the commanding officer in charge of surgical care of the wounded in the Mediterranean theater.

Even at the time of the fire, Churchill was emphatic about the importance of defining the pattern of injury in any particular engagement or geographical area. From such an understanding should emerge better treatment for each individual patient as well as for the wounded as a group. I do not know when this concept first became prominent in his mind, but he certainly applied it to the Cocoanut Grove fire by outlining the nature of the combined burn and pulmonary injury with the assistance of the Departments of Pathology and Radiology.

Another of Oliver Cope’s contributions lay in advocating a simple, nontoxic bandage (boric acid, petrolatum gauze) instead of the sometimes toxic materials such as tannic acid, picric acid, and dyes that had been used for years. Although we did not take the opportunity to show by tracer work the dynamics of absorption of substances through the wound surface, it was Cope’s conviction that this occurred and led to his abandonment of tannic acid in the treatment of burns. Only a few years later we were to encounter the same phenomenon of absorption with a vengeance in the application of antibiotics to burns. Several patients became totally and permanently deaf because they had been treated with a surface ointment containing an antibiotic that was dangerously toxic when absorbed

through the burned surface. In those early days it seemed inconceivable that enough antibiotic could be absorbed to damage auditory nerve conduction, but it was absorbed, in large quantities, and caused severe damage.

The supplement to the Annals of Surgery that presented the total MGH experience of the Cocoanut Grove fire:

Ann. Surg. 117(6):801-965, 1943.

Near the time of its 50th anniversary, there was a flurry of interest in the Cocoanut Grove fire that prompted several articles on the subject:

Coleman, T.H., F.D. Moore, O. Cope, and B. Cannon. 1991/92. The night the Grove burned. Harvard Med. Alumni Bull. 65(Winter):10-19.

Grant, C.C. 1991. Last dance at the Cocoanut Grove. NFPA J May/June, pp. 74-86. (Official magazine of the National Fire Protection Association.)

Bass, J. 1992. No way out. Boston Magazine, October, p. 74.

Our article on the redistribution of body water in the fluid therapy in burns was based not only on the Cocoanut Grove experience, but also on the application of radioactive isotopes to document the expansion of the extracellular fluid volume at the expense of the plasma volume in severe burns. This turned out to be one of the first researches to apply isotopes directly to problems in surgical care:

Cope, O., and F.D. Moore. 1947. The redistribution of body water and the fluid therapy of the burned patient. Ann. Surg. 126:1010-1045.

Oliver Cope was also one of the first to recommend early immediate excision of the burn and grafting. This method has been especially useful in children:

Cope, O., J.L. Langohr, F.D. Moore, and R.C. Webster, Jr. 1947. Expeditious care of full-thickness burn wounds by surgical excision and grafting. Ann. Surg. 125:1-22.

Recently, at the invitation of Andrew Munster (a former Brigham resident), who is in charge of the Johns Hopkins Burn and Trauma Service at the Baltimore City Hospital, I reviewed the history of our knowledge of respiratory injury in burns, placing in perspective the Cocoanut Grove experience and the remarkable contributions of Oliver Cope:

Moore, F.D. 1990. The respiratory tract injury of burns: Lessons from the past, pp. 1-15. In Respiratory Injury: Smoke Inhalation and Burns, E.F. Haponik and A.M. Munster (eds). New York: McGraw-Hill.

Dr. and Mrs. Oliver Cope died as these Notes were being composed, in April 1994.

Claude Welch was one of our teachers at the MGH and later Clinical Professor of Surgery at HMS. Recently, he published his autobiography, which presents a delightful account of the MGH during this period, including the episode of the bogus Victorian staff portrait in which several of us participated. It hung on the wall of the surgeons’ room for quite a while before anybody discovered it was a phony. Commentary (with pictures) about many of the people mentioned here are included in Welch’s engaging story:

Welch, C.E. 1992. Twentieth Century Surgeon: My Life in the Massachusetts General Hospital. Boston: Massachusetts General Hospital.

Edward Churchill received the diaries of John Collins Warren, Harvard’s fourth Professor of Surgery and the first Moseley Professor, from Warren’s grandson, Richard Warren, for comment and possibly annotation. Churchill responded by writing an important historical book, tracing in detail the course of surgery in the United States in general (and Boston and Harvard in particular) as seen through the eyes of one of the movers and shakers of that period:

Churchill, E.D. 1958. To Work in the Vineyard of Surgery. The Reminiscences of J. Collins Warren, 1842-1927. Cambridge: Harvard University Press.

Looking back on his wartime work 25 years previously, Churchill wrote a brief account of the Italian campaign, including his activities in Sicily and Anzio:

Churchill, E.D. 1972. Surgeon to Soldiers. Philadelphia: J.B. Lippincott Co.

J. Gordon Scannell, a long-time friend and associate, was one of Churchill’s most devoted pupils in thoracic surgery and has maintained a continuing interest in Churchill’s surgical and intellectual accomplishments. He has recently published a brief story of Churchill’s study year abroad, his “Wanderjahr.” This is based on Churchill’s account of his travels shortly after World War I, when he made personal contact with many eminent European surgeons and physiologists:

Scannell, J.G. 1990. Wanderjahr. The Education of a Surgeon. Edward D. Churchill. Boston: The Francis A. Countway Library of Medicine.

Among Churchill’s many papers, two seem especially notable. First is his account of removal of a lobe of the lung to treat chronic infection (bronchiecta-

sis). His safe performance of this hazardous operation brought him an international reputation:

Churchill, E.D., and R. Belsey. 1939. Segmental pneumonectomy in bronchiectasis. Ann. Surg. 109:481-499.

The second is a delightful analysis of the history of surgery as a tension between the Graeco-Roman-French-British humanistic tradition of patient care and the rigid, intensive, research-scientific approach of the German universities in the nineteenth century:

Churchill, E.D. 1947. Science and humanism in surgery. Ann. Surg. 126:381-396.

Many philosophical discussions have attempted to define the nature of surgery and its relationship either to medicine as a whole or to what is now termed internal medicine, meaning by that the work of physicians (internists) who do not operate in the care of adult patients, but who serve adults in much the same way pediatricians serve children.

All physicians alike, be they pediatricians, surgeons, internists, psychiatrists, family practitioners, radiologists, or anesthetists, work from a massive reservoir of factual learning in human biology, now termed cognitive knowledge. Surgeons must master an understanding of a large segment of this knowledge of man and of his diseases. In addition, the surgeon must also master his craft, his handicraft. A skill.

It is therefore not surprising that among these several medical callings one has brought to perfection those methods by which some diseases can be treated by manipulation, by removal or anatomical rearrangement through what is now termed a surgical operation. The performance of operative surgical technique is demanding enough to occupy the full attention of one segment (about 20%) of the medical profession.

Despite its basis in all of biomedical science, the separation of surgery as a mode of treatment from the rest of medicine has given rise to many books, analyses, and reveries. Probably few of these are more trenchant than that written just after the turn of the century by Allbutt:

Allbutt, T.C. 1905. The Historical Relations of Medicine and Surgery to the End of the Sixteenth Century; An Address Delivered at the St. Louis Congress in 1904. London: Macmillan.

Dr. Churchill first called my attention to this small book that tells about the

increasingly clear separation of medicine and surgery. It was written by a physician practicing what we would now call internal medicine, which in 1905 he termed “inner medicine.” He expresses regret that he and his colleagues had lost their ability to deal with these diseases directly, personally, by their own hands. He writes

The clarity of Allbutt’s vision has been borne out by the fact that the great leaders of surgery have been those who shared a broad view of all biomedical science but superimposed upon it their surgical skills. By the same token, the greatest of physicians are those who greet and understand surgery as a collaborator in the treatment of illness, calling upon surgery as they might call upon any other arm of therapy when it is needed. In contrast, the less elevated of our surgical profession carry out their technology with little view to the underlying biology, while the less talented of those practicing “inner medicine” regard it as a defeat or disaster if their patient comes to the surgeon. Mutual knowledge and respect form the most effective bond between these two major approaches to the treatment of human illness.

Now, 90 years after Allbutt’s book, the academic branches of medicine and surgery in our medical schools are being separated by a widening gulf that could become worrisome, because it involves teaching the new generation.

The surgeon, be he senior professor or lowly intern, is brought into close contact with the patient and the patient’s family by the hands-on personal intimacy bred of the operation itself. In even the most academic of teaching hospitals, with its laboratories and lecture halls, the surgeon is a clinician, a practitioner.

By contrast, many academic physicians (internists) have become so oriented toward research, especially in molecular genetics, that they (the faculty) see patients but rarely, if ever. One month on the ward or in the clinic does not a clinician make; private practice is often minimal or nonexistent. Inevitably, the teachings by such faculty members in internal medicine transmit more excitement about molecular genetics than about patient diagnosis or care. Are we spawning a generation of hands-off internists? Possibly most disturbing is the growing lack of role models for excellence in patient care in the groves of academic medicine.

A formal approach to the evaluation of errors and complications in surgery

(likewise in medicine, pediatrics, psychiatry, and radiology) inevitably attracts comment. Fox and Swazey have been particularly interested in this subject:

Fox, R.C., and J.P. Swazey. 1974. The Courage to Fail: A Social View of Organ Transplants and Dialysis . Chicago: University of Chicago Press.

In 1979, Charles Bosk, a medical sociologist at the University of Pennsylvania, published his monograph on medical error, invoking a sociological authority-stratum theory of error confession and classification. Although this interpretation is more theoretical than real-life situations would attest, his book title inspired our expression, “Forgive, but do not forget.”

Bosk, C.L. 1979. Forgive and Remember. Managing Medical Failure. Chicago: University of Chicago Press.

Early in this century, Ernest Amory Codman drew up the currently used classification of surgical errors and complications:

Codman, E.A. 1914. The product of a hospital. Surg. Gynecol. Obstet. 18:491-496.

About 30 years after my contacts with them, I enjoyed looking back on the careers of both Walter B. Cannon and Ernest A. Codman and wrote the following (presented as an address to the Boston Surgical Society on the occasion of the award of the Henry Jacob Bigelow Medal, November 5, 1973):

Moore, F.D. 1975. Surgical biology and applied sociology: Cannon and Codman fifty years later. Harvard Med. Alumni Bull. 49(Jan/Feb):12-21.

The terrible price paid for surgical error, mishap, and complications was borne in on us daily by telephone calls seeking admission to our intensive care ward, the Bartlett Unit. Nathan Couch and Nicholas Tilney worked with me in analyzing the common threads so often interwoven in these miscarriages of surgical care, often in very complex cases:

Couch, N.P., N.L. Tilney, and F.D. Moore. 1978. The cost of misadventures in colonic surgery—a model for the analysis of adverse outcomes in standard procedures. Am. J. Surg. 135:641-646.

Couch, N.P., N.L. Tilney, A.A. Rayner, and F.D. Moore. 1981. The high cost of low-frequency events. The anatomy and economics of surgical mishaps. N. Engl. J. Med. 304:634-637.

My first article in The New England Journal of Medicine resulted from an unusual encounter with a rare infectious disease:

Moore, F.D., C.S. Sawyer, and G.S. Blount, Jr. 1944. Tularemia in New England. A review of eighteen cases with the report of two additional cases. N. Engl. J. Med. 231:169-173.

My first publication in the Journal of the American Medical Association was based on a national study of drug toxicity:

Moore, F.D. 1946. Toxic manifestations of thiouracil therapy (a cooperative study). JAMA 130:315-319.

Throughout this century, duodenal (and gastric) ulcer has been a prime concern of both internists and surgeons. Now, after all this time, the disease seems to be declining in frequency, while evidence is increasing that a bacterium, Helicobacter pylori, is somehow involved in its causation. For several decades before and after World War II, surgical treatment for ulcer that was both safe and effective was an ideal not always attained.

The principal cause of death after subtotal gastrectomy for duodenal ulcer was peritonitis resulting from rupture of the suture line closing the duodenum (i.e., the intestine just beyond the stomach). Several solutions were proposed for this. One of them, by McKittrick, was to carry out the operation in two stages. Not only did this bring sharply into focus the commonest cause of death after this operation, but it also brought up some other important physiologic questions concerning the secretion of gastric acid. This is the only paper in which Richard Warren and I were coauthors, although we worked together on many topics over the years:

McKittrick, L.S., F.D. Moore, and R. Warren. 1944. Complications and mortality in subtotal gastrectomy for duodenal ulcer. Report of a two-stage procedure. Ann. Surg. 120:531-561.

Lester Dragstedt, at the University of Chicago, was the first to carry out vagotomy for duodenal ulcer. As described in the text, I began studies on this topic in 1942 without knowledge of his work but had become fully aware of his pioneering effort, and was grateful for his experience, by the time my first patient was operated upon:

Dragstedt, L.R., and F.M. Owens, Jr. 1943. Supradiaphragmatic section of vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exp. Biol. Med. 53:152-154.

Moore, F.D., W.P Chapman, M.D. Schulz, and C.M. Jones. 1946. Transdiaphragmatic resection of the vagus nerve for peptic ulcer. N. Engl. J. Med. 234:241-251.

The following year we reported some of the physiologic effects of severing the vagus nerves:

Moore, F.D., W.P. Chapman, M.D. Schulz, and C.M. Jones. 1947. Resection of

the vagus nerves in peptic ulcer. Physiologic effects and clinical results, with a report of two years’ experience. JAMA 133:741-749.

Having worked with both gastrectomy and vagotomy and having seen many patients treated by nonsurgical means alone, I felt it was clearly important to compare the three. Horatio Rogers and I started out rather ambitiously with 1,000 patient records from the Massachusetts General. Only three of these patients were lost to follow-up. We and our collaborators, Brooks, Erskine, Richardson, and Peete, wound up with the 997 cases mentioned in the title of the paper. When subtotal gastrectomy could be carried out with a low mortality, the results more than justified the investment of time, cost, and effort even though digestive changes over the long term were sometimes a severe problem. Even in nonsurgical management (alkali powders and pills) there was still some intrinsic risk of perforation, obstruction, or hemorrhage. The two treatments (surgical and nonsurgical) could be directly compared. Our platitudinous conclusions from this laborious study were (1) each case is different and (2) clinical judgment is important. But there was a third major conclusion. While obvious to the sophisticated reader, this was never stated clearly enough. This was the skill factor. Pick your surgeon carefully! Not everyone could carry out this operation with a low mortality and morbidity:

Moore, F.D., W.P.J. Peete, J.E. Richardson, J.M. Erskine, J.R. Brooks, and H. Rogers. 1950. The effect of definitive surgery on duodenal ulcer disease. A comparative study of surgical and non-surgical management in 997 cases. Ann. Surg. 132:652-680.

Under Dr. McKittrick’s guidance I managed the postoperative ulcerative colitis clinic at the Massachusetts General Hospital. We saw a large number of patients with this disease and wrote several papers, in one of which we sought to identify some of the judgmental factors in selecting elective surgery for these patients:

McKittrick, L.S., and F.D. Moore. 1949. Ulcerative colitis. Ileostomy: problem or solution? JAMA 139:201-207.

The concept of making a radioactive dye led to that wonderful fellowship year with Joseph Aub, my introduction to biophysical research, and then several decades spent in the study of body composition and the biology of convalescence. At least one element in this sequence had its origin in our pathology course, where Valy Menkin told us how certain dyes tended to concentrate in abscesses:

Menkin, V. 1929. Studies on inflammation. I. Fixation of vital dyes in inflamed areas. J. Exp. Med. 50:171-180.

After 6 months of hectic and intensive work, our first research was rather surprisingly crowned by at least a modicum of success. Lester Tobin was able to synthesize a radioactive dibrominated derivative of trypan blue. We could induce the abscesses in rabbits. It all worked out well enough so only a few months later we presented our findings at a scientific meeting. Although we were unaware of it at the time, this would have to be listed as one of the first successful efforts to apply radioactive isotopes for external detection of a disease process (now called nuclear medicine). This article was followed by our description in animals of the concentration of this radioactive dye in tumors:

Moore, F.D., and L.H. Tobin. 1942. Studies with radioactive di-azo dyes. 1. Localization of radioactive di-brom trypan blue in inflammatory lesions. J. Clin. Invest. 21:471-481.

Tobin, L.H., and F.D. Moore. 1943. Studies with radioactive di-azo dyes. 2. Synthesis and properties of radioactive di-brom trypan blue and radioactive di-brom Evans blue. J. Clin. Invest. 22:155-160.

Moore, F.D., L.H. Tobin, and J.C. Aub. 1943. Studies with radioactive di-azo dyes. 3. The distribution of radioactive dyes in tumor-bearing mice. J. Clin. Invest. 22:161-168.

About 5 years after we had completed our radioactive dye work, and after the first human studies using isotope dilution for the study of burns and body composition, we published a review article about the use of isotopes in surgical research:

Moore, F.D. 1948. The use of isotopes in surgical research. Surg. Gynecol. Obstet. 86:129-147.

Arthur Solomon, an early advocate of isotope research and of applying biophysics to medical research, later became director of the Laboratory for Biophysics in the Department of Biochemistry under A. Baird Hastings. In 1940 he had written an account for the public, which was helpful to us as neophytes in the field:

Solomon, A.K. 1940. Why Smash Atoms? Cambridge: Harvard University Press.

In undertaking a year in fundamental research, learning how to use the new methods of nuclear physics for the study of surgical illness, I was crossing a bridge from the bedside to the laboratory, from the operating room to the world of basic science. In any medical field it is important for some clinicians to cross this bridge and bring back to the bedside whatever they can find out there.

The Latin pontifex (later shortened to “pontiff”) refers to the ancient ecclesi-

astical concept of bridge-tending for churchmen bringing the word to earth from heaven.

In my address as President of the Society of University Surgeons in 1958, I pointed out that such a bridge-tending surgeon often finds himself caught in the middle of the bridge. He is accused by his associates of not spending enough time in the operating room, while his scientific associates know full well he is not really one of them. So he is an illegitimate hybrid, and he must learn to live with the appropriate sobriquet.

By taking a year or two at the NIH or other laboratories, thousands of young clinicians in many fields have tended that important bridge and have lived quite happily with their bar sinister.

Moore, F.D. 1958. The university in American surgery. Surgery 44:1-10.

Our first paper laying the foundation for our work in body composition and paving the way for the application of multiple isotopes to measure several elements of body composition was published in Science in 1946:

Moore, F.D. 1946. Determination of total body water and solids with isotopes. Science 104:157-160.

The principle of measuring total solids in solution depended upon the dilution of radioactive isotopes, not in a body fluid, but rather among their sister isotopes. In scientific parlance, this required measuring the specific activity of the radioactive isotope. Our first paper on the use of this principle for measuring the total potassium of the body:

Corsa, L., Jr., J.M. Olney, R.W. Steenburg, M.R. Ball, and F.D. Moore. 1950. The measurement of exchangeable potassium in man by isotope dilution. J. Clin. Invest. 29:1280-1295.

Details on total body water measurement were published at the same time:

Schloerb, P.R., B.J. Friis-Hansen, I.S. Edelman, A.K. Solomon, and F.D. Moore. 1950. Measurement of total body water in the human subject by deuterium oxide dilution. With a consideration of the dynamics of deuterium distribution. J. Clin. Invest. 29:1296-1310.

Soon we had perfected the method for measuring both sodium and potassium using the two appropriate isotopes simultaneously:

James, A.H., L. Brooks, I.S. Edelman, J.M. Olney, and F.D. Moore. 1954. Body

sodium and potassium

Isidore Edelman was a junior member of our group but soon showed himself to be a remarkably gifted scientist. He later became Professor of Biochemistry at Columbia College of Physicians and Surgeons in New York. Six years after our first description of how to analyze body composition in Science, we published a follow-up study relating how the methods had improved:

Edelman, I.S., J.M. Olney, A.H. James, L. Brooks, and F.D. Moore. 1952. Body composition. Studies in the human being by the dilution principle. A progress report. Science 115:447-454.

Then, to make this method more readily available to other laboratories, we published a “cookbook” paper describing in detail exactly how the procedure was carried out:

McMurrey, J.D., E.A. Boling, J.M. Davis, H.V. Parker, I.C. Magnus, M.R. Ball, and F.D. Moore. 1958. Body composition: simultaneous determination of several aspects by the dilution principle. Metabolism 7:651-667.

Standards and measurements for permissible radiation dosage were in their infancy in the period 1946 to 1956, when we established normal compositional values by studying healthy volunteers, including our own families. The idea that life on Earth once existed in a radiation-free environment was exploded by 1960 with increasing knowledge of cosmic radiation and unavoidable background radiation from the Earth, especially that of radium, radon, uranium, and their decay products. In addition, all living cells since the dawn of evolution have been bombarded by their own naturally radioactive potassium—a factor that may have accelerated evolution by favoring mutations:

Moore, F.D., and K.S.R. Sastry. 1982. Intracellular potassium: ⁴⁰K as a primordial gene irradiator. Proc. Natl. Acad. Sci. USA 79:3556-3559.

The greatest unknown in body compositional analysis was the weight of the bones that hold us up, the skeleton. Compared with the other tissues of the body, the skeleton is dry, dense, large, and therefore heavy. It is heavier in men (especially athletic men) than in women. In slight and less athletic women, it is remarkably less prominent than in men both chemically and by weight and becomes even lighter, smaller, and less dense with osteoporosis after the menopause. We worked out a method for estimating the weight of the skeleton by isotope dilution. It was in connection with this work that we analyzed the body of a patient who had offered her earthly remains to our laboratory specifically for this purpose, as described in the text:

Moore, F.D., J. Lister, C.M. Boyden, M.R. Ball, N. Sullivan, and F.J. Dagher. 1968. The skeleton as a feature of body composition: values predicted by the isotope dilution and observed by cadaver dissection in an adult female. Hum. Biol. 40:135-188.

Seventeen years after that initial paper in Science, we were able to publish in book form both the method and the results of body compositional studies over a wide spectrum of injury and disease:

Moore, F.D., K.H. Olesen, J.D. McMurrey, H.V. Parker, M.R. Ball, and C.M. Boyden. 1963. The Body Cell Mass and Its Supporting Environment; Body Composition in Health and Disease. Philadelphia: W.B. Saunders Co.

About 15 years later, a young Spanish surgeon and scientist, Jesus Culebras, came to work with us. Using the most modern isotope technology, which had changed drastically in the 25 years since we began the work, he checked out the body water method using the dilution of tritium (radioactive hydrogen of weight 3.0). Although not terribly exciting scientifically, these analyses and carcass desiccations to reconfirm an old method were truly a labor of love. Many accepted methods or standard dogmas of research need to be checked out or reestablished every few years or discarded if they do not stand the test of time. This important work, supporting the validity of our old method, was published in 1977:

Culebras, J.M., G.F. Fitzpatrick, M.F. Brennan, C.M. Boyden, and F.D. Moore. 1977. Total body water and the exchangeable hydrogen. II. A review of comparative data from animals based on isotope dilution and desiccation, with a report of new data from the rat. Am. J. Physiol. 232(1):R60-R65.

Our studies of body composition and the metabolism of water and salt led directly to an appreciation of the importance of the patient’s response to injury and surgery in determining the most suitable treatment after injury, shock, burns, and fractures. In 1948 I was asked to summarize the use of fluids, salts, and nourishment in surgical patients and published a paper in the Journal of the American Medical Association that anticipated our future work in the biology of convalescence:

Moore, F.D. 1949. The adaptation of supportive treatment to the needs of the surgical patient. JAMA 141:646-653.

The late Tom Randall of New York and Providence was long a close friend and key contributor to our knowledge of water and salt metabolism in surgical patients:

Randall, H.T. 1952. Water and electrolyte balance in surgery. Surg. Clin. North Am. 32:445-469.

The concept of an evolved response to injury consisting of a series of physiological changes favoring survival and hastening convalescence can be traced back to three influences. The first was gained from our studies in medical school under Walter Cannon, most especially from the book in which he summarized his view on a similar topic:

Cannon, W.B. 1915. Bodily Changes in Pain, Hunger, Fear and Rage. New York: D. Appleton & Co.

The second influence came from the work of David Cuthbertson, a Scottish veterinarian-physiologist who described the changes in body protein after injury using changes in nitrogen excretion as a proxy for body protein and was later knighted for this work. In Cuthbertson’s first study (carried out 10 years before World War II), he showed clear changes in protein metabolism after injury:

Cuthbertson, D.P. 1930. The disturbance of metabolism produced by bony and non-bony injury, with notes on certain abnormal conditions of bone. Biochem. J. 24:1244-1263.

Cuthbertson, D.P. 1932. Observations on the disturbance of metabolism produced by injury to the limbs. Q. J. Med. [N.S.] 1:233-246.

The third influence was the work of Fuller Albright, who in so many ways and for so many people set the standard for metabolic research in our era:

Albright, F. 1942-1943. Cushing’s syndrome. Its pathogenic physiology, its relationship to the adrenogenital syndrome, and its connection with the problem of the reaction of the body to injurious agents (“alarm reaction” of Selye). Harvey Lect. 28:123-186.

Our first publication dealing with the natural history of convalescence and the chemical changes in the body that set the stage for recovery was a book of case studies of chemical and metabolic change, done with Margaret Ball, my chief laboratory technician. Based on measurements in patients and using a standardized method of charting (inspired by the metabolic charts of Fuller Albright), the reader could for the first time see at a glance the sequence of nitrogen (protein) loss followed by gain, with appropriate changes in water and salt, after severe injury:

Moore, F.D., and M.R. Ball. 1952. The Metabolic Response to Surgery. Springfield, IL: Charles C Thomas.

In 1952, shortly after the publication of that first book on metabolism in

surgery, I was asked by the Excelsior Society (a group of officers who had served in the Mediterranean theater under Dr. Churchill) to give the first E.D. Churchill Lecture. In that lecture I tried to summarize our growing picture of the normal sequence of metabolic changes after severe injury:

Moore, F.D. 1953. Bodily changes in surgical convalescence. I. The normal sequence—observations and interpretations. Ann. Surg. 137:289-315.

About 4 years after the Churchill Lecture, I was asked by the Harvey Society to summarize our studies on the natural history of convalescence with particular reference to endocrine changes, i.e., the hormonal changes that occur after injury. Here was an opportunity to assemble what was known at the time about the interrelationships among an injury or a wound, the function of the endocrine glands, and metabolic changes within the body: an overall picture of the normal biology of convalescence. This was 14 years after Albright’s Harvey Lecture (cited above) had clearly anticipated these findings:

Moore, F.D. 1956-1957. Metabolism in trauma: the meaning of definitive surgery—the wound, the endocrine glands, and metabolism. Harvey Lect. 52:74-99.

George H.A. Clowes, long-time friend and worker in surgical metabolism both at Harvard and at Brown, described a leading candidate for the wound hormone that I had postulated in my Harvey Lecture:

Clowes, G.H.A., Jr., B.C. George, C.A. Villee, Jr., and C.A. Saravis. 1983. Muscle proteolysis induced by a circulating peptide in patients with sepsis or trauma. N. Engl. J. Med. 308:545-552.

While this general view of metabolism after injury has stood the test of time, many additional changes in endocrine function and cellular biology—unheard of in 1956—have been shown to be important in the response of the body to injury and surgery.

A couple of years after the Harvey Lecture, following a long period of labor pains, I finally delivered the “big green book” to the Saunders Company, setting forth many aspects of metabolic change after injury and relating them to the everyday care of surgical patients. This was my only commercially successful book. It was read widely, translated into Spanish, Polish, Japanese, and probably Russian, though we never knew that for sure. Even today, when I visit with surgeons, I am still pleased to see this book on their shelves:

Moore, F.D. 1959. Metabolic Care of the Surgical Patient. Philadelphia: W.B. Saunders Co.

John Dusseau of Saunders helped us to produce that large book in an attrac-

tive format and with many illustrations. He helped me with several projects over the years and has given me valuable advice about the publication of this story.

About 30 years after our first work on the subject, I was given an opportunity again, this time in 1975, to summarize the present state of our knowledge about the biology of convalescence. With Murray Brennan, soon to assume his responsibilities as Chief of Surgery at Memorial Sloan-Kettering in New York, I wrote an up-to-date summary:

Moore, F.D., and M.F. Brennan. 1975. Surgical injury: body composition, protein metabolism and neuroendocrinology, pp. 169-222. In Manual of Surgical Nutrition, Committee on Pre- and Postoperative Care, American College of Surgeons. Philadelphia: W.B. Saunders Co.

An important aspect of the growing knowledge of nutrition, biochemistry, and metabolism in surgical recovery was the development of total intravenous feeding. Although we had used this method and it was described in the big green book cited above, we had not carried out the fundamental research to prove its effectiveness. This had first been done by Fuller Albright, with whom I had worked as a junior member of the staff at the MGH during the war. His description of total intravenous feeding of a surgical patient is as follows:

Albright, F., E.C. Reifenstein, and A.P. Forbes. 1944. Effect of total intravenous feeding with mixtures of protein hydrolysate (Amigen) and glucose on the metabolic data of a patient before and after a bone operation, pp. 168-176. In Macy Conference on Metabolic Aspects of Convalescence Including Bone and Wound Healing, E. C. Reifenstein (ed), Eighth Meeting, New York, NY, October 13-14.

Albright’s studies showed the brisk increase in nitrogen excretion (despite constant protein intake) after operation and an increase in glucose excretion (despite constant carbohydrate intake).

But even Albright’s work lacked some of the detail that can be achieved only through experiments in laboratory animals. These experiments were carried out by Jonathan Rhoads with his collaborators Wilmore, Dudrick, and Vars, who for many years had been trying to improve nutrition in surgical patients. Their work was summarized in 1968. Almost immediately following this publication, the word on total intravenous feeding spread over the world, finding a special usefulness in infants born with disorders of the gastrointestinal tract, in people suffering severe wounds, and in those debilitated because of cancer or chronic infection. Few events in the field of nutrition and metabolism have changed worldwide practice as much as this publication by Rhoads and his group:

Dudrick, S.J., D.W. Wilmore, H.M. Vars, and J.E. Rhoads. 1968. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 64:134.

Recently, Jonathan Rhoads has summarized this era of nutrition in surgery:

Rhoads, J.E. 1994. Memoir of a surgical nutritionist. JAMA 272:963-966.

Several histories of the MGH have been published. One of the most recent discusses particularly its recent corporate evolution and financial arrangements. The books by Faxon tell a little bit more of the philosophy of the MGH and of the study of human illness as a means toward understanding normal human physiology:

Castleman, B., D.C. Crockett, and S.B. Sutton. 1983. The Massachusetts General Hospital, 1955-1980. Boston: Little, Brown.

Faxon, N.W. 1949. The Hospital in Contemporary Life. Cambridge, MA: Harvard University Press.

Faxon, N.W. 1959. The Massachusetts General Hospital, 1935-1955. Cambridge, MA: Harvard University Press.

Myers, C.W. 1929. History of the Massachusetts General Hospital, June 1872 to December 1900. Boston, private printing.

In celebration of the 50th anniversary of the founding of the Brigham, the poet David McCord (long-time friend and a patient of mine) wrote a history, making use of the term Fabrick of Man, first coined in 1543 by Vesalius, to denote the work of a hospital:

McCord, D. 1963. The Fabrick of Man. Fifty Years of the Peter Bent Brigham. The Corporation of the Peter Bent Brigham Hospital. Portland, ME: Anthoensen Press.

No books have been written that cover adequately the entire span of surgical research and teaching at the Harvard Medical School over the course of two centuries. Although Beecher and Altschule (see Notes for Chapter 2) covered all of Harvard medicine over three centuries (going back to the first colonists), the surgical story is pretty well buried in the text.

The Truax book is a story of the Warren family of surgeons:

Truax, R. 1968. The Doctors Warren of Boston; First Family of Surgery. Boston: Houghton-Mifflin.

John C. Warren and Edward Warren also wrote of their work and their family:

Warren, J.C. 1846. Inhalation of ethereal vapor for the prevention of pain in surgical operations. Boston Med. Surg. J. 36:375-379.

Warren, E. 1874. The Life of John Warren, M.D. Boston: Noyes, Holmes & Co.

Warren, E. 1860. The Life of John Collins Warren, M.D. Boston: Ticknor & Fields.

The textbook of surgery by our contemporary, Richard Warren:

Warren, R. 1963. Surgery. Philadelphia: W.B. Saunders Co.

Several books and many articles have been written about Cushing and his work. The Fulton biography is the standard:

Fulton, J. 1946. Harvey Cushing. A Biography. Springfield, IL: Charles C Thomas.

The forces that shaped Cushing’s life and the remarkable variety of advances that came from this most productive of America’s surgical researchers make a fascinating story:

Moore, F.D. 1969. Harvey Cushing: General surgeon, biologist, professor. J. Neurosurg. 31:262-270.

Moore, F.D. 1993. The universities in Cushing’s life. In Harvey Cushing at the Brigham. P. Black (ed). Park Ridge, IL: American Association of Neurological Surgeons.

Nicholas Tilney wrote several articles on the history of surgical research and on Harvey Cushing:

Tilney, N.L. 1980. Harvey Cushing and the surgical research laboratory. Surg. Gynecol. Obstet. 151:263-270.

Tilney, N.L. 1986. Harvey Cushing and the evolution of a polymath. Surg. Gynecol. Obstet. 162:285-290.

In addition to his work on the heart (described in Chapter 23), Elliott Cutler’s major contribution was in systematizing the teaching of surgical technique. He and Robert Zollinger developed an atlas of surgical operations to help young people learn how to carry out operations safely. This book was first published just at the time when our class started internship in 1939:

Cutler, E.C., and R.M. Zollinger. 1939. Atlas of Surgical Operations. New York: Macmillan. (Subsequent editions 1949, 1961-67.)

Zollinger, R.M., and R.M. Zollinger, Jr. 1993. Atlas of Surgical Operations, 7th ed. New York: McGraw-Hill. (Previous editions 1975, 1983, and 1988.)

A practice that started many years ago but is now rapidly gaining momentum is the use of a lighted telescope, or endoscope, to view and manipulate the anatomy involved. This method was originally used to sever adhesions in the pleural cavity as early as 1940. Richard Sweet, a thoracic surgeon on the MGH staff, often used this technique as part of collapse therapy (such as pneumothorax) in tuberculosis. Tubes for viewing the interior of the stomach, esophagus, bladder, and colon have been used for 100 years. In the past decade electronic transfer of such images to a T.V. screen has revolutionized this field. Gallbladder surgery, hernia repair, and even removal of the appendix or of the cancerous colon have fallen within the reach of endoscopic surgery. Two or three small incisions replace the long skin incisions of previous years.

In view of Cutler’s atlas of 50 years ago, it is perhaps fitting that a new atlas— this time of endoscopic surgery—has now emerged from the Brigham staff:

Brooks, D.C. (ed). 1994. Current Techniques in Laparoscopy. Philadelphia: Current Medicine, 1994.

Cushing’s operating room orderly, Adolph Watzka, stayed on to work under Cutler and then in the Moore regime until his death in 1956. Adolph emigrated from Bohemia as a teenager in 1912. In 1917 he came to Boston and arrived at the Brigham in answer to a “help wanted” ad.

In my annual report for 1956, at the time of Adolph’s death, I included a brief description of his life and remarkable career:

An illustrated article featuring Adolph’s story appeared in Collier’s Magazine:

Dineen, J.F. 1951. The hospital orderly they call “Doctor.” Collier’s, December 1, p. 27.

Mr. Arthur Porritt, a New Zealander as well as a London surgeon of great charm and ability, served as sergeant surgeon to the Queen and was knighted because of his distinguished war record and his long service on the British Olympic Committee. He was later appointed Governor General of New Zealand, the first native New Zealander to receive this honor. He was firmly ensconced at Government House in Wellington when Laurie and I were houseguests there. On the basis of this service he was made a Lord; later, as one of the four surgical Lords, he greeted a group of us from the American College of Surgeons for a reception at the House of Lords (1974). His appointment to the Olympic committee came about on the basis of his victorious career as an Olympic runner. As mentioned in the text, it was in those Olympic years that he met J. Murray Forbes of Boston (also an Olympic runner) and later joined with him in supporting our Brigham–St. Mary’s resident/registrar exchange program in 1950. Porritt’s career as a runner was well known; in fact, in the motion picture Chariots of Fire the reference to the speedy New Zealander was a reference to Porritt. Lord Porritt was Pro Tem at the Brigham on two occasions, once with Elliott Cutler as chief and once with me.

The Brigham–St. Mary’s exchange of surgical residents between Boston and London began in 1949 and brought new skills and experience to young surgeons from both sides of the Atlantic for almost 20 years. Despite the British and American collaboration, it was actually two Canadians, Keith Eric Rogers and

Felix Eastcott, who were the first to cross. Eastcott, long a leader of the staff at St. Mary’s, with an office on Harley Street and eminence in British vascular surgery, has visited the United States often, both as an Honorary Fellow of the American College of Surgeons and as a friend of many American colleagues. For a time he was Acting President of the Royal College of Surgeons of England.

The heal-in at Boston City Hospital was in essence a strike or job action carried out by the interns and residents and was mimicked (if rather faintly) at other Boston hospitals in the late 1960s. The inspiration for this came from Philip Caper, a young left-leaning physician of the “white suit, clenched fist” stripe in those antiestablishment years. It was his idea to stir up the hospital administrators, not by going out on strike (which would have left many helpless patients bereft), but rather to do just the opposite: admit them all! So swamped, with their beds overwhelmed by not-very-sick people seeking hospitalization, the hospital administrators quickly capitulated and gave the white suits a raise, hoping the clenched fists would go away.

Philip Caper later became a Senate staff aide to Senator Kennedy and developed computer software to document geographical differences in the utilization of medical and surgical procedures.

Since about 1975, interns and residents have received pay that, although hardly generous, recognizes their public service while they are in a learning mode and helps them eke out a living with the help of spouse and parents.

The Notes and References for these four chapters on transplantation are presented together. The references include papers and books on the development of transplantation at Harvard, the Brigham, and around the world between 1950 and 1970.

The remarkable case of the “arm kidney” has never been described fully in the literature. As mentioned in the text, after the patient’s death from acute hepatitis, the case was written up to document the complete healing of the kidneys:

Burwell, E.L., T.D. Kinney, and C.A. Finch. 1947. Renal damage following intravascular hemolysis . N. Engl. J. Med. 237:657-665.

While I was gathering material to write Give and Take (cited below), I asked Charles Hufnagel if he would send me his own account of the arm kidney episode. The letter that follows was his response to this request:

When I first arrived at the Brigham 2 or 3 years later, this episode had already become surrounded by myth; within 2 years we were going ahead with the Hume series of clinical transplants, and I am very grateful to Charles Hufnagel (who died in 1989) for sending me this note in 1962, while his memory of the matter was still so clear.

About 1947, immediately following the arm kidney episode mentioned above, the development of the artificial kidney became basic to the care of renal failure at the Brigham Hospital. The classic paper that first described this work and formed the basis for future work in the field was published in the Netherlands during the war:

Kolff, W.J., and H.Th.J. Berk. 1944. The artificial kidney. A dialyzer with a great area. Acta Med. Scand. 117:121-134.

When George Thorn received the plans for the artificial kidney from Kolff, there was one nagging design defect still to be resolved. The elaborate rotating drum machine leaked blood at the rotator coupling. Such a leak would also be a dangerous entry point for bacteria. Thorn sought the help of Carl Walter, an innovative surgeon on the Brigham staff with a remarkable gift for engineering improvements in medical technology. He developed the leak-proof, bacteria-proof coupling that made this machine both safe and effective. Later in his inventive surgical career, Carl developed the plastic blood transfusion apparatus now used worldwide and made many improvements in the machinery of operating rooms and the safety of sterilization equipment.

With its improved design, the Brigham-Kolff artificial kidney was employed widely and, with the clinical record of Thorn and Merrill as a guide, remained the standard dialyzer in the United States for many years. The role of the artificial kidney in the treatment of renal failure was central to the development of kidney transplantation and to the Hume series, our first exploration of that new field.

The Hume unmatched-cadaver-kidney series was described in a special supplement to the Journal of Clinical Investigation in 1955. Here will be found the story of all those patients, including that first patient whose kidney was put in the normal position of the kidney, which was never again attempted in the thousands of subsequent cases. Here also is told the story of the last patient of that series, the doctor from South America, whose long survival set the stage for the work of Joseph Murray and John Merrill:

Hume, D., J.P. Merrill, and B.F. Miller. 1952. Homologous transplantations of human kidneys. J. Clin. Invest. 31:640-641.

Hume, D.M., J.P. Merrill, B.F. Miller, and G.W. Thorn. 1955. Experiences with renal homotransplantation in the human: report of nine cases. J. Clin. Invest. 34:327-382.

Joseph Murray’s work in kidney transplantation, starting with the identical twins, was described in a series of articles published over several years. Upon receiving the Nobel Prize, Joe, like all other Nobel laureates, had the opportunity to summarize his work. Here will be found not only that story but the references to much of the earlier work:

Murray, J.E. 1991. The First Successful Organ Transplants in Man. Les Prix Nobel, Stockholm: Norstedts Tryckerie AB, The Nobel Foundation.

In 1964 I published a brief history of transplantation, hoping this might be of interest as the story of a scientific discovery more recent than some of the ancient examples so often used in high school and college courses. Then, in 1972, this book was updated (as a sort of second edition) to include several additional developments, most especially transplantation of the liver and heart:

Moore, F.D. 1964. Give and Take. The Development of Tissue Transplantation. Philadelphia: W.B. Saunders Co.

Moore, F.D. 1972. Transplant: The Give and Take of Tissue Transplantation (revised edition). New York: Simon and Schuster.

Thomas Starzl, working first in Chicago, then at Denver, and later in Pittsburgh, established in the latter two cities major centers for transplantation that became preeminent in the world for the numbers of transplantations carried out, for the development of new drugs for immunosuppression, and for the teaching of the surgical methods of transplantation. He tells his story in a recent autobiography:

Starzl, T.E. 1993. The Puzzle People. Memoirs of a Transplant Surgeon. Pittsburgh: University of Pittsburgh Press.

Key references in the early history of transplantation follow. These include the pioneering work of Alexis Carrel, now almost a century ago, the studies of Peter Medawar during the war, and initial reports from our department:

Carrel, A. 1905. The transplantation of organs. A preliminary communication. JAMA 45:1945-1946.

Carrel’s Nobel lecture 78 years before Murray’s, on a closely related topic:

Carrel, A. 1913. Suture of Blood Vessels and Transplantation of Organs. In Les Prix Nobel en 1912. Stockholm: Imprimerie Royale, P.A. Norstedt & Soner.

The original reports of surgical research by Gibson and Medawar that laid the foundation for immunogenetics and transplant science:

Gibson, T., and P.B. Medawar. 1942-1943. The fate of skin homografts in man. J. Anat. 77:299-310.

Medawar, P.B. 1944. The behavior and fate of skin autografts and skin homografts in rabbits. (A report to the War Wounds Committee of the Medical Research Council.) J. Anat. 78:176-199.

The studies from war-torn London that clearly described reversible kidney failure after severe injury, or the “crush syndrome,” incurred during the incessant bombings of that city:

Bywaters, E.G.L. 1944. Ischemic muscle necrosis: Crushing injury, traumatic edema, the “crush syndrome,” traumatic anuria, compression syndrome; a type of injury seen in air raid casualties following burial beneath debris. JAMA 124:1103-1109.

The three classic papers describing the transplants upon which Dr. Murray’s Nobel Award was based:

Merrill, J.P., J.E. Murray, J.H. Harrison, and W.R. Guild. 1956. Successful homotransplantation of the human kidney between identical twins. JAMA 160:277-282.

Merrill, J.P., J.E. Murray, J.H. Harrison, E.A. Friedman, J.B. Dealy, Jr., and G.J. Dammin. 1960. Successful homotransplantation of the kidney between nonidentical twins. N. Engl. J. Med. 262:1251-1260.

Merrill, J.P., J.E. Murray, F.J. Takacs, E.B. Hager, R.E. Wilson, and G.J. Dammin. 1963. Successful transplantation of kidney from a human cadaver. JAMA 185:347-353.

Had John Merrill and David Hume been living in 1990, it is a fair guess that they would have shared the Nobel award with Joseph Murray.

The references listed below tell of the advent of drug immunosuppression as well as the early work of Calne, Mannick, and the French workers:

Schwartz, R., J. Stack, and W. Dameshek. 1958. Effect of 6-mercaptopurine on antibody production. Proc. Soc. Exp. Biol. Med. 99:164-167.

Schwartz, R., and W. Dameshek. 1959. Drug-induced immunological tolerance. Nature 183:1682-1683.

Calne, R.Y. 1960. The rejection of renal homograft: inhibition in dogs by 6-mercaptopurine. Lancet 1:417-418.

Calne, R.Y. 1961. Inhibition of the rejection of renal homografts in dogs by purine analogues. Transplant. Bull. 28(2):445-461.

Mannick, J.A., H.L.J. Lochte, C.A. Ashley, E.D. Thomas, and J.W.A. Ferrebee. 1959. Functioning kidney homotransplant in the dog. Surgery 46:821-828.

Michael Woodruff, a Scots surgeon who was Head of the Department of Surgery in Dunedin, New Zealand, was an early pioneer in immunogenetic research as well as clinical transplantation. Woodruff carried out the latter when he returned as Professor and Head of the Department of Surgery at the University of Edinburgh, succeeding Sir James Learmonth:

Woodruff, M.F.A., and B. Lennox. 1959. Reciprocal skin grafts in a pair of twins showing blood chimerism. Lancet 2:476-478.

Early reports from the French work:

Küss, R., M. Legrain, G. Mathé, R. Nedey, and M. Camey. 1962. Homotransplantation rénale chez l’homme hors de tout lien de parente. Survie jusqu’au dix-septième mois. Rev. Fr. Etud. Clin. Biol. 7:1048-1066.

Hamburger, J., and J. Dormont. 1968. Functional and morphologic alterations in long-term kidney transplants, pp. 201-214. In Human Transplantation, F. T. Rapaport and J. Dausset (eds). New York: Grune and Stratton.

C. Stuart Welch, Professor and Head of the Department of Surgery at Tufts, carried out experimental liver transplantation in the dog in the early 1950s, placing the liver in a new position in the abdomen:

Welch, C.S. 1955. A note on transplantation of the whole liver in dogs. Transplant. Bull. 2:54-55.

In Welch’s experiments, the animal’s own liver was left in place and intact. Because the object of many liver transplantations in man includes the removal of a diseased liver, our initial experiments involved removal of the entire liver and its replacement by a transplant. The purpose here was to place the new liver in the normal position of the old one and evaluate its function chemically and physiologically. Our work on liver transplantation began in the laboratory in 1957:

Moore, F.D., L.L. Smith, T.K. Burnap, F.D. Dallenback, G.J. Dammin, U.F. Gruber, W.C. Schoemaker, R.W. Steenburg, M.R. Ball, and J.S. Belko. 1959. One-stage homotransplantation of the liver following total hepatectomy in dogs. Transplant. Bull. 6:103-107.

Moore, F.D., H.B. Wheeler, H.V. Demissianos, L.L. Smith, O. Balankura, K. Abel, J.B. Greenberg, and G.J. Dammin. 1960. Experimental whole organ transplantation of the liver and of the spleen. Ann. Surg. 152:374-387.

Tom Starzl began to experiment with liver transplantation in his laboratory in Chicago at the same time we did in Boston. His early work was carried out as a part of his studies at Northwestern University School of Medicine, then continued when he moved to Denver:

Starzl, T.E., T.L. Marchioro, R.T. Huntley, D. Rifkind, D.T. Rowlands, Jr., T.C. Dickinson, and W.R. Waddell. 1964. Experimental and clinical homotransplantation of the liver. Ann. N.Y. Acad. Sci. 120:739-765.

Roy Calne did his early liver transplantations while based in Cambridge, England, working collaboratively with the medical hepatologist and staff at King’s College Hospital in London. Before going on to human work he studied liver transplantation extensively in the pig and showed that in this species liver transplantation was not followed by an intense rejection process:

Calne, R.Y., H.H.O. White, D.E. Yoffa, R.M. Binns, R.R. Maginn, R.M. Herbertson, P.R. Millard, V.P. Molina, and D.R. Davis. 1967. Prolonged survival of liver transplants in the pig. Br. Med. J. 4:645-648.

Calne’s early experience in man was covered in his paper in 1968:

Calne, R.Y., and R. Williams. 1968. Liver transplantation in man. I. Observations on technique and organization in five cases. Br. Med. J. 4:535-548.

Our first liver transplantation patient (in 1963) was reported in the book Transplant: The Give and Take of Tissue Transplantation (referred to above). In 1969 a conference on liver transplantation reviewed the world experience about 6 years after the first two clinical transplants by Starzl and our group, respectively. Over 90% of all the liver transplantations carried out in the world at that time had been done by Starzl and Calne:

Groth, C.G. 1969. World Statistics of Liver Transplantation. Presented at the Cambridge Liver Transplantation Conference, April 10, 1969.

Tom Starzl’s book tells of the early developmental phase of liver transplantation:

Starzl, T.E., and C.W. Putnam. 1969. Experience in Hepatic Transplantation. Philadelphia: W.B. Saunders Co.

Starzl set a high standard for all transplanters by using the immunogenetic cross-hybridization of organ transplantation to cast light on the chemical and in some cases genetic background of certain diseases involving the liver. As Starzl’s work has progressed, he has introduced an important new immunosuppressive drug (FK506), has revealed through transplantation some insights into inherited

enzymatic disorders, and has demonstrated through cell tracking that cells from donor organs (the dendritic cells of lymphatic origin) migrate to other sites in the new host and may be the key to the acceptance of foreign tissue (chimerism):

Starzl, T.E., A.J. Demetris, M. Trucco, C. Ricordi, S. Ildstad, P.I. Terasaki, N. Murase, R.S. Kendall, M. Kocova, W.A. Rudert, A. Zeevi, and D. Van Thiel. 1993. Chimerism after liver transplantation for type IV glycogen storage disease and type 1 Gaucher’s disease. N. Engl. J. Med. 328:745-749.

Our only venture in this field was the demonstration by transplantation that one of the important immune proteins (the third component of complement) is produced entirely in the liver:

Alper, C.A., A.M. Johnson, A.G. Birtch, and F.D. Moore. 1969. Human C'3; evidence for the liver as the primary site of synthesis. Science 163:286-288.

Alan Birtch demonstrated the importance of blood flow alterations in the rejection response to transplanted liver:

Moore, F.D., A.G. Birtch, F. Dagher, F. Veith, J.A. Krisher, S.E. Order, W.A. Shucart, G.J. Dammin, and N.P. Couch. 1964. Immunosuppression and vascular insufficiency in liver transplantation. Ann. N.Y. Acad. Sci. 120:729-738.

Birtch, A.G., and F.D. Moore. 1969. Experience in liver transplantation. Transplant. Rev. 2:90-128.

By moving ahead when an ideal situation arose for the availability of a fresh heart, Chris Barnard scooped his former Minnesota colleagues Lower and Shumway, who by then had moved to Stanford, and reported his first cardiac transplant:

Barnard, C.N. 1968. Human heart transplantation: the diagnosis of rejection. Am. J. Cardiol. 22:811-819.

Shumway’s clinical work had started at the same time as Barnard’s first two human heart transplants in South Africa. Within a short time Shumway could report an extensive series of operations that outstripped other surgeons in the world. Shumway performed a large series of heart transplants in man using standard methods with effective support and a very low mortality:

Stinson, E.B., E. Dong, Jr., J.S. Schroeder, and N.E. Shumway. 1969. Cardiac transplantation in man. IV. Early results. Ann. Surg. 170:588-592.

Richard Lower was one of the pioneers working in cardiac transplantation early on, starting first at Minnesota and then with Shumway at Stanford before

becoming head of the unit for heart transplantation at Richmond under Hume. He reviewed this work:

Lower, R.R. 1969. Prospects of heart transplantation, pp. 238-247. In Organ Transplantation Today, N.A. Mitchison, J.M. Greep, and J.C.M.H. Verschure (eds). Amsterdam: Excerpta Medica.

Four years earlier, Lower had been a collaborator with Shumway and Dong in the dog work that made cardiac transplantation possible. Experiments in dogs had made kidney transplantation possible and were to be the touchstone of success for all major research. This early article was one of the first to be published on experimental heart transplantation in the dog:

Lower, R.R., E. Dong, Jr., and N.E. Shumway. 1965. Long-term survival of cardiac homografts. Surgery 58:110-119.

The remarkable role of Wangensteen’s department at the University of Minnesota has been reviewed by Simmons:

Simmons, R.L. 1992. The Minnesota story. A brief history of the transplantation program at the University of Minnesota. Chimera 4:9-14.

Early reports of transplantation of the lung included the work of Hardy in

Mississippi, Blumenstock at the Bassett Hospital in New York, and Derom in the Netherlands:

Hardy, J.D., W.R. Webb, M.L. Dalton, Jr., and G.R. Walker, Jr. 1963. Lung homotransplantation in man. Report of the initial case. JAMA 186:1065-1074.

Blumenstock, D.A. 1967. The lung and other organs. Transplantation of the lung. Transplantation 5:917-928.

Derom, F., F. Barbier, S. Ringoir, G. Rolly, J. Versieck, G. Berzsenyi, R. Raemdonck, and J. Piret. 1969. A case of lung homotransplantation in man (preliminary report). Tijdschr. Geneeskd. 25:109-114.

Transplantation of the pancreas was undertaken to provide the endocrine organ that contains the islets of Langerhans. These islets secrete insulin and would be critical for survival in childhood diabetes. The papers by Lillehei and Reemtsma tell of their work in Minneapolis and New York, respectively:

Lillehei, R.C., Y. Idezuki, W.D. Kelly, J.S. Najarian, F.K. Merkel, and F.C. Goetz. 1969. Transplantation of the intestine and pancreas. Transplant. Proc. 1:230-238.

Reemtsma, K., J.F. Lucas, Jr., R.E. Rogers, F.E. Schmidt, and F.H. Davis, Jr. 1963. Islet cell function of the transplanted canine pancreas. Ann. Surg. 158:645-653.

Paul Russell, innovative transplanter of the early days, now in charge of immunogenetic research at the MGH, has used genetic manipulation to produce insulin from other cell types:

Selden, R.F., M.J. Skoskiewicz, P.S. Russell, and H.M. Goodman. 1987. Regulation of insulin gene expression. N. Engl. J. Med. 317:1067-1070.

Selden, R.F., M.J. Skoskiewicz, K.B. Howie, P.S. Russell, H.M. Goodman. 1986. Regulation of human insulin gene expression in transgenic mice. Nature 321:525-528.

Russell, P.S. 1991. Some personal reflections on the development of transplantation, pp. 307-335. In History of Transplantation: 35 Recollections, Vol. 17. P.I. Terasaki (ed). Los Angeles, CA: UCLA Tissue Typing Laboratory.

Somers Sturgis and John Brooks of our staff experimented extensively with the transplantation of endocrine organs (ovary, thyroid, parathyroid, pancreatic islet cells) within protective chambers made of Millipore filter material:

Sturgis, S.H., and H. Castellanos. 1962. Ovarian homografts in organic filter chambers. Ann. Surg. 156:367-374.

Brooks, J.R., S.H. Sturgis, and G. Hill. 1960. An evaluation of endocrine tissue homotransplantation in the Millipore chamber with a note on tissue adaptation to the host. Ann. N.Y. Acad. Sci. 87:482-500.

Brooks, J.R., and J. Levy. 1968. Endocrine transplantation, pp. 271-283. In Human Transplantation, F.T. Rapaport and J. Dausset (eds): New York: Grune & Stratton.

Brooks, J.R. 1962. Endocrine Tissue Transplantation. Springfield, IL: Charles C Thomas.

As early as 1960 Starzl was experimenting in dogs with multiple organ grafts:

Starzl, T.E., H.A. Kaupp, Jr., D.R. Brock, G.W. Butz, and J.W. Linman. 1962. Homotransplantation of multiple visceral organs. Am. J. Surg. 103:219-229.

Thirty years later such transplants in patients met with limited success and were criticized for overextending the available technology. My editorial comment, requested by the editor of JAMA, was critical of justifying such operations on the basis of desperation, but at the same time held Starzl and his group as models of complete frankness in their published reports:

Moore, F.D. 1989. The desperate case: CARE (costs, applicability, research, ethics). JAMA 261:1483-1484.

The occurrence of malignant tumors in transplant patients is described:

Sheil, A.G.R., A.P.S. Disney, T.H. Mathew, N. Amiss, and L. Excell. 1991. Cancer development in cadaveric donor renal allograft recipients treated with

azathioprine (AZA) or cyclosporine (CyA) or AZA/CyA. Transplant. Proc. 23:1111-1112.

Penn, I. 1991. Occurrence of cancers in immunosuppressed organ transplant recipients, pp. 53-62. In Clinical Transplants 1990, P.I. Terasaki (ed). Los Angeles, CA: UCLA Tissue Typing Laboratory.

Annual reports of transplantation operations and results are available from UNOS (United Network for Organ Sharing) and from Terasaki’s reviews:

Terasaki, P.I., and J.M. Cecka. 1994. Clinical Transplants 1993 (ninth in a series). Los Angeles, CA: UCLA Tissue Typing Laboratory.

Terasaki, P.I. (ed). 1991. History of Transplantation: 35 Recollections. Los Angeles, CA: UCLA Tissue Typing Laboratory.

UNOS, Division of Organ Transplantation, Bureau of Health Resources Development, Health Resources and Services Administration, and U.S. Department of Health and Human Services. 1993. Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network—Transplant Data: 1988-1991. Bethesda, MD: U.S. Department of Health and Human Services.

The data on waiting lists for 1994, presented at the end of Chapter 22, are from the periodical “UNOS Update.”

The concept that physicians and especially surgeons often must do harm so that healing can occur is hardly new. It has merely been obscured by the ancient platitude primum non nocere (first, do no harm).

Breach of this ancient maxim has sometimes been essential to healing because physicians must often do harm and put the patient at risk so healing may occur. Sometimes the harm is lasting and severe. No one who has been through cancer chemotherapy needs to be told this. Disfiguring surgery in malignancy and the giving of a donor organ by a healthy relative are clear examples of breach of that ancient saying. Hurt, risk, and harm are undertaken so the patient can heal, get well, and return to a normal life.

Although the expression primum non nocere is usually ascribed to Hippocrates, it is not part of The Physician’s Oath. The authentic reference is to Hippocrates’ Epidemics, Book I, Section xi (translated by Jones): “As to diseases, make a habit of two things—to help, or at least to do no harm.”

To harm has sometimes been essential to healing, to recovery, as in the removal of vital parts of the brain to cure a tumor. In the ancient practice of bloodletting or bleeding, the extent of harm to the patient was often severe and not recognized. Bloodletting, the object of which was to take blood from the vein in front of the elbow, and leeching, in which blood was withdrawn by placing a hungry leech over the vein, were carried out in the hope that the patient would be improved thereby. Galen is alleged to have introduced this practice in the early years of the Christian era, and it lasted until the turn of this

century. According to his translators, Galen was both realistic and conservative and cautioned against removing more than an ounce or two (30 to 60 milliliters) of blood.

Like so much of medical mythology, this widespread practice had its origin in a small crumb of truth. In some cases of congestive heart failure, the removal of large amounts of blood (up to 500 milliliters or even more) produces a decongestion of the lungs that must have seemed truly “miraculous” to the ancients. Perhaps we should not be surprised or critical that our ancestors generalized from this to overuse of the remedy. We have often committed the same error; for example, the “penicillin for everything” era of the early 1950s.

The overuse of bleeding was commonplace in the eighteenth century. It was even used for infections such as yellow fever. George Washington’s final illness was a severe septic sore throat, possibly of the type caused by the streptococcus. According to most interpretations, extreme bloodletting resulted in his death. Galen’s views as well as the care of General Washington are described in the following references:

Brain, P. 1980. Galen on Bloodletting: A Study of the Origins, Development and Validity of His Opinions, With a Translation of Three Works. New York: Cambridge University Press.

Jackson, J. 1860. Memoir on the Last Sickness of George Washington. Boston: Privately printed.

In major surgery, transplantation, chemotherapy, and radiotherapy, doctors must often do harm so the patient may heal. Sometimes the hurt wins out and the healing fails to occur. Despite such tragedy, the public clearly accepts the fact that severe hazards and physical harm are often necessary for later healing. An educated public will also welcome an updated Latin maxim to express the more realistic relationship between harm and healing in medical and surgical care. I am indebted to G. Bruce Cobbold, teacher of Latin at Tabor Academy in Marion, Massachusetts, for suggesting the phrase Nonnumquam, nocere est renovare (“Sometimes, to hurt is to heal”). Here the infinitive serves as an imperative.

I hope the reader will agree that this expression comes closer to the truth, not only in high-tech procedures such as whole-body irradiation for marrow transplantation in leukemia, but also in the seemingly minor interventions such as giving a child with pneumonia an antibiotic known to cause severe side effects.

In 1924, Elliott Cutler, a junior member of Cushing’s staff at the Brigham, attempted to open a narrowed mitral valve surgically. The idea was clear, the method was flawed. Nonetheless, his first patient did quite well for over a year. It was appropriate that 24 years after Cutler’s work, Dwight Harken carried out the first large series of successful operations on the mitral valve. These are the two historic articles:

Cutler, E., S.A. Levine, and C.S. Beck. 1924. The surgical treatment of mitral stenosis: experimental and clinical studies. Arch. Surg. 9:689-692.

Harken, D.E., L.B. Ellis, P.F. Ware, and L.R. Norman. 1948. The surgical treatment of mitral stenosis. I. Valvuloplasty. N. Engl. J. Med. 239:801-809.

The work of Bailey was contemporaneous with that of Harken:

Bailey, C.P. 1949. Surgical treatment of mitral stenosis (mitral commissurotomy). Dis. Chest 15:377-397.

John Gibbon’s early work under Churchill at the MGH was reported in his first two papers:

Gibbon, J.H., Jr. 1937. Artificial maintenance of circulation during experimental occlusion of the pulmonary artery. Arch. Surg. 34:1105-1131.

Gibbon, J.H., Jr. 1939. The maintenance of life during experimental occlusion of the pulmonary artery followed by survival. Surg. Gynecol. Obstet. 69:602-614.

John Gibbon, in his account of his early work on the heart-lung apparatus, tells the story of that crucial vigil:

Gibbon, J.H., Jr. 1978. Great ideas in surgery: the development of the heart-lung apparatus. Am. J. Surg. 135:608-619.

About 20 years after Gibbon began his work on the heart-lung apparatus, designed to remove the entire volume of blood from the veins, oxygenate the red cells, remove the carbon dioxide, and return all that blood under pressure to the arteries, he published a status report:

Gibbon, J.H., Jr., B.J. Miller, and C. Fineberg. 1953. An improved mechanical heart-lung apparatus. Med. Clin. North Am. 37:1603-1624.

Gibbon, J.H., Jr. 1954. Application of a mechanical heart and lung apparatus to cardiac surgery. Minnesota Med. 37:171-180.

Within a year Gibbon was able to report the first successful application of his pump-oxygenator to surgery in man, after which John Kirklin and Walt Lillehei applied this device to many patients with heart disease, particularly infants and children. The modern era of open-heart surgery had truly begun:

Kirklin, J.W., J.W. DuShane, R.T. Patrick, D.E. Donald, P.S. Hetzel, H.G. Harshbarger, and E.H. Wood. 1955. Intrathoracic surgery with the aid of a mechanical pump-oxygenator system (Gibbon type): report of eight cases. Proc. Staff Meetings Mayo Clin. 30:201-206.

Warden, H.E., M. Cohen, R.A. DeWall, E.A. Schultz, J.J. Buckley, R.C. Read, and C.W. Lillehei. 1954. Experimental closure of interventricular septal defects and further physiologic studies on controlled cross circulation. Surg. Forum 24 5:22-28.

The concept of using a pump-oxygenator for purposes other than cardiac surgery was especially prominent in our department in the 1970s with the work of Philip A. Drinker and Robert Bartlett. They planned to develop a device of this type for use wholly as an artificial lung, the object being to substitute a machine to oxygenate blood in patients with life-threatening but reversible lung disease. This application of the pump-oxygenator has found its greatest usefulness in newborn infants with respiratory distress syndrome. Philip Drinker’s interest in the artificial support of lung function came naturally to him because it was his father, Philip Drinker, who in 1927-29 developed the automatic respirator, later known as the Drinker Respirator, for use in cases of polio. Bartlett carried the work forward in California and then at Ann Arbor as the foremost exponent of

this method for treating severely handicapped infants. His record is a remarkable one, with many long-term survivors among infants who would otherwise have died:

Bartlett, R.H. 1990. Extracorporeal life-support in cardiopulmonary failure. Curr. Probl. Surg. 27:627-705.

In their most recent article, the Michigan group reports on 20 years’ experience in using the extracorporeal life support in 444 critically ill newborn infants. Survival rates in severe respiratory distress (formerly fatal in almost all cases) have risen from 72 to 94%. Here is the successful application of a device invented for the surgical treatment of heart disease being used to help with severe crises in newborn babies. I am sure that Jack Gibbon, were he still alive, would be proud of this totally unforeseen application of the pump-oxygenator he worked so long to perfect:

Shanley, C.H., R.B. Hirschl, R.E. Schumacher, T. Delosh, R.A. Chapman, R.H. Bartlett, and M.C. Overbeck. 1994. Extracorporeal life support for neonatal respiratory failure: 20 year experience. Ann. Surg. 220:269-282.

As a research fellow at the Brigham, Charles Hufnagel was a pioneer in many aspects of cardiovascular surgery. The ball valves that he explored so thoroughly in dogs became the prototype later developed by Harken for use in the aortic valve position. Hufnagel later became Professor and Department Head at Georgetown University in Washington, D.C.:

Hufnagel, C.A. 1950. Aortic plastic valvular prosthesis. Bull. Georgetown Med. Center 4:128-130.

Ancient history of cardiac surgery includes work by Harvey Cushing. Cushing was an innovator in many fields of surgery and physiology. He carried out some early cardiac surgery in the laboratories at Johns Hopkins:

Cushing, H., and J.R.B. Branch. 1907-1908. Chronic valvular lesions in the dog and their possible relation to future surgery of the cardiac valves. J. Med. Res. 17:471-486.

In England, Souttar had carried out work of this type at the same time as Elliott Cutler’s efforts but never proceeded with his studies:

Souttar, H.S. 1925. Surgical treatment of mitral stenosis. Br. Med. J. 2:603-608.

Harken’s wartime work on removal of bullets and shell fragments from the heart was an early report of successful surgery within the heart:

Harken, D.E., and A.C. Williams. 1946. Foreign bodies in and in relation to the thoracic blood vessels and heart. Migratory foreign bodies within the blood vascular system. Am. J. Surg. 72:80-90.

The operations carried out by Robert Gross for patent ductus and coarctation of the aorta before and during World War II were milestones in the surgical correction of defects of the heart and great vessels in infants and children:

Gross, R.E., and J.P. Hubbard. 1939. Surgical ligation of patent ductus arteriosus: a report of the first successful case. JAMA 112:729-731.

Gross, R.E. 1945. Surgical correction for coarctation of the aorta. Surgery 18:673-678.

I am indebted to M. Judah Folkman for details of Robert Gross’ early work, as related in the text.

The early work by Churchill on pericardiectomy and the work of Alfred Blalock in rerouting the blood in congenital heart disease also provided essential background for the development of surgery in the interior of the heart. Helen Taussig was a leading scholar of congenital heart disease in children. Her long collaboration with Blalock is an example of the sort of collaboration between a surgeon and physicians, scientists, or scholars in other fields that has produced major advances in surgery:

Churchill, E.D. 1936. Pericardial resection in chronic constrictive pericarditis. Ann. Surg. 104:516-529.

Blalock, A., and H.B. Taussig. 1945. Surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 128:189-202.

The Department of Surgery at the University of Minnesota under Owen Wangensteen was a center of innovative research in cardiac surgery for several decades after World War II, despite the fact that Wangensteen’s own interests lay mostly in the surgical management of duodenal ulcer. Early reports from Minnesota describe the cross-circulation method of supporting the open, quiet heart as well as early adaptations and improvements of the pump-oxygenator:

Warden, H.E., M. Cohen, R.C. Read, and C.W. Lillehei. 1954. Controlled cross circulation for open intracardiac surgery. Physiologic studies and results of creation and closure of ventricular septal defects. J. Thorac. Surg. 28:331-343.

DeWall, R.A., H.E. Warden, V.L. Gott, R.C. Read, R.L. Varco, and C.W. Lillehei. 1956. Total body perfusion for open cardiotomy utilizing the bubble oxygenator. J. Thorac. Surg. 32:591-603.

Dudley Johnson was one of the first to report an impressive series in which blood was shunted (bypassed) from the aorta to the coronary arteries. This was the coronary artery bypass graft, which, with many variations and improvements, is now used throughout the world to assist people with coronary heart disease:

Johnson, W.D., and D. Lepley, Jr. 1970. An aggressive surgical approach to coronary disease. J. Thorac. Cardiovasc. Surg. 59:128-138.

The story of Dwight Harken’s life work as surgeon to the human heart would be incomplete without acknowledging the expert work of Anna Mae Fosberg, R.N., Associate in Surgery. Ms. Fosberg was the cardiac technician who operated the pump-oxygenator for him and for his successor, John Collins, from the earliest use of that device at the Brigham (about 1956) until her retirement in 1993. Essential to the success of open-heart programs in all the hospitals that undertake such work is a person, often known as the pump technician, who keeps this complex apparatus clean, safe, and functioning properly. Anna Mae Fosberg, affectionately known as “Scottie,” fulfilled this role for almost 40 years and so ably that she became the teacher of many nurses and bioengineers who then filled this role at hospitals elsewhere in this country and abroad.

Our early studies of pituitary removal in the treatment of advanced breast cancer were done in collaboration with Andrew Jessiman and Donald Matson, who performed the operations. While some excellent results were obtained for individual patients, the treatment itself was too taxing, and long-term survival was infrequent:

Jessiman, A.G., D.D. Matson, and F.D. Moore. 1959. Hypophysectomy in the treatment of breast cancer. N. Engl. J. Med. 261:1199-1207.

McWhirter, a Scottish radiologist, was one of the early vocal antisurgical advocates. He always carried out radiation therapy without ever questioning whether or not even that was necessary after conservative surgical removal of the breast in very early cases:

McWhirter, R. 1955. Simple mastectomy and radiotherapy in treatment of breast cancer. Br. J. Radiol. 28:128-139.

We reviewed the mixing of all these cross currents on several occasions:

Jessiman, A.G., and F.D. Moore. 1956. Carcinoma of the Breast: The Study and Treatment of the Patient. Boston: Little, Brown.

Moore, F.D., S.I. Woodrow, M.A. Aliapoulios, and R.E. Wilson. 1967. Carcino-

ma of the Breast: A Decade of New Results and Old Concepts. Boston: Little, Brown.

Jerome Urban of New York was one of the voices calling for more radical surgical removal of the breast:

Urban, J.A., and H. Farrow. 1963. Long term results of internal mammary lymph node excision for breast cancer. Acta Union Int. Contre Cancer 19:1551-1554.

The most successful of our innovations in advanced breast cancer was the combination of surgical adrenalectomy immediately followed by chemotherapy. Some of the few long-term survivals that we obtained resulted from this combination, with these patients living a pain-free existence for 5 to 15 years despite the initial presence of advanced disease:

Moore, F.D., S.B. Van Devanter, C.M. Boyden, J. Lokich, and R.E. Wilson. 1974. Adrenalectomy with chemotherapy in the treatment of advanced breast cancer: objective and subjective response rates; duration and quality of life. Surgery 76:376-390.

Early efforts to modify the growth of cancer by means of toxins or immune stimulants go back many years. Although we would now lump all those early efforts under the general rubric of immune modulation in cancer treatment, some of the early workers and authors in this field would hardly agree with such terminology, since they considered these agents poisons or toxins that affected the cancer directly rather than as stimulants of the patient’s immune defenses. The work of Bradley Coley, using what were known at that time as Coley’s toxins, stands out:

Coley, W.B. 1894. Treatment of inoperable malignant tumors with the toxines of erysipelas and the bacillus prodigiosus. Trans. Am. Surg. Assoc. 12:183-203.

Steven Rosenberg’s work on adoptive immunotherapy can be traced through his reports:

Grimm, E.A., A. Mazumder, H.Z. Shang, and S.A. Rosenberg. 1982. The lymphokine activated killer cell phenomenon: lysis of NK resistant fresh solid tumor cells by IL-2 activated autologous human peripheral blood lymphocytes. J. Exp. Med. 155:1823-1841.

Rosenberg, S.A., J.J. Mule, P.J. Spiess, C.M. Reichert, and S. Schwarz. 1985. Regression of established pulmonary metastases and subcutaneous tumor mediated by the systemic administration of high dose recombinant IL-2. J. Exp. Med. 161:1169-1188.

Rosenberg, S.A. 1992. The immunotherapy and gene therapy of cancer. J. Clin. Oncol. 10:180-199.

In 1993 Rosenberg published an autobiography describing his work on genetic manipulation and adoptive immunotherapy in cancer. His book presents a fascinating view of both the promise and the limitations of the method. He tells the story of Lieutenant Commander L.G., whose course and recovery (with many additional details supplied to me by Steven Rosenberg) are related in Chapter 24:

Rosenberg, S.A., and J.M. Barry. 1992. The Transformed Cell. New York: Putnam.

John Howard’s book describes his elegant studies at MASH #8209 where the Surgical Research Unit was established:

Howard, J. M., ed. 1955. Battle Casualties in Korea. Studies of the Surgical Research Team (Vols. 1-4). Washington, D.C.: U.S. Government Printing Office.

In 1955, nine articles on this subject were published in the March issue of Annals of Surgery (Volume 141, Number 3).

Early in this century, about 1906, Paul W. Harrison was one of the first medical missionaries to visit Arabia and one of the early explorers and ethnographers of the region. His book describes the scene at Dhahran. He remembered that he could not see anything but desert scrub and the burning hot sun. He commented that it was bone-chilling cold at night and broiling hot during the day and that there was no sign of anything to support the activities of human beings in the air, on the ground, or beneath it. He wrote his classic description of the Arabian desert while he was standing on top of the largest oil dome in the world.

The site of the first productive oil well, known as Dhahran No. 1, is now enclosed by a silver fence that celebrates the date when the oil began to flow (1936). Within a few years the Saudi dynasty made the move from camels to Cadillacs and fell prey to the relentless pressure of western economics. The many flaws of western civilization became engrafted on the life of courageous desert nomads.

Harrison’s early account was reprinted in 1927:

Harrison, P.W. 1927. The Arab at Home. New York: Thomas Y. Crowell.

The son of this exploring Harrison, Timothy Harrison, is a surgeon on the staff of the medical school in Hershey, Pennsylvania. He has followed in his

father’s footsteps, doing medical missionary work in the Middle East, particularly Lebanon, the Emirates, and Arabia. He married Eliza Cope, the daughter of Oliver Cope, who was so important as a teacher and leader in my early years in surgery at the Massachusetts General.

C.M. Doughty was also a scholar of early Arabic civilization. At the time of my studies in the Department of Anthropology at Harvard College, his books were the source books on the Arabian Peninsula:

Doughty, C.M. 1921. Travels in Arabia Deserta. Boston: P.L. Warner.

Doughty, C.M. 1927. Wanderings in Arabia. New York: Boni.

The discovery of oil was not the first thing to bring the impact of Western civilization to the Arabian desert. The northwest frontier between Arabia and what are now Syria and Jordan was the scene of the efforts of the British to oust the Ottoman Empire from the Fertile Crescent and Mesopotamia. This heroic story of the desert war in World War I has never been told better than by T.E. Lawrence:

Lawrence, T.E. 1937. Seven Pillars of Wisdom: A Triumph. Garden City, NY: Doubleday, Doran & Co.

Many recent American and British visitors have described their reactions to Arabia. One of the recent medical visitors was Seymour Gray, a medical associate of ours at the Brigham for many years. Upon returning from an extensive visit to Arabia, he wrote a revealing analysis of the atmosphere that surrounded the royal family:

Gray, S.J. 1983. Beyond the Veil: The Adventures of an American Doctor in Saudi Arabia. New York: Harper & Row.

The Arabian-American Oil Company (ARAMCO) was clearly in charge of United States–Saudi relationships at the time of my visit. This company issued (in 1960) a remarkable handbook for all their employees about to be stationed in Saudi Arabia. It is one of the best reference books obtainable on this subject.

Arabian-American Oil Company (ARAMCO). 1960. Arabian Handbook.

Many years of work with the National Institutes of Health included my term as Chairman of the Surgery Study Section. During these years (1958 to 1961) we funneled generous amounts of research support into the development of the

pump-oxygenator for cardiac surgery and the earliest immunological studies to make transplantation safer. A retrospective summary of those years:

Moore, F.D. 1961. The Surgery Study Section of the National Institutes of Health. Ann. Surg. 153:1-12.

My association with the National Aeronautics and Space Administration (NASA) as a consultant began in 1968 when I was asked to be a member of the NASA committee under Bentley Glass (Dean of the Medical School at the State University of New York at Stony Brook). We were looking into the matter of deconditioning and other physiologic problems that arise during prolonged space flight. While deconditioning consists of changes in the astronauts’ body composition that are a major nuisance and at times a hazard, it now seems clear that deconditioning can usually be prevented by engaging in rigorous exercises against spring-loaded resistance. Such conditioning exercise requires special equipment because gravitational force is absent. In the reports written by the Glass committee and its successor, the Robbins committee, we reviewed many of the current issues of space flight:

Glass, H.B., ed. 1970. Life Sciences in Space. Study to Review NASA Life Sciences Programs. Washington, D.C.: National Academy of Sciences.

Robbins, F. 1988. Exploring the Living Universe: A Strategy for the Space Life Sciences. A Report of the NASA Life Sciences Strategic Planning Study Committee. Washington, D.C.: NASA.

All manned space flights of the Soviets and the Americans, with the single exception of the Apollo (Moon) flights, have been in low Earth orbit, beneath the protective magnetosphere. It is in deep space, beyond this protection, that radiation presents a severe hazard. For several years I devoted my full attention to reviewing this problem. Because no single reference had presented evidence on the severity of the hazards traceable to exomagnetospheric radiation, I prepared a brief review:

Moore, F.D. 1992. Radiation burdens for humans on prolonged exomagnetospheric voyages. FASEB J. 6:2338-2343.

Visits to other universities were sometimes the occasion of my receiving honorary degrees or honorary fellowships in the surgical colleges and societies of other countries.

One of the first honorary degrees I received was from the National University of Ireland. At that time the aging Eamon De Valera—father figure of the Wars of Irish Independence—was the honorary chancellor of the National Uni-

versity. He handed me my diploma, and it is signed in his shaky hand. This was in 1961. De Valera was an instigator and survivor of the revolution that led to the independence of the Irish Free State, an uprising referred to in England as “the troubles.” For everyone in Ireland (with the possible exception of the Anglo-Irish), this was the beginning of modern times in their national life.

Becoming an Honorary Fellow of the Royal College of Surgeons of England has been a source of continuing pleasure, and I always visit there when I am in London. I had the pleasure also of being inducted into the Royal Colleges of Surgeons of Edinburgh, Glasgow, and Canada and of becoming an honorary member of the Polish and Italian Surgical Societies as well as a Fellow of the International Surgical Society. My cherished fellowship in the American College of Surgeons, one of the largest professional associations in the world, goes back to 1946.

Citations for the honorary degrees usually mentioned our work in the biochemistry and metabolism of body composition and of convalescence, improving the care of surgical patients after burns and other injuries, the development of transplantation by my department, and my own work in liver transplantation.

Honorary degrees:

For its historical interest, the citation for the Edinburgh degree is reprinted below. The reader will appreciate the unfailing humor of the Scots orator:

The Glasgow citation (1965):

The citation for the honorary degree from Harvard University in 1982 at the time of the HMS Bicentennial Convocation was as follows:

Of other honors and awards, those of particular importance seem to me to include the Blakeslee Award of the American Heart Association. This was awarded upon the publication of my first history of transplantation, Give and Take.

The Alvarenga Prize of the Philadelphia Academy recognized the contribution of our first books on metabolism. The Purkinje Medal of Czechoslovakia was presented to me at the embassy in Washington; Hartwell Harrison received the medal at the same time. The Silver Medal of the International Society of Surgery and the Lister Medal of the Royal College of Surgeons of England in London were also examples of recognition abroad of the work of our group.

I was awarded the Gross Medal of the American Surgical Association in 1978. Originally named in honor of Samuel Gross of Philadelphia, one of the founders of the association, this award is now designated the Medallion for Scientific Achievement.

The Nathan Smith Award of the New England Surgical Society was awarded to me in 1989. Nathan Smith was an apostle of medical education in the early years of this nation. He contributed to the founding and growth of several medical schools in New England.

The Beaumont Medal of the Wisconsin Surgical Society commemorates the work of that army surgeon at a frontier fort in Prairie du Chien, who in tending a stomach wound in a trapper (Alexis St. Martin) became one of America’s first physiologists. He was a contemporary of Gurdon Saltonstall Hubbard, who, 250 miles south of Beaumont, knew of his work only a few months later (see Notes to Chapter 3).

I was awarded the Bigelow Medal of the Boston Surgical Society in 1974. While I have not spent as much time as I would like in the councils of these societies and academies, I have always found the meetings a good antidote for any self-satisfaction that might creep in. The stream of talent in American society defies description. Such associations enable their members to drink deep of this refreshing spring.

In 1981 I was elected a member of the National Academy of Sciences. Our trip to China in 1981 brought us close to the matter of acupuncture and into closer friendship with Professor Tseng (of the Chinese National Academy of Sciences), who had operated on the famous American reporter James (“Scottie”) Reston for appendicitis in 1971. Was Mr. Reston one of the first eminent American visitors to the People’s Republic of China to have a major operation (appendectomy) under acupuncture anesthesia? In his autobiography, reference is made to an appendectomy “under acupuncture,” but then a considerable passage is devoted to the consultation with Li Chang-Yuan, doctor of acupuncture at the hospital, seeking treatment for Mr. Reston’s postoperative gas pains. Long needles were inserted, incense was burned, and the gas pains went away. Because of our acquaintance with Mr. Reston through the Bill Saltonstalls, I was interested in this detail. On our visit with Professor Tseng I asked about this, and he stated (as he had several times before) that he did not like to use acupuncture anesthesia for abdominal surgery because of its failure to relax the abdominal muscles. He clearly recalled using the procedure in Mr. Reston’s case for gas pains but shrugged that off with “... but they usually go away anyway,” as mentioned in the text. Whatever actually happened, Mr. Reston recovered and, as a widely read jour-

nalist, was able to increase the interest in acupuncture throughout the United States. That he was possibly more enthusiastic about it than his surgeon was 10 years later, epitomizes the changing view of acupuncture among the Chinese themselves after the end of the Cultural Revolution (about 1975). Reston’s autobiography:

Reston, J.R. 1992. Deadline: An Autobiography. New York: Norton.

Professor Tseng died in 1982. His wife, Dr. Qin-sheng Ge remains a friend and frequent visitor. She is Director of Gynecologic and Reproductive Endocrinology at the Chinese National Academy of Medical Sciences. Their son, Hung Tseng, is a thoroughly American molecular biologist at the University of Pennsylvania, and, as mentioned in the text, the father of Francis Moore Tseng.

In 1986, about 6 months before the death of Stan Deland, I was appointed an honorary member of the Board of Trustees of the newly formed (i.e., merged) Brigham and Women’s Hospital. As this book goes to press, we are forging a new affiliation with the Massachusetts General Hospital. It appears that this will take the form of a corporate merger, with the two hospitals operating as partners in a chain with one joint Board to govern the merged entity. This is an increasingly familiar hospital organizational pattern in the United States. This MGH-Brigham chain (Partners HealthCare Systems, Inc.) is to include, in addition to the two principal general hospitals, the McLean Hospital and the Spaulding Rehabilitation Hospital, and nursing homes or rehabilitation units that might later be established. Initially, it is planned that the clinical operations of the individual hospitals, and more notably of the two large partner hospitals, will be unchanged.

In a time of stress due to reduced insurance reimbursements, of competition among the urban teaching hospitals themselves, and with community hospitals in bitter price wars, it may turn out to have been wise for these two major hospitals of the Harvard community to join forces. While competing for service contracts (with HMOs or insurance carriers), neighboring hospitals can literally destroy themselves in an effort to ensure occupancy by reducing their day rates and consequently their income. When the era of increased commercialization of American medicine began (about 1975), this self-destructive outcome could scarcely have been predicted. Now, mergers between competitors are an obvious survival strategy being followed in several cities, eliciting a countervailing merger of HMOs, indemnity carriers, and other health-care brokers.

The Brigham-MGH affiliation of 1994 would never have occurred without the prior merger of four hospitals to form the present Brigham and Women’s Hospital (BWH), as related in this chapter. The former Peter Bent Brigham

Hospital, with only 250 beds and a shaky financial structure, would not have been a very attractive corporate partner for the huge MGH. If this new merger turns out to be a successful venture in American hospital history, those of us who worked over so many years to bring about the earlier merger creating the BWH will be gratified at this new flowering of our efforts. The continuing growth of the BWH and the success of its mission after its long and laborious birth are due in no small part to the leadership of John McArthur, dean of the Harvard Business School and Chairman of our Board, and of H. Richard Nesson, a native Brighamite who is currently the President and C.E.O.

Looking back on the merger of 1958 to 1980 that brought the four hospitals together to form the BWH, the role of Stan Deland and his fellow hospital presidents is mentioned in the text, as well as the Deans of the medical school in that period (Berry, Ebert, and Tosteson). The account would be incomplete without telling of the remarkably important role of all the department heads in addition to George Smith (gynecology), Duncan Reid (obstetrics), and George Thorn (medicine). Herbert Abrams had been a catalyst for new departures in radiology, Leroy Vandam in anesthesia, Gustave Dammin in pathology, K. Frank Austen in rheumatology, and, as their successors came on the scene with enthusiasm for the new undertaking, Eugene Braunwald in medicine, Kenneth Ryan in obstetrics, Ramzi Cotran in pathology, and Harry Mellins in radiology. Marion Metcalf in nursing, Mary Ellen Collins in nutrition, and Maureen Mac Burney in intravenous feeding services, all of the Brigham staff, took overall responsibility in the new undertaking. Most of these stalwarts who implemented a successful merger of four of Harvard’s teaching hospitals to form the BWH are now at or after retirement. A few have died. To all of them the BWH, and now the new BWH-MGH Partners, owes an immense debt of gratitude.

While our decades-long effort to achieve the four-hospital merger was not undertaken with any national objective in mind, it became a part of the national trend to join smaller hospitals together (particularly specialty hospitals) in order to provide a better balance of services more economically to the public. This was and still remains an important objective in national health policy.

As the commercial interests of hospitals have become more dominant, and insurance support of their patient care costs more essential to survival, mergers of smaller community hospitals and private clinics have become increasingly frequent. By regional merger these institutions can maintain a higher level of bed occupancy than they could as single units forced into destructive price competition. Protection of census (i.e., the fraction of beds in use) is overcoming the time-honored avoidance of merger noted among community hospitals at the start of this chapter.

This is an appropriate place to note, however briefly, several other undertakings in health policy that occupied my attention at various periods over the past 25 years: the Study on Surgical Services for the United States, the Harvard Community Health Plan, the Brigham Surgical Group, the Kennedy School of Government, and the Massachusetts Health Data Consortium.

The Study on Surgical Services for the United States (SOSSUS) had its origin in several meetings of the Committee on Issues of the American Surgical Association in 1970 and 1971. These led to an uneasy alliance with the much larger American College of Surgeons, based in Chicago and operated by a full-time staff. The two organizations (one small, senior, and voluntary; the other large, all ages, and run professionally) together sponsored and financed this study. George Zuidema, Professor and Head of the Department of Surgery at Johns Hopkins, directed the study. He asked me to join him as co-director of the project and to be in charge of the largest subsidiary section of the study, United States Health Manpower in Surgery.

We enlisted an active group at the Harvard School of Public Health under Professor Osler Peterson and Rita Nickerson, principal research associate (biostatistician), who joined to look at many aspects of surgical training and daily practice. Several years later the massive report was published, as well as its widely available summary:

American College of Surgeons and the American Surgical Association. 1975. Surgery in the United States: A Summary Report of the Study on Surgical Services for the United States. The Short Form Report. Baltimore: ACS/ASA.

Several other publications emerged from this study, which was a broad survey of surgeons’ activities:

Nickerson, R.J., T. Colton, O.L. Peterson, B.S. Bloom, and W.W. Hauck, Jr. 1976. Doctors who perform operations. A study on in-hospital surgery in four diverse geographic areas. N. Engl. J. Med. 295:921-926 and 982-989.

Hauck, W.W., Jr., B.S. Bloom, C.K. McPherson, R.J. Nickerson, T. Colton, and O.L. Peterson. 1976. Surgeons in the United States. JAMA 236:1864-1871.

At that time many surgeons were underemployed and their services underutilized. A large number of surgeons were being trained in the residency pipeline, and it was recommended that there be some downregulation of surgical trainee numbers, achieved principally by raising the standards set by the credentialing agencies (the American Boards). This recommendation was not popular. Amidst bitterness that had an adverse impact on me and on the members of our study unit, an attempt was made to discredit the entire study. This attempt was unfortunate and misinformed. Government agencies and later the American College of Surgeons itself became aware of the undesirable effect of an oversupply of surgeons on patient care and costs. Despite this adversity, the importance of assessing the size and training of qualified surgeons in the United States seemed clear. We therefore continued, over the next two decades, to issue periodic status reports on accredited surgical manpower (and now womanpower) in the United States:

Moore, F.D., C.M. Boyden, D. Sabiston, R. Warren, O.L. Peterson, R. Zeppa, D. Heer, and N. Murthy. 1972. The production, attrition, and biologic lifetime of surgeons in relation to the population of the United States: a look into the future through the clouded computer crystal. Ann. Surg. 176:457-468.

Moore, F.D., and S.M. Lang. 1981. Board-certified physicians in the United States. Specialty distribution and policy implications of trends during the past decade. N. Engl. J. Med. 304:1078-1084.

Moore, F.D. 1982. A community-size model for physician distribution in the United States (Parts I and II). J. Clin. Surg. 1:162-173 and 242-255.

Moore, F.D., and C. Priebe. 1991. Board-certified physicians in the United States, 1971-1986. N. Engl. J. Med. 324:536-543.

These 20 years have seen some striking changes. After the steep upsweep in the 1970s in numbers of total physicians and percentage of those in surgery, there has been a plateau and most recently a decline in the growth rate of surgery. This has been due to the decline in the number of foreign medical graduates licensed in the United States, an increase in specialty surgery (with a sharp decline in the number of general surgeons), and the growth of two entirely new fields of surgical endeavor that mandate extra training: cardiac surgery and transplantation.

The number of surgeons required by a population is determined by (and sharply limited by) the epidemiology (i.e., the prevalence) of those diseases treatable by surgery. This is a finite need that changes but slowly over decades. A continued sharp eye on the numbers, distribution, and activity of qualified surgeons is essential for any new initiatives in health-care reform in the United States. As I look back on this difficult and, for me, traumatic effort to hold to that standard, I regret only my inability to sell the importance of this work to a few of my colleagues. I was buoyed by the support of thousands of surgeons who by letters or words of support upheld its importance and validity. I was elected President of the American Surgical Association in 1973.

The Harvard Community Health Plan (HCHP) grew out of the efforts of Dean Ebert and Jerome Pollack (an experienced labor organizer) to establish in the mid 1960s an academic-based, staff-model, nonprofit, prepaid health delivery plan, later termed a health maintenance organization, or HMO. Our hospital was asked to make available all our residents and emergency staffing provisions (without extra pay) for the subscribers to HCHP.

George Thorn and I complied, but on one major condition: that the benefits of HCHP be made available to all segments of our society. Our nearest neighbors to the south were the minority residents of Mission Hill and Roxbury. They must be included somehow and by some reimbursal mechanism. We did not wish to sponsor another large private clinic serving the middle class on the Mayo or Lahey model, worthy though they were for their time and purpose.

This breadth of coverage became possible because the Office of Economic Opportunity was active at that time as a federal agency sponsoring some health-

care financing for the poor. Our residents, students, and staff would clearly benefit from the added experience and teaching value of this new kind of health mandate in our community.

Gordon Vineyard of our staff has become the Director of Surgery for HCHP. Many staff in all fields, as well as in all the nearby hospitals, now participate in what has become a giant HMO. The care made available to subscribers is excellent thanks to Vineyard and his colleagues, and the plan has prospered. While I have some reservations about what seem to be increasingly restrictive insurance constraints on membership status for patients in the plan, and while many HMOs have drifted downstream, away from the all-inclusive ideals and nonprofit status of their inception, I believe HCHP is a credit to Dean Bob Ebert, Jerry Pollack, George Thorn, and myself, as well as the hundreds of others who joined in its establishment so many years ago. In those ancient times our Dean was a man of vision.

Another matter of medical economics and practice policy, even closer to home, was the organization of the Brigham Surgical Group (BSG). After several years of planning, the BSG began its work as a partnership of all the members of our department in 1969. This was the first department-wide faculty group practice in the Harvard Medical School. By pooling the business functions in a central office under a full-time director, we could handle the blizzard of paper-work much more efficiently than in multiple solo practices. At the same time, we could make funds available to younger staff for start-up research as well as provide “perks” and new retirement benefits for the senior staff. Mr. David Heider was our first chief financial officer, followed in 1972 by Douglas MacGregor, who has brought this office to a state of perfection in fiscal management. I am especially grateful to John Brooks, Richard Wilson, and Hartwell Harrison, who helped me draw up the constitution for this group practice, and to the entire staff for their unanimous espousal and support of this project, now about 25 years of age.

One of my most interesting opportunities in the field of health policy was that of working with some of the faculty at the Kennedy School of Government, which in the mid 1970s listed health-care analysis and reform as one of several prongs in their multipronged thrust into the areas of sociological and governmental teaching and research.

During that period, Christopher Zook, a doctoral candidate, came to work with me. I had been impressed by the category of illnesses that became extremely expensive to manage because those afflicted must be repeatedly admitted to the hospital for further treatment of an ongoing disease process. These “repeaters” were not patients with cancer or stroke, most of whom sadly died too soon to require extraordinarily expensive care; rather, they were often found to be suffering from more benign but longstanding diseases such as chronic cardiovascular disease, congenital anomalies, diabetes, or chronic neurological or mental impairment. Zook set about a systematic study of this phenomenon and turned it into his thesis, entitled “The High-Cost Users of Medical Care”—an expression that

was soon taken up by other workers and became the subject of several subsequent papers:

Zook, C.J. 1979. The high-cost users of medical care. A thesis presented to the Kennedy School of Government for the degree of Doctor of Philosophy in the subject of Public Policy. Cambridge: Harvard University.

Zook, C.J., and F.D. Moore. 1980. High-cost users of medical care. N. Engl. J. Med. 302:996-1002.

Zook, C.J., S.F. Savickas, and F.D. Moore. 1980. Repeated hospitalization for the same disease: a multiplier of national health costs. Milbank Memorial Fund Quarterly/Health and Society 58:454-471.

Zook, C.J., F.D. Moore, and R.J. Zeckhauser. 1981. “Catastrophic” health insurance: a misguided prescription? Public Interest 62(Winter):66-81.

At the same time Chris was working on this aspect of health-care policy, I was beginning my search for hidden causes of expense in U.S. medical care. This led to an examination of the prevalence of profit-making enterprises within American medicine, initially described in an article in the Harvard Magazine:

Moore, F.D. 1985. Who should profit from the care of your illness? Harvard Magazine Nov-Dec:45-54.

This has been a continuing quest and has led to a conviction that corporate profits in our health-care budget are a cost-multiplying factor virtually unique to the United States. Control of such profits, largely those of insurance companies, would lower the fraction of our Gross National Product devoted to medical care to a level comparable to costs in Europe, Canada, Australia, and New Zealand. As this book is being prepared, we are working with a group at the Harvard School of Public Health seeking to nail down some of the data on profiteering from American medicine—a pursuit that might lead to important national economies. In any such analysis, charitable teaching hospitals and physicians themselves (two groups that have usually been held as largely blameless in the profit matrix) emerge from their cloak of righteousness. Such hospitals accumulated huge surpluses in the 1980s and early 1990s, and some physicians’ incomes have soared to a level that many regard as excessive.

Roe, B.B. 1981. The UCR boondoggle: a death knell for private practice? (Sounding Board). N. Engl. J. Med. 305:41-45.

The Massachusetts Health Data Consortium was established in 1978 by the major public and private health care organizations of the Commonwealth of Massachusetts to provide a standard data set to monitor their occupancy, case mix, and adequacy of service to the public. Elliot M. Stone, a gifted worker in this highly specialized field, has been the executive director since its founding.

Paul M. Densen, professor of community health and medical care, emeritus, was the first president and I, the second (1981 to 1987). This important neutral turf in the “number wars” of health-care providers is needed in every state. It is often done by government. A nongovernmental neutrality seems preferable. I congratulate Elliot Stone and my two successors, Frederick W. Ackroyd (1987 to 1993) and Alvin R. Tarlov, beginning his term in 1994, on their continued refinement of our knowledge of how the hospitals of our state behave.

Accounts of the life of Alfred Nobel and some lore about the Prize and its history are to be found in the following:

Crawford, E.T. 1984. The Beginnings of the Nobel Institution; The Science Prizes, 1901-1915. New York: Cambridge University Press.

Crawford, E.T. 1987. The Nobel Population 1901-1937. Berkeley: University of California Press.

Sourkes, T.L. 1967. Nobel Prize Winners in Medicine & Physiology, 1901-1965. London: Abelard-Schuman.

Recently, a new biography of Nobel has appeared that emphasizes the breadth of his scientific interest:

Fant, K. 1993. Alfred Nobel: A Biography. New York: Arcade (distributed by Little, Brown).

Joseph Murray’s address on receiving the Nobel award is cited on page 396. At the time of this Award to Dr. Murray, I was asked to describe some of the background at a meeting of the New England Surgical Society:

Moore, F.D. 1992. A Nobel Award to Joseph E. Murray, M.D.: some historical perspectives. Arch. Surg. 127:627-632.

In the history of science, each new age regards itself as making new and sweeping advances that will revolutionize the world. Each also sees itself as operating with an improved and enlightened ethical view on the relationships between human beings. Accordingly, we regard the second half of this century as absolutely preeminent in both regards: scientific and ethical progress. Within 100 years we will surely be shown to have been operating under some sort of a delusion.

Any ascending logarithmic curve describes a hyperbola, the most recent por-

tion of which appears as a steeply upsweeping slope. Then with longer time coordinates leading to a later date, that steep upswing disappears into the background slope and a more recent upswing appears. That is in the nature of the graphic representation on linear coordinates of any exponential progression or logarithmic hyperbola.

Thus, each age regards itself as the paragon of science. To paraphrase a popular statement, “In the last 50 years more new scientific facts have been discovered than in all previous world history.” This same statement could have been made any time in the past 300 years. The same secular conceit is found in ethics. At the founding of this country, the most important new ethical concepts were “all men are created equal” and a government should be directed toward “life, liberty and the pursuit of happiness” of its citizens, remarkable rhetoric from a nation beset with slavery and a subjugated population devoid of opportunity, education, wealth, or equal protection under the law. One of the byproducts of Lincoln’s presidency, the Civil War, and the freeing of the slaves was a new ethical view toward citizens with black skin. Who knows what future ethical insights or retrospective judgments will lead to revised opinions about our views of right and wrong today?

Some landmark papers on ethics include the following. In 1966 Henry K. Beecher pointed to the ethical lapses clearly displayed in the published literature on medical research:

Beecher, H.K. 1966. Ethics and clinical research. N. Engl. J. Med. 274:1354-1360.

Shortly thereafter, Beecher chaired the Commission that defined death as being the irreversible cessation of cerebral function:

Beecher, H.K., chair. 1968. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death: a definition of irreversible coma. JAMA 205:85-88.

Both these publications of Beecher helped the medical community reach a more enlightened understanding of the ethical aspects of their work and of the need for public education about organ donation.

In 1968, during a symposium of the American Academy of Arts and Sciences on clinical experimentation, I spoke about the ethical problems of doing new things for the first time in the treatment of the sick. To innovate is essential for advance. How best can it be done? With what safeguards?

Moore, F.D. 1969. Therapeutic innovation: ethical boundaries in the initial clinical trials of new drugs and surgical procedures. Daedalus 98:502-522.

Other articles of mine on ethics and safeguards:

Moore, F.D. 1960. Symposium on the study of drugs in man. II. Biological and medical studies in human volunteer subjects; ethics and safeguards. Clin. Pharmacol. Ther. 1:149-155.

Moore, F.D. 1965. Ethics in new medicine. Tissue transplants. Nation 200:358-362.

Those who would stop the use of animals for research profess that they are motivated by ethical considerations. While the antivivisectionists are critical of scientists who use animals for experiments, they themselves daily violate the fundamental biblical ethic, “Do unto thy neighbor....” They refuse to engage in the discourse so essential to human relationships and the evolution of more lasting ethical values. On one occasion an executive of one of the antivivisection societies ssaid to me, “Dr. Moore, we don’t want to win. But we don’t want to lose either. All we want to do is keep the fight going because that’s the way we raise our money.” Since the antivivisectionists avoid public discourse with their opponents, preferring instead a blanket condemnation of those with other views, we do not have a chance to ask them what they would think of doing a new and hazardous operation to help a child without first testing it in laboratory animals.

Antivivisectionists and creationists are part of the anti-intellectual fringe of our society. They are not going to go away. In one form or another they—or other zealots of the fringe—have always been out there and always will be. Our most important function is to educate the public about the ways in which such people recruit the young and impede the growth of biological science in the care of the sick.

Marcia Angell, executive editor of The New England Journal of Medicine, has taken a firm stand on the need for physicians to confront and embrace the deeply felt emotions of patients who find life a burden because of pain and hopelessness. She has written a statement on this:

Angell, M. 1993. The right to die. Bull. Am. Acad. Arts Sci. 46:12-30.

Two recent statements further clarify the problem of physician-assisted death:

Cohen, J.S., S.D. Fihn, E.J. Boyko, A.R. Jonsen, and R.W. Wood. 1994. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N. Engl. J. Med. 331:89-94.

Miller, F.G, T.E. Quill, H. Brody, J.C. Fletcher, L.O. Gostin, and D.E. Meier. 1994. Regulating physician-assisted death. N. Engl. J. Med. 331:119-123.

The stories of patients in this chapter and this reference to Dr. Angell’s work is a fitting way to close the scientific narrative of this book. New views of ethics and new scientific understanding are needed to move ahead in solving this problem of today in such a way that the solution will still be acceptable tomorrow. Breaking this barrier and enabling doctors to help with merciful death will be an

ethical advance of which any generation can be proud. Maybe it will be the next generation. It certainly was not ours.

Termination of both pregnancy (at the start of life) and hopeless suffering (at the end of life) polarizes public opinion in similar ways, as mentioned in the text: free choice for self versus stubborn protection of all life. The two have another interesting common ground: they will be done whether we like it or not, whether or not the church opposes them, with or without legislative approval. This makes clear our job as physicians: we must help make these sad terminations, either of pregnancy or of suffering, clean, safe, and sure.

Before Laura’s death, she and I spent several years gathering the histories of the four grandparental families that together made up our genealogy:

Moore, F.D., and L.B. Moore. 1986. Bartlett-Daniels-Huston-Moore; A Family Journey (Book I, Moderns; Book II, Ancestors; Book III, Potpourri; Book IV, Sources). Boston, private printing.

Katharyn Watson Saltonstall’s book about her years in Africa is based on her service there with her husband, William Gurdon Saltonstall, who in 1963 was asked by President Kennedy and Sargent Shriver (head of the Peace Corps) to be the Peace Corps representative in Nigeria. This was one of the largest of the Peace Corps efforts, with 750 volunteers under their supervision. Her book tells not only of the challenges and achievements of the Peace Corps, but also of some of the crises, illnesses, and even deaths in this service:

Saltonstall, K.W. 1986. Small Bridges to One World. Portsmouth, NH: Peter Randall.

Prior to their African adventure, William Saltonstall had been on the faculty of Phillips Exeter Academy for 32 years, the last 16 as Principal, succeeding Lewis Perry in that post. The biography of Perry was a collaborative project of Bill and Katharyn, just as were their Exeter years:

Saltonstall, W.G. 1980. Lewis Perry of Exeter: A Gentle Memoir. (Foreword by David McCord.) New York: Atheneum Books.

With poetic nostalgia, Joseph Conrad wrote about Youth:

Conrad, J. 1923. Youth. Garden City, NY: Doubleday, Page & Co.

This book is sometimes referred to as “Conrad in quest of his youth”—a phrase that became a metaphor for nostalgic revisitations of any sort, such as ours to Wyoming in recent years.

Conrad wrote: Only a moment; a moment of strength, of romance, of glamour—of youth!... A flick of sunshine upon a strange shore, the time to remember, the time for a sigh, and—Goodbye!—Night—Goodbye—!