At some point in the spring of 1940, fully scrubbed and suitably attired, I stood a few paces back from an operating table on which lay a naked boy of about 10, anesthetized. One of my colleagues was sponging off the patient’s abdomen with little gauze sponges soaked in an iodine solution. The drapes were then firmly set in place, with a small opening over the bare skin where I planned to make the incision. I can remember thinking how remarkable it was that institutions in our society could set things up so all the pieces would fall in place and I, then less than a year out of medical school and only 26 years of age, might have the immense privilege of relieving the pain, anguish, and threat to a wonderful small boy by making an incision in the right lower quadrant of his abdomen and taking out a pus-filled appendix skillfully and safely. Only 5 years previously I had greeted that smelly collection of organs in the anatomy laboratory, and it was only 3 years since Mrs. Szintax had been warned of our arrival. Now here I was, with skilled nurses and an experienced anesthetist, shiny sterile instruments at hand, ready to operate, with all the protection given the patient by a venerable institution. I felt that this was both a miracle and a privilege. I still do.

In those years we learned surgery by doing, and we also learned some of the ethical values of a professional. During my internship and residency years I did my surgical firsts—operations done by each of us for the first time from the surgeon’s side of the table. These operations were performed in the care of charity patients on the public wards. The patients were charged no professional fee, and their hospital bills were minimal or forgiven. Those patients on the charity wards held our loyalty and devotion. They were ours; we knew it and they knew it.

The fundamental act of medical care is the assumption of responsibility. The essence of professionalism is that the servant, the caregiver, the professional, values the interest of his client or patient above his own. Patients can never acquire the knowledge to make basic decisions about their own care or negotiate costs intelligently. They want their doctor to do these things on their behalf. Even when physicians find themselves as patients, they experience great difficulty in joining in medical decisions outside of their own field. The compact of care is taken on faith and given in trust. Although in so doing the professional makes a living, his income includes no capital gains from his work. He derives no unearned income from his work. He cannot sell at a profit. Personal inconvenience is assumed in professional care: midnight calls, long operations.

During our residency years we learned these values, almost unconsciously it seems now, without preaching or sermons, just by the behavior of our peers and the example of our teachers. We cared for the charity-ward patients in a clearly professional setting. Senior surgeons saw patients with us, advised us, and scrubbed in to assist us on difficult operations. The challenge in surgical residency training is for the young learner to gain skill by taking responsibility without jeopardizing the safety of the patient. To attain this ideal requires a special organization and a strong tradition of interpersonal trust. The Massachusetts General (MGH) has been a leader in achieving this ideal now for the better part of two centuries.

Medical students and young physicians are native idealists. They are also bright. At one time almost a third of entering Harvard freshmen listed medicine as their future career. People often ask, “Why do so many

young people want to enter medicine?” My reply: “Offer the most fascinating and rapidly advancing field of science (biology) and join it with the most gratifying of human instincts (giving care to the suffering) and you are bound to get a lot of takers.”

Filled with idealism, students nowadays are plunged into a gaudy and greedy commercial world of corporate profit and personal wealth. They see the huge earnings of insurance companies, hospitals (even the “nonprofits”), administrators, and doctors. They are not blind to the million-dollar incomes of many physicians and surgeons today, shocking though they may be to us old-timers. Everyone wants to make a buck out of the medical monster. That is why it costs so much to keep it alive.

What is needed is a return to the charitable purpose of all of medicine, to the church ancestry of all the great hospitals of England and France, our progenitors. The “family values” of medicine are as real as ever, and they are still out there, epitomized by care of the sick poor. But they are also experienced when the affluent suffer and need help. The poor sick. Huge corporate profits (dividends to stockholders) and personal aggrandizement are foreign to this tradition. Commercialism and professionalism are parallel streams in our society that can coexist in peace. When they start to get mixed up with each other, beware. Teaching hospitals of the 1930s—such as the MGH—indoctrinated their interns into a down-to-earth and old-fashioned professional ambience of hard work and few or no material rewards.

At the MGH and the other Boston teaching hospitals in those days, the process of applying to the internship-residency system in the spring of our fourth medical school year was a chancy business. The Boston hospitals held off on their internship appointments until all the other hospitals in the country had made theirs. In waiting for a Boston appointment you were therefore taking a big risk. Out on a long limb. If you missed, you had nowhere to go except the “Radcliffe Infirmary,” the joke for a worthless appointment. Years later when I was visiting professor at Oxford, where the principal teaching hospital is the ancient and honorable Radcliffe Infirmary, it became clear that our sarcastic joke was

strictly local, not to mention displaying male chauvinistic snobbery of the least politically correct variety.

On July 1, 1939, I started surgical internship. Two of us started every 3 months, for a total of eight beginners each year. For the first 3 months of internship we were called “pups,” and this first period of servitude was known as the pupship. The pup begins by analyzing effluvia. During pupship we were assigned several important tasks involving the analysis (in the early hours, 6:00 to 6:45 AM) of all the urine and stools of patients for whom such analyses were deemed necessary by the more superior interns who had been pups fully 6 months before.

Our equipment for this simple but important (albeit odoriferous and inelegant) task was primitive in the extreme and left an unmistakable mark on the decor of our tiny attic laboratory in the Bulfinch Building. Urinalysis consists in part of spinning down the urine in a centrifuge and examining the sediment under a microscope for signs of infection. This required a small centrifuge, with little pointed tubes that were apt to break at the tip if dropped too heavily into the centrifuge. If a tube filled with urine had a tiny hole in it and was twirled at a rapid speed, the walls of the room and everything at a certain height around the wall would be decorated with a narrow brown stripe, this being the even distribution of urine around the room at the precise level of the spinning centrifuge. I wore an apron.

While neither of these activities could be considered complicated, one or two unsuspected cases of bowel cancer (by stool blood test) or diabetes (by measuring urine sugar) were discovered each year thanks to the humble labors of the pup. There was the constant suspicion among the older interns that the pup might be goofing off on his marvelous job. It was therefore their practice to add a little sugar, protein, or bile to the occasional sample of urine or to put a tiny drop of blood in the occasional fecal sample. Such “plants” would keep the pup fully alert, because he would be expected to detect and report these important (if intentional) abnormalities accurately. If these spurious samples (what we might now call “stings”) were not discovered, the pup was to be relegated to an even more humble role. It was difficult to conceive exactly what that penalty might be.

Having performed this vital function, the pup would wash up and

make himself socially presentable, as well as surgically acceptable, to join ward rounds about 7:00 AM. As pup on rounds, I walked appropriately a few steps behind the more advanced interns and those two or three austere surgeons known as residents, one of whom (the chief resident) led the parade. The most senior residents were about 30, fully 4 years older than the pup. The pup was supposed to trail behind the residents and interns (and even the students) with his little pup list, on which he would note which patients were to have chemical tests, intravenous infusions (becoming rather frequent at that time), blood transfusion (still rather rare), or those vital 6:00 AM analyses of excreta.

By 1939 the method for transfusing blood had improved somewhat over the two decades since 1914, when Landsteiner described the blood groups, making blood transfusion at least a reasonably safe procedure. Transfusions had been done by the direct method—literally letting the blood flow arm to arm in a series of tubes from donor to recipient. This system involved awkward and complicated paraffin-lined tubes. I carried out only one or two of these direct transfusions in my early days. Since the equipment rarely worked, and none of us understood it very well, a good deal of very precious blood wound up on the floor. Any blood that finally reached the patient was assuredly warm and fresh.

By the time I joined the scene, the method used for blood transfusion had advanced perceptibly. Most blood transfusions were carried out by the pup, drawing blood from family donors into a bottle containing citrate solution to prevent clotting. In due course (1 to 3 hours) it was given to the patient. Fresh. The pup himself, unassisted, did the blood typing (known then as grouping) and cross-matching (under the microscope) to ensure compatibility, much as we had been taught in medical school.

Furthermore, it was our job as pups to ring up the patients’ families, ask for volunteers to give blood, get them in, do the typings and cross-matchings, find those with compatible blood groups, draw the blood from the arm vein at the elbow, and supervise the infusion of the blood personally. As I look back, it is remarkable that we gave as many blood

transfusions as we did during those pre-war years. That we accomplished this quite successfully with very few adverse reactions is not surprising. When one person carries out a complex procedure himself, it is done carefully because his personal reputation is on the line. Severe reactions to blood transfusions, such as mismatch or the growth of bacteria in the blood, were infrequent. While it seemed that we transfused a lot of blood in those days, it was but a drop in the bucket compared with the gallons of banked blood that would be used only a few years later in taking care of severe war wounds, extensive injuries, and radical operations.

Pups also had duties that more glamorously resembled operative surgery. After the matins in the lab and the ceremony of rounds, we would proceed to the operating rooms to assist our elders. But there would come a time, usually at night, anticipated for weeks or months, when an emergency “acute belly” would come in, and a junior intern (possibly, in rare instances, even a pup) might be permitted to remove an inflamed appendix. In a crowded surgical life, few operations would seem more important than this, as described at the start of this chapter. The older residents, despite a gruff exterior, took a sort of avuncular pride in the progress of their pups, and after such an operation (strictly routine in any larger sense) they would give a handshake and a “Good job.” “Nicely done.”

In certain cases the pup also administered anesthesia. This was a duty with which I was very unhappy because, without suitable training, it obviously posed a hazard to the patient. I considered it a breach of professionalism in surgical training. If a patient with a relatively simple fracture (such as a fracture of the wrist or of the bones just above the ankle) was admitted to the emergency ward at night, the broken bone was set right then and there in the emergency ward. That is, it was manipulated and drawn apart by traction so it could then assume (and ultimately set in) its normal position. This nocturnal setting of fractures was usually done by a young resident just completing his internship (after 12 to 18 months in the hospital) or possibly by one of the more senior residents 2 or 3 years out of medical school. When properly done, such immediate

setting of fractures gives the ideal result for the patient. But there was a catch. The anesthetic—essential not only for the patient’s comfort, but also for the relaxation of spastic muscles around the fracture—was administered by the rawest intern, the pup.

It was shocking to me, and I still look back on it as a dereliction of the high standards of our surgical education at the MGH, that I was suddenly confronted late at night with an anesthesia machine, valves, cranks, and canisters of nitrous oxide and oxygen, and was expected to proceed, untutored, to induce anesthesia and put the patient “to sleep.” At night, hurried, harried, and tired, with no help. That I and my fellows got through this without causing any deaths (at least none of which I was aware) was pure luck. Indeed, it was the death of a patient in just such a circumstance as this in Harvey Cushing’s hands (when he had been a Harvard medical student about 40 years previously) that led him to revolt against the lack of supervision in “simple” (but dangerous) anesthesia for minor procedures. As a result, Cushing devised the type of anesthesia chart now universally used throughout the world to monitor the patient’s course under anesthesia.

My own revolt against this practice as a pup was simply to state clearly—after my first frightening experience—that I would never give another night emergency anesthetic unless I (and the other interns to come) could do it safely under experienced supervision. By the look in my eye, that hospital administrator must have realized that he was dealing with the bark of a fairly determined pup. After that we enjoyed better help and fewer brushes with disaster. The bark must have had a little bite.

I devote so much of this account to the pupship because it was our introduction to those crucial 3 to 5 years spent in finally becoming full-fledged surgeons. It was a sudden deep plunge into the world of the sick, injured, and powerless. Or, to change the metaphor, kind of a trial by fire. Almost a hazing.

In subsequent months and years I climbed up the ladder. In those days at the MGH, removal of the gallbladder, known as cholecystectomy, was the bellwether operation for the first couple of internship years. By

the end of 24 months, I was doing much more complex procedures, including the removal of diseased intestine (usually for cancer) or the uterus (hysterectomy, usually for benign tumors), operations for injury to the tendons of hand and arm, and extensive procedures on the veins of the leg.

The following (third) year, we undertook more complicated operations, such as subtotal gastrectomy. The safe and expert performance of this operation was the criterion of operative experience in advanced residency training. Subtotal gastrectomy involves the removal of about two-thirds of the stomach either for duodenal ulcer or for cancer. Although not a completely forgotten operation now (since we still use it for patients with stomach cancer), the tens of thousands of subtotal gastrectomies previously done for duodenal ulcer each year in hospitals throughout the United States and Europe have today been reduced to only tens or hundreds with the introduction of vagotomy (in which the vagus nerves to the stomach are severed) or by the use of acid-reducing drugs or even antibiotics in the treatment of ulcer.

I carried out many subtotal gastrectomies for duodenal or gastric ulcer. Like most of my operations, they seemed to go easily and well, and like most of my fellows, I gained in self-confidence. I felt secure and knew that the weeding-out process would leave me intact. Every couple of years an intern would be found to be clearly unfit for surgery, though possibly perfectly suited to some other field of medicine. Such miscast trainees either resigned or were not promoted, often moving on to distinguished careers in other fields.

In the final years of residency, our repertoire expanded to include operations on the liver and bile ducts and the pancreas; those done for cancer of the colon, rectum, or breast; and procedures for disease of the adrenals, thyroid, and parathyroid. The MGH provided an absolutely remarkable experience.

One of the key assignments, usually coming about 2 years after medical school, was that of being in charge of the emergency ward. There were two surgical services (the East and the West) and they alternated nightly coverage of the emergency ward. When you had that duty, you were on the job all night on alternate nights for several months. The MGH always had a very busy emergency ward, caring for accidental

injuries, bullet and stab wounds, burns, fractures, infections, gangrene. Only the Boston City Hospital cared for more emergency patients. On one particular night, that of November 28, 1942, several hundred casualties, many already dead, were brought into the emergency ward within an hour, and I was to witness one of the most lethal civilian disasters in our history.

Charles Burbank and I were the two surgical residents in charge of the emergency ward on the night of November 28, 1942. Charlie was a year senior to me. We worked together days and nights for many months both in the operating room and in the emergency ward. We had known each other in college and medical school, were good friends, and worked well together even in tough and demanding tasks.

It had been a quiet evening, just after Thanksgiving, the time when those final football games were settling championship titles. We were up in our rooms listening to football games on the radio. At around 10:30 PM, over the noise of the crowd on the radio, we heard the whine of an ambulance outside on the street. It did not stir us much because such whines were commonplace. But then came another and another. So we donned our white coats and ran downstairs gripping our pockets so our stethoscopes wouldn’t fall out.

We got to the emergency ward pretty fast. More ambulances, trucks, and cars were moving in and out of the entry circle. By the time we arrived, dead bodies were lined up in rows in the hall. The smell of burnt clothes and hair permeated the entryway and the hall. Obviously, there had been a major fire with many deaths. Where and why we would not know for several hours.

The Cocoanut Grove was a large nightclub situated not too far from the center of downtown Boston: near the Common, just off Charles Street. Under new management, it had recently been redecorated with groves of imitation palm trees, paintings, hangings, and drapes. Designed to handle about 600 patrons, the club was overcrowded that night. Almost 1,000 people were packed in for drinks, dinner, and a show. The place was popular with the young. Officers recently inducted into the armed services were there (now one year after Pearl Harbor) looking handsome in their new uniforms and with their best girls in their finest dresses. An autumnal scene of youthful beauty and vigor having a big time after the big game.

At about 10:15 PM some of the drapes and decorations suddenly caught fire, followed by a rapid, almost explosive conflagration. According to survivors, within 5 minutes the entire nightclub was filled with flames, especially high in the drapes. Just where the fire started and how it all got going no one was quite sure at the time. Recent analysis confirms the story that it started in a basement lounge in the drapes, possibly from a match or a cigarette.

The fire department put out the flames within 30 minutes. By 10:45 PM the structure was a smelly, smoldering hulk with a pandemonium of ambulances, fire trucks, hundreds of dead, and a few severely injured in the streets, where there was a strong smell of burning clothes, hair, food, and maybe flesh, described by onlookers as sickening.

The burning (oxidation) of the decorations and drapes had three chemical consequences. First, the oxygen inside the tightly closed restaurant was rapidly used up, so there was little left to breathe. Many died of suffocation, their skin and lips deep blue because their blood lacked oxygen. For some, death from suffocation was so sudden that they were found sitting at their tables, unburned, rigid in death, fingers clutching glasses. Others were crushed or smothered at the blocked exits.

Second, when oxygen runs out, carbon dioxide cannot be produced from the carbon in all the wood, drapes, and paint. The fire cannot breathe, either. Carbon dioxide—a carbon atom with two oxygen atoms

attached—is, in itself, quite harmless. We produce and exhale a good deal of it every day. It is the fizz in fizzy water. But when there is not enough oxygen to feed a fire, many carbon atoms are incompletely oxidized; only one oxygen atom is attached to it instead of two, and it is transformed into carbon monoxide, the deadly substance abundant in automobile exhaust. In carbon monoxide poisoning, blood forms a special kind of hemoglobin that is bright cherry pink rather than deep crimson red. This abnormal hemoglobin is itself too thirsty for oxygen to relinquish its precious cargo to the tissues crying for it, causing a sort of chemical asphyxiation. The face of a person dying of carbon monoxide poisoning is often rather cherry pink. Some of the dead, and a few of those who reached the hospital alive, had that ominous and sometimes deceptively healthy-looking cherry-pink color.

Third, combustion of the paint on the walls and the dyes in the drapes produced irritant poisonous gases. Some of these were like the mustard or phosgene gases used to poison soldiers during World War I. People exposed to these gases cough up frothy, bubbly, sometimes bloody secretions. In severe cases their lungs fill up with this liquid, and they drown in their own secretions. It takes a bit of time for irritant gases to fill the lungs with froth. One naval officer actually got to the MGH and ran from room to room and down the hall of the dead, looking for his family. Then he fell, gasped, tried to cough up the secretions that were drowning him, and died.

Many people were trapped in the club because of locked exits or doors that opened only inward. Such doors still kill people every year in theater, restaurant, and factory fires. At the Cocoanut Grove there was also a large revolving door. When masses of people hit both sides of a revolving door at once, it becomes an impenetrable wall. Those who got out included some who were badly burned, others who had been severely poisoned with carbon monoxide or phosgene-like gases, and some who were unlucky enough to have both kinds of injuries. Many died within minutes of arrival at the several hospitals to which they had been taken.

When Charlie Burbank and I arrived in the emergency ward, we could see that a lot of the bodies in the hall were those of young people whose skin was either deep blue (suffocation) or cherry pink (carbon monoxide) or they had froth emerging from lips and mouth (irritant gases).

Many victims of the fire showed no burn whatsoever; skin and clothes were not burned at all. We began looking for, and soon found, patients still living but in need of our help because of lung problems, burns, or both.

Morphine can be a problem as well as a mercy. Burned patients experience both pain and anxiety. Giving them an injection of morphine is a safe enough way to reduce pain and anxiety, so long as they are not given too much. Too large a dose of morphine interferes with breathing, which is especially dangerous when there is lung injury.

In any sort of a mass disaster and in the clearing (and sorting) of casualties, it is important to attach a label or a tag to each patient on which the doctors or nurses can record exactly what measures have been taken. Then, when the patient is moved, the new team will know what has gone before. In the first hours after the Cocoanut Grove fire, patient tags were not used. Sometimes the nurses used lipstick to mark an “M” on patients’ foreheads, signaling that morphine had been administered. But this was not always clear, and sometimes a second or even a third dose of morphine was given. One or two may have died of this overdose. We never knew. But many others were deeply anesthetized by it, and for the rest of that first night, each of these patients was assigned a doctor whose job it was to keep the patient breathing until the morphine wore off and the patient woke up.

A total of 490 people died in the fire. The Boston City Hospital and the MGH received most of the casualties. It was estimated that 440 survived, making a total of 930 at risk and a mortality of about 55%. The largest number of dead and injured (about 300) were taken to Boston City Hospital. Of these, 132 were alive when they got there, 36 soon died. The MGH received 114 casualties of which 39 were still alive after the first few hours. Ten had severe burns while 29 were largely lung injuries. Two months later (late January 1943) there were still nine severely burned patients in the hospital receiving care and grafting. By April, all had been discharged. Some returned later for plastic surgery. I remember one in particular, a naval submarine officer whose hands and forearms I resurfaced when I first entered practice the next fall.

In seven of the patients suffering from inhalation of the toxic phosgene-like gases or severe respiratory tract obstruction owing to neck swelling from burn, we carried out a tracheostomy. An incision is made surgically in the neck and a tube is placed in the trachea so air and oxygen can be delivered directly to the lung, permitting the patient to breathe more easily. Many other patients were placed in oxygen tents.

Deaths from respiratory tract injury occurred within the first day or two. These patients often had telltale soot stains on the nose, lips, and mouth. Some had burns around their head and neck that within a few hours caused a grotesque swelling, making tracheostomy much more difficult. One or two died while a tracheostomy tube was being inserted. I lost one such patient, literally in my own hands, because we had waited an hour or two too long before deciding on tracheostomy.

Since the late 1960s, tracheostomy and oxygen tents have virtually disappeared from the scene, replaced by direct intubation of the trachea through the nose or mouth (less injurious to the trachea) followed by automatic machine-assisted respiration. Oxygen tents never accomplished much anyway. The oxygen concentration in the air we breathe normally is about 20%. An oxygen tent—even with all the leaks tightly closed and oxygen being delivered at full throttle—could push that up to maybe 25 or 30% at best. With the oxygen stream running directly into the tracheostomy tube (or, nowadays, an endotracheal tube), the concentration of oxygen can be much more enriched, sometimes dangerously so.

In those first agonizing hours after the fire, the scene in the emergency operating rooms and in the halls and nearby wards was wild. Many relatives were panic-stricken and screaming, desperately searching for their companions. This was during the early years of the war. I remember one handsome young naval officer in full uniform, severely burned, also lung-injured and short of breath, lying restlessly in bed and repeatedly calling out the name of his girl. Although we did not know it at the time, she had been found in the pile of dead behind the revolving door. There was one suicide, attributed to despair at losing a beloved person.

Within a couple of days after the fire, things began to stabilize. Several floors and operating rooms were reserved exclusively for the Co-

coanut Grove patients. New supplies of blood plasma for transfusion and of dressing materials came in from all over the city. Some disaster-readiness drills had recently been conducted because American cities expected to be bombed, so the city and the hospitals were not caught unprepared. In fact, our hospital had gone through a disaster drill only a few days before. There were extra burn dressings available and a stockpile of fluids for intravenous infusion. Blood banking as we know it today had not yet been developed. But within days donors across the city had given 3,800 units of blood, largely processed into plasma by removing the red cells.

We treated the burned skin surfaces by wrapping them in a thin greasy gauze sheet covered with bulky dressings to soak up the body fluids that exude from burns. While this covering protected the burn from the outside atmosphere and made the patients more comfortable, it required a lot of dressing changes. These were so difficult and painful that in many instances we used a general anesthetic.

It was 1942, the year that penicillin was first being tried in tiny quantities as an experimental drug, soon to be supplied in larger amounts to our army and navy surgeons. At the time of the fire itself we did not have penicillin, but within a few weeks some became available and we were able to give small amounts to our patients. We did have the sulfa drugs, sulfanilamide and sulfadiazine, but not the bacteriologic methods for assessing the sensitivity of bacteria to these drugs. All these burns became infected, but the patients survived their infections. Probably the most important precautions were gentleness in handling the burned surfaces, changing the dressings often enough, and placing skin grafts at the right time. Bradford Cannon (son of Walter Cannon, our professor of physiology [Chapter 2]), a skilled plastic surgeon, was in charge of the skin coverage procedures and later plastic repair of these severe burns. He set a high standard that few of us could emulate.

Everything done in the early care of burns is designed to keep the patient as healthy as possible in spite of the severe physical insult. This involves keeping the burn wound reasonably clean and then covering the burn with new skin grafts just as soon as possible. This is a long, arduous, painful, and exhausting process. Final skin replacement with skin grafts that take (i.e., grow and cover the raw areas) is the ultimate achievement that lets the patient get up and go home. All the severely burned patients who weathered their lung injuries ultimately got well and returned home.

We lost no patients after the first week, when lung damage took its heavy toll.

For part of the year before the Cocoanut Grove fire, I had been studying burns as a junior collaborator with Oliver Cope, a senior member of the staff particularly interested in burns. He had primary responsibility for care of the Cocoanut Grove patients, and we were indebted to him for developing the type of dressing that was used (boric-petrolatum gauze) and for elucidating the nature and treatment of lung injury in fire victims.

The understanding and care of patients with severe lung injuries was revolutionized by this disaster, a direct result of the work of Oliver Cope, surgeon; Tracy Mallory, pathologist; and Richard Shatzki, radiologist. The entire team was under the direction of Edward Churchill, who was soon to leave for military service in charge of the care of the wounded in the Mediterranean theater.

The two major lessons from the Cocoanut Grove fire pertained to safety laws and to the treatment of the lung injury in burns. The threat of death from fire in public buildings can be reduced by the installation of battery-illuminated signs and fail-safe exit doors that can be opened from the inside. This fire had been in a closed space; there was no escaping the smoke and fumes. The problem posed by fire in closed spaces is especially severe on ships and in tanks in battle, largely because of suffocation and lung injury. The care of such patients was important to both army and navy surgeons. Over the next 5 years Oliver Cope and I did research on burns for the Navy (and I later for the Army), much of it to describe the disordered physiology in burned patients and to improve treatment for burn shock and severe respiratory tract injury. In the treatment of the latter—pulmonary injury in burns—the Cocoanut Grove was a turning point thanks to Oliver Cope.

And yet the central problems of burn injury and the subsequent causes of death remain unchanged. As long as there are fires in which people are trapped and severely burned, these problems will persist. The three leading causes of death from burns have always been infection,

direct lung injury, and organ failure (kidney and liver) if there has been burn shock. Use of any one of several present-day treatment procedures has made burn shock a rarity. But in the wild, away from organized hospitals, or in combat, burn shock is still a cause of early death.

Many other lessons were learned from the Grove, possibly less spectacular. One was a reemphasis on the importance of overall organization of the hospital for disaster, as well as organization of the surgical and medical staffs under the clear authority of senior members who had done research in the subject and were interested, experienced, and competent to care for such patients.

While there were few civil suits for damages, there were two public hearings. Finally, 10 men were indicted for negligence, one of them a fire inspector who had declared the decorations and drapes non-combustible because he could not light them with a match. Later it was declared that the fire inspector, without malfeasance, had merely applied the usually accepted test. It was wartime. Many more had died at Pearl Harbor a year before. At that time, exorbitant damage claims, bitter battles over insurance settlements, and incarceration for involuntary man-slaughter were rare. There were some criminal indictments. One busboy was made a scapegoat by the media when he testified that he saw the fire start but failed to put it out. He was indicted but later acquitted and released. One of the owners was judged guilty of negligence and served 3½ years in jail.

The cost of caring for these patients was borne by the hospital through its endowment. To my knowledge no money from public sources ever found its way to recompense either the hospital or the surgeons for their services.

Now, more than 50 years later, I am one of only a small group of physicians, surgeons, and nurses still alive who were there, hands-on, in the emergency ward that night and on the burn floors through the weeks of travail. I never lost my interest in burns, nor my concern for the safety of public places, many of which still pose a hazard, nor my respect for how the people of the MGH rallied to deal so effectively with this sudden, unexpected, and overwhelming challenge.

The realities of human injury and illness, of birth and death, were commonplace in our lives as residents. Part of our education was in learning to make our peace with these realities, or at least accommodate our lives to their impact.

The first patient who died after an operation I had carried out myself was a woman of about 62, suffering from breast cancer. I had performed a radical mastectomy, the only operation used for treatment of the disease at that time, about 1940. She was doing very well when on the 10th day (note that she was still in bed in the hospital) she got up to walk to the bathroom. While on the toilet, she fell to the floor, dead. Autopsy showed a massive clot in the artery to her lung, a pulmonary embolus. A pulmonary embolus is a clot dislodged from the legs that travels to the lung and plugs a major artery there. This dangerous and sometimes lethal event is especially apt to occur after injury or surgery. In this case the clot may have been dislodged by changes in intra-abdominal pressure associated with straining on the toilet. That was not an unusual sequence of events.

When, after the war, we began to get patients up out of bed and walking sooner, such clots and the resulting emboli became less common, though they were still a threat in many situations. Had I been a little bit more sensitive to the slight rise in her temperature and pulse the day

before, I might have suspected the large clot lodged deep in the vein of her leg that was the source of the fatal snakelike embolus (almost 6 inches long). Despite her husband’s distress when I told him of his wife’s death, he granted permission for the autopsy. He did not resent the request and appreciated my attention to his wife. He wanted to try to help others by consenting to the postmortem examination. The families of most patients are trusting and grateful. Even though this event took place before the anticlotting drug heparin was available and before the technique of deep venous interruption (in which the veins of the leg are closed off so a clot cannot migrate to the lungs) was accepted as an emergency procedure, somehow I felt her death was my fault. Maybe young surgeons always feel that way about their first deaths.

A few days later another patient of mine died after an operation performed by one of the senior surgeons. I was only the second assistant at the operation, but the patient was on my floor, so I was responsible for her daily care. I knew her well. She had undergone an exploratory operation to examine both sides of her neck in search of a tumor of the parathyroid gland. Possibly the operation was not as expertly done as it should have been. Had the chest been opened (which later became common practice), the operation would have been safer, because the anatomy of the upper chest, the great vessels, and the lungs and their coverings (the pleurae) could have been more easily and safely exposed. Often, in surgery, the bolder, seemingly more radical step is the safer one.

After the operation, the patient never looked quite right. Because this was before hospitals had recovery rooms or intensive care units, the patient was returned directly from the operating room to her regular ward bed even though she had not yet recovered from all the effects of the anesthesia. This was the usual practice. Her blood pressure, breath sounds, and heartbeat were as expected at this stage. An hour or two later, I was up on that floor seeing nearby patients when the nurse called and said this patient was breathing hard and was very blue. A moment later when I got there on the run, she was indeed dark blue and almost dead. By stethoscope I could hear the last few distant beats of a laboring heart. No breath sounds. No reflexes.

Air had accumulated under pressure in both the pleural cavities that line the lung and are normally free of air. This caused both lungs to

collapse. During the operation her surgeon had inadvertently entered the chest cavities and nicked the lung on both sides without knowing it. The tiny leaks had not become evident until the trapped air built up pressure that prevented her from breathing normally. Such events were preventable and diagnosable. Although we placed drainage tubes in both sides of her chest to let some of the air rush out, it was much too late. The patient died of a bilateral pressure pneumothorax.

Among surgeons there is a variation in sensitivity. Every doctor is shocked by the first few deaths close to his or her daily work. For the surgeon they are especially close. Once an internist said to me, “You surgeons take death so damned seriously.” What did he expect? If he was the patient, he would certainly like us to take any threat quite seriously. Somehow he seemed to be implying that we cared too much.

Because the surgeon is so close to the reality of life in the balance and of death, he needs to develop skin of exactly the right thickness. If it is too thick, he is resistant to learning, too resistant to feeling the death of a patient, a little bit slow to seek the autopsy permission, his mind closed to new ideas. Sometimes he may even tell the family some blarney to spare them the truth about why the patient died, a truth that families thirst for and deserve. But if the surgeon’s skin is too thin, then he is whipped by death, he broods and worries, cannot sleep, learns little, and is not ready for the next day’s operation. Like a cowboy thrown from his horse, the surgeon, although hurt, must be able to get back on his horse and ride again.

That middle ground of sensitivity is something that is either inborn or acquired from parents, probably in childhood. While it cannot be created, it can be strengthened by example. And it must be sought in the young. In later years I saw interns and residents I considered too tough and hard-boiled, big talkers, and I was not impressed. But I also remember one or two who were just the opposite: too sensitive, too worried, too introspective. I was concerned about their future in surgery. One of these later became a leader of research in heart disease at the National Institutes of Health. A better niche for him.

Sometimes the heavy blows of a surgical career do not come from the death of patients but from some other miscarriage of medical care that has resulted in complication, misunderstanding, or litigation. In my early days as intern, resident, and practitioner, malpractice suits were almost unheard of.

Severe injury, life-threatening diseases, and the very act of surgery itself come close to the essence of life. The circulatory system, the bloodstream, the heart, the brain, the kidney: all are vulnerable, exposed to the possibility of injury in many operations and affected by drugs, including those used for anesthesia. Surgeons should constantly be reminded that the state of patients under anesthesia is not sleep, it is drug-induced coma. Despite our use of the blissful word “sleep,” the anesthetized state bears little resemblance to normal sleep, in which the blood is free of sedatives or hypnotic drugs, arousal is immediate, and the brain is resting, idling in a state of near-readiness. Under anesthesia, the bloodstream and the brain are affected by depressant drugs that profoundly alter sensation, tissue irritability, thought, consciousness, and arousal. These drugs of course affect other organs, particularly the liver and kidney. Research and development in anesthesia are devoted to making these drugs less harmful. In case some anesthesiologist might be offended by a surgeon writing about how dangerous is the state of anesthetized coma, he should be reassured. I am emphasizing my admiration for those colleagues who can induce, manage, and achieve arousal from this drug-induced coma as smoothly as they do.

The death of a baby boy born with a faulty stomach shows how dangerous anesthesia and even simple operations can be and how events sometimes defy us. He was a precious and appealing baby suffering from a narrowing of the stomach outlet called pyloric stenosis, usually due to overgrowth of the muscle. This overgrowth impedes emptying of the stomach and results in severe and repeated vomiting. The disorder develops rapidly in infant boys (very rarely in infant girls) and, if not treated, soon leads to dehydration and death. The diagnosis is not difficult to make

if you suspect it, because the little olive-shaped enlargement impinging on the stomach outlet can be discerned by gently feeling the abdomen.

I operated on this little boy while I was a senior resident. The operation is not a difficult one, but it is potentially dangerous and is sensitive to accuracy in detail. If by accident the incision made to open up the thickened muscle bundle is a millimeter too deep, it opens the mucous membrane lining of the intestine, releasing the bowel contents and producing peritonitis. Prevention of such a catastrophe is the major precaution of this operation.

The operation had gone well and took only a few minutes. The nurse who gave the anesthesia was someone with whom I had worked a lot in the care of infants and young children. I trusted her. The baby had been deeply anesthetized with ether and nitrous oxide. The operation over, I checked a few details of the child’s condition, as well as the orders to be carried out by the nurses. We agreed to meet in a few minutes back at the infants’ ward, a few hallways down from the operating room, to which the infant would usually be trundled, still asleep, in a small, wheeled crib. As mentioned earlier, there were no postoperative recovery rooms or intensive care units in those days.

As I left the operating room to go the surgeons’ dressing room, I noticed out of the corner of my eye that the nurse lifted up the unconscious baby as a mother might, draped his head on her shoulder, and clasped him firmly with one arm, holding the record sheets in the other hand. She set off through the swinging doors of the operating room to go down the hall and around a few corners to the infants’ ward to place the child back in his crib. The nurses there would take over.

After a change of clothes, I started off for the infants’ ward to talk with the parents. This would probably be one of those reassuring conversations accompanied by a hand clasp and maybe an embrace from the mother. “It all went well...he’ll be fine.” As I turned through the door into the infants’ ward, my calm feeling, that pleasant feeling of assurance and confidence that surgeons have when operations go well, disappeared in a blinding flash of suspicion. It was replaced by a full alert.

A small group was gathered around the baby’s crib. The anesthetist was there, the head nurse, a pediatric intern. The infant’s mother, who was still wearing her overcoat, had come in from the waiting room a few

steps away. The atmosphere of the normally quiet infants’ ward with the late-morning sun streaming in the windows was somehow different, ominous.

My walk changed to a lope, and I was at the bedside in an instant. The whole scene could be taken in at a glance. The pink, lovely infant was now ashen pale, deadly white, and absolutely still.

“He’s dead!” the mother shrieked and held a handkerchief to her mouth, her fists clenched and white.

The nurses, anesthetists, and pediatric intern had all been trying to revive the child. Breathing mouth-to-mouth. An intracardiac injection. A quick look under the bandage to see if there was hemorrhage, but there was none. I just watched, somehow knowing it was all futile.

In tiny children, the events of life and death progress very fast. After a moment or two the child’s face and head were already cold. I took the weeping mother, who was still crying aloud and calling out, to the waiting room. I tried to find some words somewhere. There were none. There are none now. Some things in life simply do not translate into language.

If some specific memory of a life in surgery could somehow be wiped out in one stroke, it would surely be my memory of those few moments with that mother. Suddenly she had changed from a young Italian girl from the North End into a distraught, protective animal, fighting for her young.

What had happened? It is only a guess. The deep anesthesia paralyzed the infant’s poorly formed blood vessel reflexes that, when we stand up, keep the venous blood flowing against gravity, up from the legs and lower part of the body to nourish the brain and the heart itself. In an infant just beginning to stand upright and walk, these reflexes are not yet strong. When the nurse anesthetist so lovingly picked up the child and held him against her shoulder, she unwittingly restrained him in the upright posture. If a person is forced for long periods of time to maintain this position, the stagnant blood pools in the legs. The brain, robbed of blood, starts to die, and with it the drive for respiration. And then the person dies. Death by crucifixion occurs because, when the body is held helplessly upright, all blood flows to the feet and legs and stays there. Fainting is soon followed by death. While the nurse anesthetist held the baby with

his head on her shoulder, she could not see his face. For this little boy, deeply drugged with anesthetics, lying down in his wheeled crib would have been safe.

Nothing since then has changed my interpretation of those events, now more than 50 years ago. This was not of any interest to the mother, only to those of us who went over the details again and again, hoping that it would never happen again. Whose fault was it? Mine, of course. The surgeon, like the captain of a ship or the pilot of an aircraft, is responsible for everything that happens. His word is the only one that cannot be gainsaid.

I never spoke harshly to the nurse anesthetist or blamed her. I knew how she felt. She later volunteered that she shouldn’t have picked the child up. I agreed, and asked her if she had ever done that before. She did not respond. Criticism was not necessary, nor were false reassurances.

In the long pace of days and weeks and the long years of human life with remembrance of things past and apprehension of things to come, it is hard to remember that in preserving human life there are occasions when seconds count, minutes are too long. This is especially true in infants. A single minute of poor blood flow to that tender brain, a single moment of open bleeding from the heart or a major vessel, may spell the end of a life.

Surgery has plenty of hidden dangers for the unwary. I enjoy a rather mixed metaphor about surgery, the sea, and flying: Surgery, like aviation, is in itself not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity, or neglect.

Sir Berkeley Moynihan, the great British surgeon who helped perfect abdominal surgery, said: “Every surgical operation is an experiment in bacteriology.” The skin is our barrier against surroundings that teem with bacteria: a microbiological world unfriendly to large animals like us. Once the skin has been breached, by accident or design, infection can occur. This has been a cause of death after battle wounds since the

dawn of time or after surgical operations since a sharp knife was first used to make an intentional incision.

Besides the threat of bacteria from the outside world, there are viruses, fungi, and parasites out there seeking admission. We also harbor billions of bacteria inside us, mostly in the lower intestine, the colon. These bacteria are called Escherichia coli in honor of Theodor Escherich, a scientist of the nineteenth century. This name is usually abbreviated E. coli: Theodor’s germs from the colon. Our normal intestinal tract excludes these E. coli from the true interior of our bodies or the bloodstream. During intestinal surgery and in infections such as acute appendicitis, there is always the threat that these usually cohabiting bacteria, if given a chance, will leak into the peritoneal cavity where they wreak havoc only a half-millimeter away from where they usually reside in peace. Some of these E. coli secrete potent toxins that can kill if they grow in food that has spoiled. Or if they grow in the peritoneal cavity or in abscesses.

Despite antibiotics, infection remains the bane of surgery. Most surgical patients who die after severe injury or with complications after major surgery still die because of infection. Our intensive care wards save many lives, but we still lose patients to multiple infections caused by organisms that are either resistant to antibiotics or, like some of the fungus infections, enhanced or worsened by antibiotics. In such multiple infections, many of our vital organs fail in sequence: first the kidneys, then the liver and brain, and finally the heart. The term multi-system organ failure describes these troubles. Without antibiotics many of these patients would have died of their injuries 1 or 2 weeks previously. Some survive because of antibiotics and intensive care. In some cases these infections are, in a sense, the byproduct of antibiotics. Sometimes, as in acute appendicitis, the surgeon actually removes the infection along with the infected organ. And then there are other situations in which the infected tissue is surgically removed but under more perilous circumstances.

The story of a teenager dying of colitis is a case in point and emphasizes some of the challenge and human satisfaction of surgery. The patient was a young man of 16. Before his illness he had been robust, healthy, and athletic. He played tackle on the high school football team. But in the 6 or 8 months before I saw him in the hospital, he had become increasingly ill with intestinal bleeding and diarrhea due to a dangerous

disease of the large intestine—ulcerative colitis. For the past 6 weeks he had been wildly, dangerously, and overwhelmingly ill with a rampant form of the disease. He was given large doses of cortisone. In ulcerative colitis the colon seems to infect and literally digest itself with its own bacteria, those same colon bacilli with which we usually live in peace. The colon becomes swollen, and bacteria spread to the lymph nodes near the bowel. Over time, the patient’s immune system fails and other commonplace bacteria become involved in the infectious process. The bowel disintegrates and then perforates, producing a foul, stinking peritonitis and death. This condition is called toxic megacolon, and it was frequently associated with cortisone treatment.

In the realm of surgery, there are a number of operations wherein the procedure itself solves most of the patient’s most urgent problems. Recovery starts immediately and dramatically. The surgical act can cure the awful wrongs that the body has been suffering. The recovery mechanisms of the body easily accommodate to the relatively minor stress of the operation itself. Stopping a major hemorrhage, removing a piece of food from the trachea, relieving a blocked kidney, draining an abscess, restoring blood flow to a blocked coronary artery early in a heart attack, transplanting a new kidney or liver to replace one that is failing, setting a painful and shock-producing break in the thigh bone are examples of some of the most dramatic effects of operation itself. Sometimes these rescue procedures are rapid and simple, such as removing a ruptured spleen in an athlete hurt in a football game or removing a ruptured tubal pregnancy in a young mother.

Although the removal of the infected, decaying colon in toxic megacolon is more complicated and more time-consuming than the operations mentioned above, it has the same dramatic effect on the patient. The colon must be gently dissected out, blood vessels and lymphatics ligated to avoid bacterial spill into the general circulation, and the entire length of the colon (often 3 or 4 feet) removed. No bleeding can be left behind. A new intestinal opening (an ileostomy) is made. The abdominal cavity is washed, rinsed out, and returned to its normal glistening appearance. The rectum is then removed and these two large incisions are closed.

In this teenage patient, infection and fever had made him delirious; in the last hours before operation he was hallucinating, his pulse

racing. His blood pressure was edgy and falling, his kidney and liver function were deteriorating. A positive blood culture showed that E. coli bacteria were growing in his bloodstream.

The operation I performed, although done as an emergency, was deliberate. It took over 3 hours. Within minutes after his colon was removed, his pulse slowed down and became steadier, his blood pressure became stable and normal. Kidney and liver function soon improved. And his brain, once cleared of the anesthetic, was soon back to normal. In a short time the blood culture became sterile. The students who helped with this surgery were immensely impressed with how this long, difficult operation, requiring several blood transfusions, could produce such an immediate improvement.

When I next visited the patient, a few hours later, he was coming around from his anesthesia. One might think that just the pain of those incisions and the worry about the new intestinal opening on the abdomen would overwhelm any feelings of relief or improvement. This boy had lived for some time with raging infection and the pain of spreading peritonitis, not to mention the dread of what might come next. Relief from this suffering was evident. The clearing of his mind, reduction of the work of his heart, and the new ease of his breathing were evidence of how rapidly and completely a sturdy young person can recover from severe disease and an extensive operation when it has abated the crisis. Somehow the survival responses of the body were able to reach down into evolutionary processes, some very ancient, and summon recovery once he was relieved of the infected tissue of his colon.

The following day when I visited him on rounds, his face broadened into a smile of joy, relief, and a kind of bodily animal pleasure that is difficult to describe. The ordeal was over. He could distinguish the pain of a healing incision from the anguish of infection. He was safe and he knew it without anyone telling him.

“Hey Doc! You saved my life!” Sort of a teenage greeting-shout, one of joy. A bit corny, but from the heart. My only answer, with a squeeze of the hand, was the usual mumbling of something along the lines of, “Hell, you did most of it yourself.”

How true. His body was already back at work, returning to tissue growth and synthesizing new proteins for healing. Little cells—fibroblasts

that heal wounds and are the surgeon’s best friends—were already moving in to restore his tissues to their normal strength.

Every student of medicine, everyone concerned with what medical treatment is about and how the body can respond, should join in the care of a patient like this every now and then. It is good for understanding what doctoring is all about. We were looking at the remarkable combination of modern surgery in a vigorous youngster and the truly marvelous primal recovery mechanisms deep within his body. We were witnesses to mental and physical processes that are inseparable.

A few days later, “Say, Doc, when can I start eating? I’m starved! They haven’t given me anything to eat for weeks.”

“Wait a while. Another day or two until you get settled down, and then we’ll give you a turkey dinner.”

Another squeeze of a newly strong young hand, no longer sweaty, but pleased and confident and grateful.

“See you tomorrow.”

In learning the surgical care of the sick, we were most influenced by the practicing surgeons of the attending staff. Arthur W. Allen in abdominal surgery, Joseph Vincent Meigs in gynecology, and Richard Sweet in thoracic surgery were national leaders in their fields and typical of the senior surgical staff at the MGH in those days. For me, the most influential was Leland S. McKittrick. He was a middlewesterner, hailing from Wisconsin. Maybe this Illinoisian intern was drawn to him by that background. He was plainspoken and clear thinking, his eye on patient welfare and clinical teaching rather than social status, hospital hierarchy, or national medical politics. When I finished the residency, I became his private assistant for 2 years before devoting all my time to academia, to the university in research and teaching. The academic surgeons to whom I was closest were Edward Churchill and Oliver Cope.

The MGH had a large surgical staff rich in talent of all ages. George Washington Wales Brewster was, for me, quite special as an example of the most senior group, after retirement. His son Henry had been a classmate of mine at college, and the father, a legendary old-time surgeon, took an interest in both Laurie and me. He and his wife often

treated us to Sunday dinner in their brownstone townhouse at 213 Beacon Street. It was typical of the Boston doctor’s house of that day. His office was on the first floor. The living quarters were on the floor above. The food rose from the cellar kitchen to the upper floors on a dumb-waiter. Patients and social acquaintances came in through the same door, but the latter walked up a staircase or took the ramshackle elevator.

George W.W. Brewster was an old man by the time I knew him, an old-school cutting surgeon of the most pragmatic type, often given to pithy opinions, many unprintable. Maybe this time-honored toughness was a sort of bluff protection against newfangled surgery; the more precise, slower, meticulous operations; research; elaborate x-ray diagnosis (to him always a newfangled gadget); and academic concerns of the younger surgeons. Brewster had been active in surgery when the x-ray was invented. He did not always trust those strange pictures. Early x-rays were taken on glass plates rather than films, hence the term “plate” for an x-ray picture. The Brewster treatment of fractures consisted of making rounds, seeing an x-ray plate that did not agree with his perception, breaking it over his knee, throwing the pieces into the wastebasket, and making it clear that the patient was progressing just fine despite that damned x-ray.

One of the younger clinical surgeons who influenced us was Claude E. Welch, the Nebraskan assistant to Dr. Allen. He later became the senior clinical teacher for generations of surgeons and was the acknowledged leader of MGH surgery for years, even after his retirement. Then there were Marshall Bartlett, Horatio Rogers, Langdon Parsons, Bradford Cannon, Richard Wallace, and a whole group of clinical teachers who, with boundless energy and good humor, shepherded all of us fledgling surgeons through innumerable operations and made a profound imprint.

The youngest member of this group was Fiorindo A. Simeone. He had been my chief resident when I first started as pup and it seemed certain that he was the greatest of Italian surgeons! He looked, acted, and talked like New York’s feisty mayor, Fiorello La Guardia, and came from the same part of Italy. Simi, as he was known, later became Professor of Surgery in Cleveland (at Western Reserve). Then he moved to Providence (at Brown University) where he found a large Italian clientele and

continued to operate on patients and play the role of a sort of father figure in surgery until his death, when he was almost 80.

During my time at Harvard Medical School, a subtle change was taking place in the home origins of staff and faculty in surgery and indeed throughout Harvard University as a whole. While George Brewster may have epitomized the old Boston lineage, tracing his line straight back to an elder on the Mayflower, Allen (Kentucky), Welch (Nebraska), and McKittrick (Wisconsin) hailed from other parts. Churchill was from Illinois. Cope from Philadelphia. At one point six of the senior university full-time professors of surgery at the Harvard Medical School came from the middle west: Churchill, Gross, Russell, Austen, Folkman, and Moore. In fact there was an article in The Atlantic Monthly not long after the war about how the center of gravity of faculty leadership at Harvard was shifting westward and away from the Charles River tidewater; the blue blood was beginning to run pretty thin with the outgoing tide. To me— and I think to most of the interns and residents—this did not make any difference whatsoever. A remarkable group of men constituted Boston surgery, and many of the leaders were at Harvard, the Brigham, and the MGH.

Simeone and Welch were involved in one of our rare hospital pranks. In the surgeons’ room there were a lot of stuffy old pictures of stuffy old surgeons: formal pictures of the hospital staff that went back at least to the invention of the photograph if not back to the daguerreotype, the tintype, and the discovery of ether anesthesia. Under the stimulus of Claude Welch, some of us dressed up in frock coats, glued on stage mustaches and beards, and stared seriously at the camera. We wanted to see if anyone ever really looked at all those old pictures. We hung our phony photo in the surgeons’ room. It was several weeks or months before somebody gave away the secret. No one ever noticed that the picture showed a bunch of young upstarts dressed up to look like old Boston Brahmins.

Then there were the “change parties.” Every 3 months the resident staff changed. That is, the various members were rotated upward to a

more advanced position. Every year or so the change might involve a new man at the top in the form of the chief resident. These milestones were marked by events known as change parties, at which the off-duty staff became especially cheerful after a few drinks. A bit rowdy. It had long been noted and was a source of some humor that a surgeon should not wear a long tie that could dangle embarrassingly and dangerously down into the wound or incision while he leaned over the patient. Our white uniforms did not include ties or even shirts with collars. But the change parties were mostly for the off-duty residents who attended in their rarely used civvies (i.e., charcoal grey suits with neckties). So it became a custom during change parties that a few of the white-suited on-duty troops (cold sober) would invade the party for a few minutes, bandage scissors in hand. Now bandage scissors can cut through almost anything, including plaster. So cutting off the necktie just below the knot, thus in effect defrocking the rowdy civilian-clad celebrants, became a customary activity at change parties. If you wore a tie at all, it had better be a bow tie or a very old one.

In spite of all our work and many duties, there was also time to do some writing and begin some clinical research. As mentioned earlier, I had, while still a medical student, done research on a placental hormone. In 1941, 2 years after medical school and during my junior residency, I applied for a fellowship from the National Research Council to learn how to use the then-new radioactive isotopes in research. To my surprise and delight, the fellowship was granted for a year starting in July 1941. During that time I carried out research using radioactive isotopes under Joseph Aub and Waldo Cohn and began the study of the chemical anatomy of the body, otherwise known as body composition (described in Chapter 14). A year later, in July 1942, my research fellowship being over, I returned to the residency, operating on many patients, serving in the emergency ward, applying dressings, setting fractures, making rounds, and teaching students.

The war in Europe had begun on September 1, 1939, with the German invasion of Poland. This was the start of our third month of internship. It was clear that a terrible event, long anticipated, had now

arrived. Then, in December 1941, in the midst of that research year, came the attack on Pearl Harbor. Now we, too, were at war.

By spring 1942, every aspect of the hospital and our surgical work, as well as research and teaching, had become part of the war effort. Because of bronchial asthma I was classified 4F in the doctor draft and declared essential to the home front. I was told by Dr. Nathaniel Faxon, the hospital director, “Your job is right here.” I finished up my junior residency, became senior resident and then chief resident, and finished the whole span of residency in November 1943, 4½ years after graduating from medical school and starting internship. Actually, this amounted to only 3½ clinical years because of the year taken off for research. During this time I gained expertise and a fair load of confidence. But 42 months was quite a speed-up over the 50 or 60 months many of my predecessors had been able to spend covering the same ground. While I might have enjoyed a longer residency and felt more confident, I was glad to get out of a white suit and join the MGH attending staff in surgery as its most junior member, on November 1, 1943.

Almost immediately after the attack on Pearl Harbor, the surgical residency plan at the MGH was changed around to adapt it to wartime, shortening surgical training from the former 5 or 6 years to a basic 9-9-9, or 27 months. This involved giving very young physicians lots of surgical responsibility, which meant they would require lots of supervision. It soon became my job to help make this supervision effective. This is when I came to feel most keenly the obligation to emphasize professional conduct, ethics, and honesty—as well as surgical skill—in the residency years. For those young wartime surgeons required to finish their residency in only 27 months after medical school, it was a severe challenge. The appetite of the army and navy for surgeons seemed insatiable. The teaching hospitals of the United States turned them out by the thousands.

In November 1943, Oliver Cope called me to his office. Edward Churchill, then head of the West Surgical Service at the MGH, was away at war. In his absence it fell to Oliver Cope to discuss career plans with the residents. Because he had been party to my classification by the hospi-

tal as essential to the home front and was aware of my asthmatic status and 4F classification in the draft, he knew he could count on my availability. He offered me an academic job at the most humble Harvard faculty level, as instructor in surgery, and a staff appointment at the MGH. Most important, he generously offered me a laboratory—at first, to share his own laboratory quarters—and money to buy biophysical apparatus not then available at the MGH, such as those used in radioactivity measurements (Geiger counters, electrometers), special handling equipment, and storage facilities for radioactive isotopes. I accepted his offer of an academic position but asked if I might also help one of the senior surgeons in practice. It was evident that my own ambivalence remained, that I was part surgical practitioner, part surgical scientist. I always remained so, never wishing to abandon completely the joy of surgery despite the pull of the research laboratory.

Cope assented to this plan, muttering that there wouldn’t be much time for both academic work and practice. At the same time, as the end of my residency approached, Arthur Allen also considered me for a position. He was one of the most active of the senior surgeons at the MGH and headed up the East Surgical Service. His assistants, among them Claude Welch, were away at war. Dr. Allen asked Laurie and me to dinner one evening at his home. The next day at his office he discussed his practice arrangements with me. After our talk he said, “Franny, you are an academic, a professor, at heart.” Yet he offered me the possibility of working with him for a year or two to help out while others were away. Although I was grateful for and flattered by Dr. Allen’s offer, I turned it down. I felt that he should look further, that my commitment to research would interfere too much with my work as his assistant.

Within a few days Leland McKittrick, in a sense Allen’s rival in Beacon Street practice, called me to his office and asked me if I would assist him in his practice. His most recent assistant had been Richard Warren, who was away at the war with the Harvard unit in Ireland and southern England, soon to go to the Continent after Omaha Beach. Warren and I were close friends and had done some work together. Dr. McKittrick’s practice was situated at the MGH as well as at the New England Deaconess Hospital and its older branch, the Palmer Memorial Hospital. Leland McKittrick was understanding of my irregular hours in

the lab, away from the office, so I chose to work as his assistant. Thus, for about 2 years I led a whirlwind existence including both research and practice, tolerable only to one of irrational ambition, unforgivable ego, and insufferable determination—possible only for one with a supportive wife who possessed an inexhaustible reservoir of forgiveness.

Thus, I became Leland McKittrick’s assistant in November 1943. I had enjoyed my progress through the residency and the contacts with colleagues and senior surgeons of the staff, many of whom became close friends. I especially appreciated the chance to take a year off for research (Chapter 13) and even to do some clinical studies. But most of all I enjoyed my patients, many of whom followed me—or rather I followed them—over the years. They and their families were my contact with the continuing warmth and shared trust of surgical care.

Laurie and our family surely suffered a good bit with my constant absence during those residency years, though they never complained. Usually I was off to the hospital between 5:30 and 6:00 in the morning and didn’t get home until quite late. The residents remained on duty in the hospital alternate nights. We also worked on Saturdays, Sundays, and holidays every second week.

A few days after entering practice in November 1943 and becoming a staff member at the MGH, my first private patient was referred to me, a woman with a small thyroid tumor. All surgeons remember that moment, a sort of debut after white-suited years in training. From that time forward my practice thrived, waxing and waning with the press of other responsibilities in teaching, in running a department, and in research. I always enjoyed the personal practice of surgery and that very special relationship with my own patients.

During those years as a beginning instructor and then as assistant professor at Harvard and as Leland McKittrick’s private assistant, I did quite a lot of surgery. I enjoyed the art of surgery and my practice grew as McKittrick referred many patients to me. McKittrick himself practiced general surgery, that is, operations involving the abdominal cavity, the gastrointestinal tract, liver, and pancreas. He also did thyroid and breast

surgery, as I did. I operated on the parathyroids and adrenals and the autonomic nerves, but he did not. We both were interested in ulcerative colitis and cared for many patients with that disorder. I became surgical director of the ulcerative colitis clinic at the MGH.

McKittrick was especially concerned with vascular surgery because he was the surgical consultant to the Joslin Diabetic Clinic. Diabetic patients are prone to severe obstructive disease of the arteries of their legs, which eventually leads to insufficient flow of blood (ischemia) and often to amputation. While I was with McKittrick, we took care of many diabetics. Unfortunately, without the benefit of present-day x-ray techniques for visualizing the arterial blood flow and with no means of restoring blood flow to previously closed arteries, we had to perform hundreds of amputations. McKittrick used to say that if he were shopping in Brookline and saw somebody coming toward him on crutches, he was pretty sure he was going to greet a patient. While this is not a happy situation for any surgeon, we were doing what was needed to save lives. That old-fashioned, long, sharp, amputation knife and the bone saw, depicted in cartoons of “Old Sawbones” since the days of Napoleon, saw lots of use in our hands in those hectic days during and right after the war. Today, with arterial reconstruction and better management of diabetes, such amputations are much less frequent.

My own health was at its worst with asthma and pulmonary infections in the 1940s and 1950s. After age 40, and thanks to good care, this drain on my time and energy gradually decreased. If age helps asthmatics, Mother Nature has smiled on many of those who began young. I seemed to have been an example.

I am grateful to those physicians who kept me going through the most severe years of asthma. Both at that time and up to the present, they have carried me through my many medical crises: Francis Rackemann, long-time MGH physician, and now Albert L. Sheffer, head of the allergy and asthma unit at the Brigham. Dr. Sheffer is an authority on asthma, which has become an increasingly prevalent problem in our society. He sets an example as one who provides personal attention, a caring about detail. This was not lost on his surgical patient.

There are three ways by which one person, the physician, can help another person in distress: words, drugs, and hands. “Words,” although the easiest to administer and seemingly the least expensive, are of immense importance. While psychiatrists use words as their main weapon against disease, some of the worst mistakes made by surgeons, internists, and pediatricians arise from the misuse of words, and some of their clearest triumphs in human relations come from saying it right. The role of the mind in healing seems to be rediscovered by every generation. Words are the pathway to the mind.

“Drugs” encompass the whole range of chemical compounds used to treat human illness. While all physicians use drugs to some extent (even psychiatrists and radiologists), the use of chemical medicines is most clearly the province—indeed the main weapon—of those in internal medicine and pediatrics. Today surgeons and psychiatrists use drugs more than ever before. In their overuse and misuse lie many of the misfires of all medical care.

“Doing with the hands” is latinized as “manipulation” and enshrined in the Greek root of the word surgery, chir-urgie. But the laying on of hands is not solely the domain of surgery. Every doctor should use his friendly touch. Any physician worth his salt carries out a physical examination that goes beyond shining a light and asking the patient to say

“Ahhh.” A common criticism of internists is their failure to examine the breasts of their female patients or to perform pelvic and rectal examinations. The gentleness with which any physician carries out those examinations (doing with the hands) is an important aspect of his empathy with the patient.

For the surgeon, this laying on of skilled hands is sometimes accomplished without any sharp instruments, as when he sets a simple fracture, or it may involve extensive sharp dissection under anesthesia in the familiar setting of the operating room. And then there are those severe injuries, such as burns, and diseases such as acute pancreatitis or advanced peritonitis, in which the responsibility of the surgeon extends over many weeks or months without any operation at all or with the selection of the right moment for operation as the key surgical decision.

If medicine is applied human biology, then surgery is its engineering arm. Surgery is based on the same corpus of human knowledge as the rest of medicine, but to this is added a craft, a skill with the hands. Surgery has no independent existence. It has no value sui generis, no existential component, no intrinsic message for the beholder. Surgery exists solely for the care of the sick and by that alone shall it be judged.

In internal medicine, pediatrics, and psychiatry, it is often the doctor’s job to enroll the patient for continuing care. It is the surgeon’s job to release the patient from care by definitive treatment and then return him to normal life. Sometimes—increasingly often—we succeed. Our failures have many causes, some of them preventable. Some of the deaths that occur on a general surgical service (including thoracic and vascular/ cardiac operations) are potentially preventable because they result from errors in diagnosis, judgment, or technique.

The other deaths are due to the progress of disease, advanced cancer, old age, hopelessly severe injury, or a combination of factors that defeat the surgeon’s best efforts. In some cases a skill factor might have been sharper. Matters of skill are never quite so clear. Only to the experienced realist is it evident that when an elderly woman with gallbladder infection dies after operation, it might have been wiser to wait another

few days before the operation, letting her stabilize after a simple drainage procedure. Then she might have made it through removal of the gallbladder or that procedure might even have been avoided. Sometimes a surgical error is very clear-cut. In cardiac surgery, for example, a single suture placed in error can be fatal. After any operation, failure to reoperate promptly for delayed hemorrhage can be disastrous. Recognition of error, of mishap, fostering rigorous honesty in the face of adversity, is essential to good surgery.

The assumption of risk is intrinsic to surgery. When you are experiencing the crushing chest pain of a severe heart attack, you want a surgeon willing to take risks, who might be willing to put his reputation on the line with an emergency bypass operation. You don’t want a surgeon too proud to lose, too timid to accept a postoperative death. But you certainly want a surgeon, a department, a hospital that has done everything possible to reduce those risks. You want a surgical team that faces each error, each mishap, straight up, names it, and takes steps to prevent its recurrence. While this is the essence of a teaching hospital, any hospital can maintain this standard if it so chooses.

Judith Swazey and Renée Fox, who have written on the ethical aspects of surgical teaching and clinical research, inspire the phrase “Forgive, but do not forget” to describe the attitude shown by conscientious teachers of surgery. This attitude was evident in the weekly review of deaths and errors conducted by our chief, Dr. Churchill, using a system developed 25 years before by a surgeon named Ernest Amory Codman.

Ernest Amory Codman was born in 1869 and graduated from Harvard College in 1891 and Harvard Medical School in 1895. He was, rather characteristically, both a Bostonian and an iconoclast. He felt that hospitals were not sufficiently concerned about the quality of the outcomes they produced and that, like a factory, a hospital should evaluate its product critically—its product being the welfare of its patients. Since he believed this evaluation was not properly done at the MGH, he started his own hospital in protest. When he found that it too was flawed, he closed it down.

Codman introduced a system for classifying imperfect outcomes, complications, and deaths. His missionary purpose was to ferret out human error and distinguish it from the inevitable downswing caused by disease itself. Complications, deaths, or other faulty outcomes were rigorously classified as being due to errors in diagnosis, technique, or judgment. These were differentiated sharply from a group identified as patient’s disease. Examples of the latter would include the continued growth of late cancer, unchecked by whatever treatment was carried out (or intentionally withheld); deaths from severe injuries; or massive burns in which the surgeon would be powerless. Such a system of classification is a good discipline for anyone in any field of medicine, especially when it is supplemented by a frank and full discussion of all the details by those most intimately involved in a patient’s care.

In considering errors in diagnosis, technique, or judgment, it is important for the individual surgeon to stand up and be counted. At our weekly service meetings we were asked to give our own account of events—often a frank statement of error—before a group of our peers and teachers. Such meetings are often called morbidity and mortality conferences, or M&M.

As playwrights look back on the ones that “bombed in New Haven,” so also a surgeon maintains a mental catalogue of the things he did wrong at various times in his career and tries never to repeat them. And if he is also a teacher, it is his job to tell his students about them. The memories always remain; some are pretty painful and are rarely brought up after that first meeting. On one occasion I left a strip of gauze in an obese woman who had undergone a mastectomy. A few days after she had returned home, it poked its tip out through the incision. I removed it under local anesthesia. I made no excuses to her husband. The hospital paid the bill. He said, “Thanks, now she’s better.” And she lived for at least two decades, a cure by most criteria.

On another occasion, I failed to drain a colostomy correctly. A severe infection followed and the patient died. Had I handled this correctly she probably would have lived. Despite my efforts to explain my own misjudgment in this complex bit of surgical technology, the family never really understood its import. I appreciated their continued expres-

sions of gratitude for the care I had given and my concern over their tragedy.

M&M meetings might seem impossible and inadvisable in today’s era of malpractice litigation, but they are conducted in most hospitals. The recognition of error and its open discussion by the surgeon are intrinsic to honesty in surgery. A young surgeon’s life should not be ruined when he discusses an error he has made, for everyone else to hear and hence to learn. “Forgive, but do not forget.” What better way of stating the philosophy of honest surgery?

The thrust of a conference on morbidity and mortality—identifying errors and the ways to avoid them—should permeate any surgical service, as it should permeate hospital departments of medicine, radiology, pediatrics, or any others that deal with the sick. Without this point of view, this self-searching honesty, medicine is somehow fraudulent, just as caring for pain and illness without a firm basis in the medical sciences is quackery.

Early in my medical school years I was impressed by the forthright habit of surgeons in analyzing and publishing their results. These clinical papers often report on a series of patients (sometimes only one patient) and describe what was learned. They constitute clinical research. Many deal with outcomes. In my experience, good clinical research is as difficult to do as good laboratory science, although the latter may require more specialized education and skill. In both, the challenge is to meet a high standard of honesty and excellence. Research of both kinds can be sloppy, dishonest, self-serving, or fraudulent. Clinical research can be marred by biased statistics or by gathering cases by computer and giving them to someone unfamiliar with and inexperienced in the field to be written up for publication. Advertising on glossy paper.

My first clinical paper, on the study of a single patient, appeared in The New England Journal of Medicine in 1943. The patient was a gardener who had an open sore on his chest and developed high fever, pneumonia, and a destructive local infection that looked for a time as if it might spread and kill him. We considered several bizarre diagnoses: anthrax, tuberculo-

sis, actinomycosis, black widow spider bite. Nothing showed up on cultures of the ulcer. Just on a hunch, I requested a blood test for tularemia. It was positive. Tularemia (a disease primarily of rabbits) was first described in Tulare County, California. This was one of the first proven cases of tularemia in New England. There was no antibiotic for this disease. After a long illness, the patient recovered completely. I was pleased at having made this diagnosis, piecing it together, and describing its significance in public health and epidemiology. When the galley proofs came back from the journal, I enjoyed the smell of printer’s ink. That first article, “Tularemia in New England,” is still quoted in reviews of that disease. It gave me pure joy and provided a special kind of excitement. As to writing, I was hooked.

In my early staff years at the MGH, I carried out several other clinical research projects in the fields of thyroid disease, duodenal ulcer, and ulcerative colitis, interests I had developed during residency.

Another of my early papers (1946) was on the treatment of thyrotoxicosis. The term “thyrotoxicosis” refers to overactivity of the thyroid gland, also known as hyperthyroidism. The former term accentuates the toxic nature of overproduction of thyroid hormone. When I was a young surgeon, we treated almost all such patients by removing most of the thyroid gland, an operation known as subtotal thyroidectomy. In the patient with severe thyrotoxicosis, this could be a hazardous procedure. Oliver Cope guided us in carrying out this operation safely. During my residency a new drug for thyroid disease, thiouracil, was introduced. This was the first of the antithyroid drugs. At first, such drugs were used primarily to make surgery safer by temporarily reducing thyroid overactivity.

As a junior member of the staff, I worked in the thyroid clinic under the leadership of Howard Means. We used thiouracil to reduce the hazards of operation. Because I felt that what we were learning could be of value to others, I corresponded with other surgeons in hospitals throughout the country and published a summary of this wide experience (theirs and ours) in using thiouracil for the preparation of patients for

surgery. The paper was accepted by the Journal of the American Medical Association and was also published in 1946.

While my paper on tularemia was of interest to me and maybe a dozen people who were concerned with such epidemiology (and hopefully to a few more who were seeing such cases), the thyroid paper attracted wide attention. Lots of patients had thyrotoxicosis. Safe surgery was hard to come by. With the tularemia article I had smelled printer’s ink, but with the thyroid article I experienced for the first time a widespread response: the medical public in this country and throughout the world was interested in an article on an important new topic. Any young person (I was about 32 at the time) would get some sort of a bang out of receiving a lot of correspondence and invitations to speak at medical meetings. I was no exception.

Duodenal ulcer is a painful disorder of the duodenum, the intestine just beyond the stomach. It is due in part to acid. The underlying cause is unknown. Two of our senior staff, Arthur Allen and Leland McKittrick, were very active in treating this prevalent disease. In the 1930s, hundreds of patients were treated surgically for duodenal ulcer every year at the MGH. When other treatments failed, the usual operation for duodenal ulcer was the subtotal gastrectomy. In this operation about two-thirds of an essentially normal stomach is removed to treat the disease next door in the duodenum. It was like taking out the engine to decrease noise in the gear box.

In the spring of 1943 it occurred to me that dividing the vagus nerves (vagotomy) might decrease the secretion of gastric acid and help the patient. The vagus nerves run from brain to stomach and activate gastric secretions. They were later dubbed the “worry nerves,” because emotional stress sometimes made ulcer symptoms worse. I read up on the matter and discussed it with several physiologists and neurologists. There was a small literature on the effect of vagotomy in experimental animals. Although this procedure had been carried out in a few patients in Italy, it had been done for other diseases. From what little was known, vagotomy

markedly reduced the acidity of the stomach without too many side effects.

It was February 1944. I had a patient with duodenal ulcer all lined up for vagotomy. His name was Barstow. He had been treated by internists with powders and pills for many years and had consulted several psychiatrists—all with little effect. His main problem was pain in the upper abdomen after meals, made better for a little while with alkali pills but always coming back. X-rays repeatedly displayed an unhealed ulcer and much scarring.

With the blessing of Chester Jones, who at that time was in charge of medical gastroenterology at the MGH, we had scheduled Mr. Barstow for the operation later that spring of 1944. One day in April or May, Chester Jones called me up and said, “Franny, Lester Dragstedt has just reported several vagotomies for ulcer.” Dragstedt had been working at the Billings Hospital (at the University of Chicago) where I had taken my third-year medicine course 6 years earlier. I had met him but did not know him well. After discovering our common interest in vagotomy, we became fast friends.

The fact that he had already done the operation did not make a great deal of difference to our plans, except to remove from me the onus of doing the first one. It never occurred to me that this news meant that I could no longer claim priority for this new operation. In fact, I didn’t consider that at all, because I had long since concluded that, in scientific work, true priority does not go to the person who does it first, but to the person who understands it and exploits it most effectively. What better example than the discovery of ether anesthesia? Crawford Long used it first, but Morton, at the MGH, and his surgical colleague Warren more clearly understood its meaning and awoke the world to its use.

I operated on Mr. Barstow on August 1, 1944. The patient got along very well. His pain disappeared completely while his stomach remained in place and intact. He continued as a grateful patient and friend of mine, and I followed his medical progress for years. He was a brilliant result from this operation, the first such performed outside the Billings Hospital.

For quite a few years many patients with duodenal ulcer were referred to me. When I published my first paper on vagotomy in The New

England Journal of Medicine with Chester Jones as coauthor, Arthur Allen quipped, “Franny, I saw your local advertising.” We laughed about it. Both he and Leland McKittrick sent me several patients for vagotomy. I was delighted and flattered to have my own senior teachers as patrons of my new art, not to mention the many patients thankful for being spared a gastrectomy.

For about 25 years (from around 1950 to 1975) vagotomy became the standard fixture, virtually replacing gastrectomy. But now the disease itself (duodenal ulcer) has almost disappeared from the scene, the surgeon has disappeared from the setting, and a bacterium (of all things!) may be part of its cause. Other methods of treatment, especially drugs that diminish gastric acidity and now antibiotics, are less dangerous and sometimes equally effective. And as for the use of words in the treatment of duodenal ulcer, psychiatrists attest to the fact that they do not accomplish much.

While I enjoyed this foray into the upper gastrointestinal tract, it never became a part of my research life. I was never a serious research scholar of duodenal ulcer (as Lester Dragstedt was) nor of diseases of the gastrointestinal tract in general, particularly the hormones that affect those diseases, subjects in which many of my colleagues soon became expert.