In the summer of 1951 at the request of the Surgeon General of the Army, I took a trip to Korea to consult with Army surgeons analyzing the patterns of wounds and illness. Two special problems were designated for particular attention: blood banking and blood transfusion, with their threat of potassium toxicity, and epidemic hemorrhagic fever (EHF). Visits therefore included the forward hospitals, the mobile army surgical hospital (MASH) units, and the base hospitals in both Korea and Japan.

One occasion I recall vividly. We were flying at about 2,500 feet in an army L-5, a two-seater artillery spotting plane. About the size of a Piper Cub but very sturdy. All khaki-colored, army style. The pilot was a young officer, flying us north across the Chinese lines. Our own front lines, dimly seen as trenches on a ridgetop, lay out there, behind us. The scene was one of dense forest, hills, and low mountains to all horizons, reminiscent of Vermont or New Hampshire.

There was some artillery crossfire. The pilot had said we would be flying through the flight pattern or trajectory of our own big guns. He seemed unperturbed. I tried to be. A sudden noiseless whoosh went by us and jostled the plane. It was not so much a noise as a small tornado, a very sudden and intense compression of the air and of our eardrums. A moment later we heard the explosive sound, again not so much a bang as

a sudden rush of noise. That was the gun behind us shooting off the shell that had whooshed by us. Soon we climbed out of this artillery trajectory pattern. While the pilot was unmoved by this safe deliverance from the geometry of gunfire, it seemed to me to be progress, at the very least.

The pilot pointed out the Chinese lines below. We could see some trenches and an occasional tent. Then, just behind them, some white shell-bursts. Not just the white of smoke or fire, but snow-white. Like cotton. “Phosphorus shells,” the pilot volunteered.

The medical department of the U.S. Army cared for casualties of the enemy, both Chinese and North Koreans as well as Turks (on our side) and other U.N. troops, including Aussies in our MASH. I had seen some Chinese who had been wounded by phosphorus bursts. Phosphorus wounds were an unsolved problem. The little bits of highly reactive phosphorus continued to burn deep in the wound and burrowed into muscle, bone, or arteries for hours or days. A fiery, burning-burrowing pain. Also a continuous hazard to survival. Nothing you could do about it. Phosphorus shells do no more troop damage than ordinary shells. They are weapons of terror. But isn’t that true of all weapons?

There was no antiaircraft fire. If there had been, we would not have stayed up there for long. The only hazard to our spotting plane was rifle fire from below. The MiG was an early Russian jet that the Chinese had modeled after the German Messerschmitts of World War II. It would have made short shrift of us. The United States did not have jets at that stage of the Korean War. None near us, at any rate. While the Chinese occasionally flew over the lines with a few MiGs, our air power remained completely dominant. That is why we could conduct helicopter evacuations successfully and take a leisurely trip with a low-flying artillery spotting plane.

We didn’t see much sign of human activity that I could recognize or interpret. It was all under camouflage. After the pilot talked to the artillery fire control people, we turned back. Upon landing we inspected the fuselage and wings and found a few small bullet holes. “The infantry always shoot at us,” the pilot said, in passing. I was driven back to the MASH, a short distance away, in a jeep.

I had witnessed an unusual view—for a doctor—of the violence of midcentury. Over the Chinese lines, watching our artillery bursts.

People I could not see, dying violent deaths. Thirty years later, when I visited our friends in China and welcomed some Chinese visitors to our hospital and our home, I did not talk about the Chinese lines or the Chinese winter offensive that drove MacArthur and our troops back with such suffering, or the casualties on both sides.

One of the most peculiar aspects of the wars of this century has been the quick and total reversal of social and nationalistic antagonisms. Think of the Germans. Two terrible wars. Now our allies. The Russians: friends, allies, then enemies, then friends again. The Italians. The Japanese. The Chinese. Over a few decades, each has made the transition from hated ogres (caricatured in cartoons as ghastly enemies) to friends, or vice versa. Although wars of implacable hatred between the French and the Germans have cost millions of lives since 1870, these two nations are now trying to form a combined army.

During my brief visit to Korea there was no major attack on either side. Just constant skirmishing and those night patrols, conducted by both sides. The “no-man’s-land” was strewn with mines, swept by machine-gun fire. On several occasions, survivors of these night patrols were brought to the MASH by helicopter (chopper) early the next morning. Just after sunrise. I made the acquaintance of several of these wounded men, helping them when they first came in, seeing them through their operation and wound debridement, through setting of their fractures, and following them until a week or so later when they could be sent back to Japan. By chance, when I was visiting one of the base hospitals in Japan, I saw several of them there again.

For a surgeon who had not been exposed to the care of the wounded in World War II, these night patrols certainly presented a terrifying aspect. A few men, often volunteering for the task, would go forward under cover of darkness and try to feel out the disposition of the enemy. The enemy was well aware that such patrols were coming, as indeed we were of theirs. So land mines were set. Among the worst of these were the Chinese shoe-box mines, informally put together, with a trigger mechanism and explosive charge plus many small pieces of metal

in a container about the size and shape of a shoe box. When a soldier stepped on one, it was impelled upward by the first charge and then exploded the second charge at about the level of the soldier’s pelvis, producing terrible wounds of the upper thigh, buttocks, rectum, and genitalia. Many of the amputations that we had to perform were rather high in the thigh because of these shoe-box land mines.

The wry humor of the GIs is notable. One of the statements, oft repeated, even as someone was being brought back by chopper from one of those night patrols, and all the intensive care team were at the ready (warned by radio), “This is the only war we got, so we better make the most of it.”

The blood-banking method for the care of the wounded in the early years of the Korean War was based on “theater banking.” That is, the collection of blood from soldiers nearby. Edward Churchill had initiated this method while serving as chief surgeon in the Mediterranean theater during World War II. Universal donor blood kept at icebox temperature for up to 10 days and in some cases 20 days was then transfused without cross-matching in the advanced battalion aid stations. Because of helicopter evacuation of casualties, these forward surgeons (and even those farther back in the MASH units) received casualties who would have been found dead on the battlefield in any prior war. Massive transfusions were urgently needed. These were men with bullet wounds of the great vessels of the abdomen along the spine (aorta or vena cava), enormous wounds of the liver, and penetrating wounds of the upper part of the heart or lungs. The throat. The brain. Blood was used in vast amounts. Transfusion reactions were rare. Although we suspected that some cases of renal failure might have resulted from undetected bloodgroup incompatibility, this was never proven.

The surgical services at the various MASH units were concerned with potassium toxicity from this over-age icebox blood. This topic was one that we had studied intensively for the Army about 8 years before, during World War II. When blood is stored over long periods of time, the high concentration of potassium inside red cells begins to leak out into

the plasma, where it does not belong. Normally there is a 30:1 ratio of potassium concentration between cells (high) and plasma (low). Leak of this potassium from cells to plasma is a chemical sign that some of the stored red cells are no longer viable. They have started to live out their life span in the icebox and are now dying. If a bottle of banked blood is kept too long, this leaking potassium can build up to dangerously high concentrations in the plasma, making the transfused blood toxic to the recipient. If a severely wounded soldier was also threatened by kidney failure, this blood-bank plasma potassium could be especially dangerous. To prevent this hazard it was essential to monitor the icebox storage time. After 7 to 10 days, unused blood was henceforth to be removed from storage and spun down to separate the red cells so that low-potassium plasma could be salvaged for transfusion in patients with wounds and burns.

Although the artificial kidney had been developed at the time of World War II, it was not used during that war. In fact, it was only later that Willem Kolff emigrated from the Netherlands to the United States and distributed the artificial kidneys he had made to physicians who might improve them by using more sophisticated engineering. As described in Chapter 19, one of these designs was sent to George Thorn at the Brigham, where it was quickly improved into a usable washing device to remove toxins from the blood of patients whose kidneys were off duty either temporarily or permanently.

Four or 5 years later, by the time of the Korean War, things had progressed significantly, and the Army possessed several of these artificial kidneys, all of them in the hands of expert young officers well schooled in the chemistry and care of renal failure. Many patients who developed renal failure after severe wounds were being dialyzed, and some of them, whose kidneys otherwise would have failed, were pulling through to complete recovery.

Americans and United Nations troops in Korea, including particularly the Turks, Australians, and New Zealanders, suffered extensively from a devastating disease never before seen by our infectious disease

specialists. This was epidemic hemorrhagic fever (EHF). Although EHF occasionally afflicted natives of the Far East, little was known about it. For a time the predominant explanation for its high incidence (and high mortality) among newly arrived U.N. troops was lack of immunity. Soon it was discovered that some Korean troops had the disease, as did the Chinese north of the 38th parallel. Supposedly they had been exposed for years but now became sick. Why now?

As it turned out, EHF was not a matter of the patients’ disordered immunity but rather of the personal habits of ground squirrels that lived in burrows. It took some sleuthing to discover the animal reservoir that kept this disease going. When a battalion reached the site of a planned encampment, bulldozers would scrape the topsoil away to clear an area for pitching tents. This de-surfacing exposed the squirrels’ underground burrows. Terrified by this turn of events, the little beasts scurried off to seek safety, leaving traces of urine and feces. It was this offal and excreta of squirrels that spread the virus of this disease, so rampant among troops. Since the Korean War, EHF has died back to the rarity it once was. But now, 40 years later, we are learning that the hantavirus and the disease it causes in the American Southwest is a similar (if not the same) virus and similarly spread by the excreta of gophers and ground squirrels.

During the period I was in Korea there was a severe outbreak of EHF; many men came down with this disease and died. The reason I was particularly asked to help treat these patients was that, although they were suffering an infection, their response resembled the response to a severe burn. As in a burn injury, EHF caused huge amounts of fluid (edema) to collect in the tissues in front of the spine, from the upper part of the chest all the way down to the pelvis. The concentration of red cells rose while blood volume fell; patients went into shock and often died of renal failure. In more senses than one, they were burned by the virus.

Those of us studying this disease came to the obvious conclusion that, just as for a severe burn, the first step was to give the patient enough plasma and fluid to keep his blood flowing, restore a normal blood volume, and avoid renal failure. Delivered promptly in adequate (often huge) amounts, this fluid infusion (including plenty of plasma) worked like magic and put the patients back into good shape. Even without antibiotics to fight this microorganism, the men were better than able to

fight the infection and survive. The second and major need was for an antibiotic that would control the microorganism producing this disease. This need was never met.

We looked into several of these problems, particularly at one MASH unit, where an active and productive surgical research team was working under the guidance of John Howard, a surgeon of Philadelphia. Howard and his group did a superb job of studying these patients and translating the results of their research into improvements in clinical care all across the front. For me, it was a privilege to work with John and help in whatever way I could.

The front at that time included regions known as Punchbowl and Heartbreak Ridge. These battlefields consisted of steep escarpments with the front line precisely on top, facing the enemy’s front line on the opposite ridge. The forward battalion aid stations were situated just behind the front lines along the slopes of these ridges. The second line of hospitals— some of them MASH units, others a little bit smaller than a MASH— were not far behind. All were close to the combat areas. Such proximity to immediate care translated into low mortality from wounds. A situation not always possible in war.

If there were wounded awaiting care, a helicopter could land on the small pad at the front line itself. The Chinese and North Koreans gave those choppers about 2 minutes to alight, pick up one or two wounded, and take off before they resumed shelling of the area. This local custom of military medical chivalry brought severe yet still salvageable wounds to the MASH soon after injury. If there were Chinese or North Korean soldiers wounded from a patrol the previous night, we took care of them also. The gunners knew that.

The battalion aid stations were mere hutments or caves surrounded by sandbags, often on a steep slope, and subject to enemy artillery fire. Probably most of these shells had been lobbed toward the front line, but being a little bit long, they came down just behind it and lit on the steep slope in the region of the battalion aid stations. The wounds cared for in

these aid stations were in many cases less severe than those selected for the immediate helicopter ride.

It was at the battalion aid stations that my belief was reinforced— as if such reinforcement would ever be necessary—that the soundest medical education consists of good basic physiology, anatomy, biochemistry, and pathology. In the words of A. Baird Hastings, our teacher of biochemistry, “The most practical thing in the world is sound basic research.” To this, add “and teaching.” The young doctors in those battalion aid stations had just finished their internships and many had no interest in a career in surgery. Yet there they were, faced with some of the most urgent surgical problems you could imagine. They were not treating casualties by rote but rather by superior intelligence. These young doctors could think on their feet, applying their knowledge of physiology, anatomy, and biochemistry and often improvising brilliant solutions to seemingly insoluble problems. They obtained battery-powered electrocardiograms for those with wounds around the heart or lungs, seeking the most accurate evaluation possible as to what organs were injured and deciding whether or not an immediate operation was required. Although these young medical officers transfused a lot of blood, they didn’t waste the precious stuff. They examined their patients in great detail and made precise diagnoses of the nature and extent of their wounds. For the most part, those battalion aid stations did not have x-ray machines, although one or two had small ones that could operate on portable generators. If major surgery was required (as in a belly wound, for example), the patient was promptly shuttled back to the MASH by jeep or chopper.

Occasionally, among those young doctors, I would encounter one of our medical students of a year or two before who had taken my courses and sometimes quoted some aspect of our studies in improving the care of burned or wounded patients. That certainly was a thrill for me.

One of my memorable patients (because of the coincidence of long follow-up) was a large, handsome, athletically built young black soldier. This soldier had been wounded by a shell or mine fragment enter-

ing the right upper quadrant of his abdomen, the chunk of steel emerging through his chest in back. One need not have studied human anatomy to realize that such a wound as this might involve liver, diaphragm, lung, and pleural cavity. Being a shell fragment rather than a bullet, it was destructive. Slow. Irregular. Wobbling. Not like the clean wound of a high-velocity bullet.

Because he was wounded at night, he was brought to a battalion aid station rather than being taken immediately by chopper to a MASH. I happened to be there at the time, and I helped a young lieutenant start transfusions and get the patient stabilized. At dawn we called a chopper to take him back to the MASH. Choppers could not fly unless the ground was continuously visible. That meant no flights at night or in thick fog.

An hour or two later I went back to that MASH and assisted a young major in the operation. The upper part of the patient’s liver was badly shredded. Fortunately, no major bleeding persisted or else he would have died at the aid station. The right lower lobe of his lung was also severely torn. We knew we were going to have plenty of trouble with this combined injury. Dirt, shreds of uniform, and dead tissue were cleaned away, removed, debrided. One lobe of his lung had to be removed along with a portion of his liver. The diaphragm was sutured, some drains were placed, including a drain into his common bile duct, and the wound was closed loosely to prevent trapped infection, always a threat in dirty war wounds.

Within a few days, that which we had feared became evident. A bronchobiliary fistula developed, a situation rarely encountered in civilian surgery. This is an abnormal opening (fistula) connecting the biliary tract (which normally conducts clear brown bile into the gastrointestinal tract) with the bronchial tree (the system of airways leading down into the lung). In no way could his body form the necessary scar tissue fast enough to close off this opening made by the traveling shell fragment. From time to time he would cough up bile, and it would also emerge from the drainage tracts. Because of our drains, this bile leak was not fatal. Maybe not fatal, but extremely unpleasant.

As soon as it was possible, we reoperated, closing off the bronchobiliary opening by interposing some healthy tissue. We then reexpanded the remaining lung and tucked the liver back where it be-

longed. Chancy, dangerous surgery so soon after a major wound. He seemed to do quite well, although the large gash remained in his upper abdomen and back.

By coincidence, a couple of weeks later I saw this same soldier while I was making rounds at a base hospital in Japan where the wounded were taken before being sent back home, the most blessed event that could happen to them. He was doing well. He recognized me, put out his hand, and said, “Thanks.” I asked him about his plane rides, when he was going home, and where home was. Soon. Detroit. He smiled warmly at the thought. I had a good look at his dressing and his healing wound. The bronchobiliary fistula was closed and dry. Our repair had held. He was beginning to heal up, and soon he would be back home.

One of the many good things that the Army Medical Corps did was to see to it that men who were evacuated to the States were taken to major hospitals near their homes and folks. I can imagine the joy and cheering and good times when this husky soldier, now thin and wan but still handsome, arrived in Detroit. The wonders of surgical convalescence, the help surgeons give, the support of people you love and need. Getting better. And getting people well.

Back in Japan, visiting MacArthur’s headquarters (I never got to meet the general himself) and our base hospitals, the scene was one of planned organization, rigid discipline. The advance northward into China, the counterattack by the Chinese, and the winter retreat leading finally to the peace talks all occurred after my visit and somewhat to the east of the area where I had been working.

With World War II in the more distant past and the bitter, agonizing national pain over Vietnam yet to come, this interim war in Korea has been caught in between and somewhat forgotten by history. Yet by its sheer magnitude in terms of American casualties and commitment, as well as the terrible destruction wrought by artillery and bombs, the Korean War was big enough and bad enough to occupy the full attention of this country for several anxious years. With new tensions in Korea, that

war may be coming back into historical focus. In any event, its surgical lessons have never been forgotten.

I was away from this country only briefly (2 months). This was nothing compared with the experience of many friends who spent 3 to 5 years in the service during World War II. But even this short visit gave me a glimpse of the surgical problems peculiar to the military and a more realistic view of the human suffering of war. Suffering borne with stoicism and sometimes even humor. I gained a great deal of respect for our average American GI and his young surgeon.

Every war and each battle is fought in a different cultural and physical environment. The nature of the political engagement itself, the weapons used, and the natural environment determine the surgical and medical needs. But the reaction of men under fire, the unrelieved stress of lethal threat, and the plight of the severely wounded have remained unchanged over the centuries. Now, as always, the mercy of prompt surgical care and expert nursing is the only balm for wartime suffering.

Now and then most everyone has a dream that turns out to be an uncannily accurate and detailed prophecy of things to come. Extrasensory perception? A space-time warp?

On a certain Wednesday night in November 1961, I had a vivid dream about being in an oriental court with a robed and burnoosed king. His court was elaborate, Persian rugs under tents. Primitive regal splendor, but at the same time brutal and ominous. In a desert. A detailed picture. I thought nothing of it save for a lingering question: “Why now?” I told Laurie about it and went about my usual day. Breakfast. Off to the hospital.

That afternoon we were in the midst of our weekly Thursday afternoon student seminar, meeting with some fourth-year students who were presenting informal papers for discussion and criticism. About halfway through the seminar, around 4:30 PM, I heard the telephone ring in the outer office. Not unusual. But then Doris Lewis, my secretary, interrupted the class and asked me to pick up the phone. Highly unusual. She had a funny look in her eye. I knew it was important. It was the U.S. State Department asking if I could leave that afternoon for Saudi Arabia to attend their ailing King Saud, Ibn Abdul Aziz. He was sick and his doctors had sent for me.

This event would change my life for a while and my view of the

Arab world and the Moslem religion for a long time. Six months earlier I had been a guest at the American University of Beirut in Lebanon, attending the Middle East Medical Assembly, where I had given several papers on a variety of surgical topics. There I had met an American surgeon, William Taylor, who had come from his job in Dhahran, Saudi Arabia. He was a full-time physician for the Arabian-American Oil Company (ARAMCO), the principal agent for export of Arabian oil to Europe and the United States. The relationship of Saudi Arabia to ARAMCO, and through that corporative intermediary to the United States, was very close.

When I met Taylor at the medical assembly, we did not discuss Saudi Arabia, ARAMCO, the trans-Arabian pipeline (TAPCO), or the royal family of Saudi Arabia, but instead talked about some of the projects I had been working on and some of the medical problems he had to cope with in Arabia. When the king became ill, the decision to call me was in response to Bill Taylor’s suggestion.

Flying to Arabia was an experience in itself. Although I had visited several out-of-the-way places in the world, including a few primitive Third World countries, I had never visited one under the iron hand of a rich, despotic royal dynasty. When we reached Saudi Arabia, it was night. From the high-flying plane all we could see were hundreds of fires from the towering exhaust pipes of the oil rigs. These fires were not oil wells burning (as we saw after the desert war with Iraq in 1991), but rather the constant burning off of the flow of natural gas that was emitted in huge amounts from rigs on the big dome near Dhahran. This can be seen in some American refineries and oil fields, but not over such a large area, extending to both horizons. A great deal of energy was being wasted on the cold desert air.

Shortly after my arrival I was taken to see the king. He was practically blind (not totally blind, because he could see a bit around the edges of his cataracts). He had a problem with recurring pain in his chest and abdomen. In addition, he had developed a ventral (abdominal) hernia and a groin hernia lower down. Because of his pain (unrelated to the hernias), medical specialists (from England) had already recorded several electrocardiograms. In their opinion, the king had not suffered a heart attack.

The king, with his blindness, undiagnosed chronic abdominal

pain, and more than a suggestion of severe liver disease, certainly could not be cared for adequately in Arabia, even in the shiny new hospital that ARAMCO had built in Dhahran for its American employees, where Bill Taylor had been in charge. It was clear to me that the king should come to Boston.

Making a plan for the king required not only the usual examinations, x-rays, and consultations, but also a meeting with the king’s brother, Faisal, who was then the ranking prince and presumed successor to the throne. I remained in Dhahran for less than a week while the royal retinue got organized. I was given a brief tour down the Persian Gulf coast to Qatar, one of the coastal Emirates, to catch a glimpse of the culture of the Arabian peninsula. The eye-seeking black flies on the faces of infants. The peasants and commoners who were not only poverty-stricken but living in primitive and disease-ridden conditions, literally on the sand. The people were several centuries out of phase with their royalty, who sped by in Cadillacs, dust flying.

To bring the king to Boston, ARAMCO hired a large jet that could accommodate about 100 people. They filled it not only with the king and his immediate retinue, but also with his chief of state (an intelligent, highly educated Arabian aristocrat who was an expert on Middle Eastern history), various sheiks and hangers-on, and four of his favorite concubines. I rode with the crew in the cockpit of this huge plane. We landed at Naples to refuel. Coming in at night, airport runway ahead, a royal retinue behind, it was certainly a moment to wonder at the experiences a lifetime in surgery can bring.

Of all the king’s retinue two persons were especially notable. One was the announcer. He was a large black man, a royal slave from the Horn of Africa, about 7 feet tall. His bare chest was crossed with bandoliers filled with ammunition, running from shoulder to hip, and he carried a loaded automatic rifle. His job was to tell everyone what was going on. Back in the camel days, radio was not available to do the job. Hence the announcer.

The other remarkable person was a small, rotund schemer and

specialist on insider influence, sinister in both appearance and reality, known as Sheikh Id (pronounced “share-eed”). He was always fully burnoosed, bejeweled headband in place. Id was crucial to the maintenance of the king as an institution. His closest personal confidant. There is no truly analogous person in our government; the closest parallel might be a few of the president’s White House advisors, some of whom in the last 20 years have turned out to be equally adept as schemers, plotters, and influence-peddlers.

There was no simple way to get rid of Sheikh Id. Nothing whatsoever could be done about him, even by the ARAMCO executive who was a specialist on the royal family and stayed with us throughout the entire episode. Sheikh Id was the ultimate power behind the throne, although he was usually found in front of it.

The king had 55 daughters and 45 sons, or so it was said, a low batting average, considering the value placed on male offspring in the Moslem world. He was falling behind the 0.500 mark. Nonetheless, many of these princes and princesses were upset by Sheikh Id and his manipulations around their father, without his or their approval. I never became party to any of this intrigue. That would have been even more unhealthy than what I was already doing.

About 4 years later we noticed in the paper that there had been a suspicious accident on a flight from Saudi Arabia to Switzerland. The plane appeared to have been sabotaged. The crash occurred in the Alps. Not much was found. Well planned. One of the passengers listed was a certain Sheikh Id. The newspaper just listed the names; the press didn’t know about Id. Possibly somebody had decided to eliminate him. Too bad this had to take so many others with him. Whatever his ultimate fate, we just had to put up with Id as best we could.

Our hospital administrator, William Hassan, of Lebanese descent, did a superb job during all the pomp and splendor of the royal visit. He spoke Arabic naturally and fluently. The choice top floor of the private wing of the Brigham was given over to the royal family. The head nurse there, Miss Bunevith, was not only an excellent nurse but also a diplomat.

She took care of the Arabian entourage with great talent, finding places for both Id and the announcer. While by current standards such might be regarded as a misuse of hospital beds, it is not every day one is called upon to attend royalty.

I had always been a little skeptical of formally garbed state department types wearing spats and double-breasted vests. Black fedoras. On the second day of the king’s stay, one such functionary came to visit the king, preceded by suitable fanfare from the announcer. He had brought the king a gift from President Kennedy, who also sent a bunch of roses daily.

Arabic is a difficult language. Few Westerners have mastered it. Lots of nouns. For example, the words for white horse, black horse, brown horse, and chestnut horse are each different nouns. I ushered our impressive diplomat into the royal presence and introduced him to the king via the announcer and an interpreter. We had sidetracked Id for the moment. Our state department dignitary sat down beside the king. I remained there for a moment, wondering what would transpire when an elegantly clad state department official visited the king of a desert empire, sick in bed. Our diplomat immediately began conversing in fluent Arabic. The king broke out in a broad smile. He was immensely pleased and delighted. There and then I dropped my prejudice about pretentious state department types.

At a medical meeting about that time, one of my friends asked, “But Franny, what did you do with the concubines?” Answer, “The nurses’ home, of course.” Our student nurses took good care of the harem, gave them plenty to eat, and showed them where to spend their fortunes on clothing even though clothing was often stated by detractors to be unnecessary for their principal function. They were pleasant women who did not conform to the Playboy image of the slim, suave, largely nude inhabitants of a harem. More like plump peasants well draped in voluminous silk dresses with long sweeping skirts.

The king’s blindness (due to cataracts, with only a trace of trachoma) was reversed by our ophthalmological surgeon, Trygve

Gundersen. Once the king’s eyesight was restored, he fired all his concubines.

The surgical procedures on the king were fairly simple ones. I explored his abdomen, hoping to find the source of his pain, and repaired his hernias. It became evident that he suffered from severe cirrhosis of the liver. Devout Muslims are never supposed to touch alcohol. Although cirrhosis can be produced by substances other than alcohol, it is nevertheless a common cause in the Arab world.

We took x-ray pictures of the king and in each we found bullets. Several of them in various places. These were the low-velocity missiles of muskets used in the many battles and small wars in which he had fought alongside his father, liberating and uniting the peoples of the Arabian peninsula after World War I, following the demise of the oppressive Ottoman Empire.

It soon became apparent that medical help for the royal family of Saud would not be confined to the king but would be extended to most of his retinue and relatives (many of whom arrived later) and would be provided by many members of the Brigham staff; the public health and tropical medicine experts at Harvard, including the School of Public Health; and even the pediatric staff at Children’s Hospital. The king sent for several princes and princesses (some of them children), ministers, and palace guards in need of medical help. One of the elegant, sophisticated, educated, and beautiful young princesses (many of whom had been sent to Paris for their education) had an ominous bone cancer from which she later died.

During their visit, our Arabian guests provided some diverting moments.

Coincidentally, the president of the Boston Red Sox baseball club, Thomas Yawkey, a distinguished and respected sports figure, was a patient in the hospital on the floor below the king, and he asked if he could pay a call on His Royal Highness. We ushered him into the royal presence with both Sheikh Id and the announcer in attendance. He made a short polite speech with good humor and friendly jokes expressing the hope

that the king might come to a Red Sox game before he returned to Arabia. After what had obviously involved considerable thought and planning, Mr. Yawkey presented the king with a brand new baseball autographed by the entire Red Sox team, including Ted Williams.

After a polite acknowledgment, smiles, and bows by the attendants and leisurely coffee all around, (and of course an announcement by the announcer), the king examined the baseball carefully, staring at it, feeling it, turning it over in his hand. Then he held it up to the light and said slowly and clearly (via his interpreter): “What does one do with this object?” Before anyone could reply, he asked for a pen, autographed the ball with his scrawl, scarcely more legible than an X, and returned it with a broad and contented smile to an astonished Mr. Yawkey. There are some situations that you just can’t do anything about.

Pouring midmorning coffee involved a bit of ceremony. An expert servant (always male, often a tall black slave) took a long-snouted, burnished-silver coffee pot and held it up with one arm, as high as he could. In his other hand he held, as low as he could, a small beautifully gilded coffee cup. Then he poured a long, thin stream of steaming hot coffee from the pot to the cup. Not a drop was spilled. No comment. No praise. Try it sometime. But not over your wife’s best carpet. To qualify for this exercise, the coffee must be boiling hot.

The ARAMCO executive told us that the Arabian royalty prized as slaves the tall, handsome African people from the Horn of Africa just across the Strait of Hormuz. The women were retained as wives or concubines. The men performed many tasks, were often honored, and in time had their own slaves: slaves’ slaves. Whatever the nature of this abject captivity or enlightened bondage (we never knew which), we did not learn any more about it and were advised not to inquire.

The king enjoyed giving away wristwatches. He had hundreds of gold Swiss watches with his picture on the watch face. These he distributed liberally, starting with the airplane crew. All members of my family received one. He also gave us a beautiful silken flowing robe, along with a burnoose (a jeweled headband) and a gold-plated belt and dagger. Some of my children used this costume to good advantage in school plays.

At one point during the king’s stay, Laurie and I gave a dinner for the Saudi Secretary of State and invited several scholars of Middle Eastern history from Harvard and other universities, some from as far away as U.C. Berkeley. The Secretary of State spoke fluent English and was an elegant conversationalist. He was a remarkable resource on Arabian and all of Middle Eastern history, much of it still unwritten. Our former teacher and professor at the MGH, Edward Churchill, had spent a good deal of time in the Middle East at the American University of Beirut and was pleased to meet the Saudi secretary at our dinner.

Finally, after several months, the king and his retinue made ready to return to Arabia, with a stopover in Florida. Before they left Boston, ARAMCO arranged a huge banquet at the Copley Plaza Hotel in Boston. Laurie and a few other wives were invited. Although Laurie had not yet met the king, we had entertained several of his retinue at that dinner for the secretary of state.

Many of our most eminent senior staff in medicine and cardiology were Jewish. They had consulted on and helped care for the royal family without complaining about the partiality being shown the royal retinue; these staff members were invited to the banquet and came. I was proud of our staff for their cooperation and backing. It was a rather quiet time in Arab-Jewish relations. In fact, at the time of my previous visit to Lebanon, there were even Jewish students at the American University of Beirut and Jewish doctors at the Middle East Medical Assembly. Never, since.

After the banquet at the Copley, the king and his group went to Florida and rented a large villa in Palm Beach. Trygve and Harriet Gundersen and Laurie and I were invited down there to visit. We had dinner with the king. It is very difficult for us in our culture to realize how absolutely unprecedented it was for two women to be guests at dinner with the Arabian king.

Our sedate dinner was an event. The king was dressed in his Arabian robes with his crown headband inlaid with jewels (our guess was rubies, diamonds, and pearls) and a gold-plated dagger in his belt. His lower legs were bare, as were his feet. In this unfamiliar environment of

mixed company, strangers at that, he kept nervously adjusting his robe to cover his lower legs, much like a woman sitting in a chair with too short a skirt who self-consciously keeps trying to pull it down to lengthen it, but to no avail.

We attempted to converse with him through an interpreter but the interchange was sparse. We gained some solace from the knowledge that we, and especially our female companions, were experiencing something of the utmost rarity: an informal coeducational dinner with the king of Arabia. His discourse was polite and gentlemanly, and he seemed to enjoy his unusual company very graciously.

After he returned to Arabia, the king survived for a short time, his condition essentially unchanged. He died (in 1964), presumably of a heart attack, and his brother Faisal took over.

I had met Prince (later King) Faisal the evening before our departure from Arabia on the king’s chartered plane. This meeting was a colorful event. At night, with covert-secrecy-security precautions, I was driven over the open desert in a large, black stretch Cadillac to Prince Faisal’s portable palace, a large, tented structure designed to accommodate him during his journey from Riyadh to Dhahran because of his brother’s ill health. I entered the huge, compartmented tent, where magnificent Arabian carpets were spread directly over sand, as the floor. On entering, I first passed between two upright burning, smoking, knotted logs of the type we associate with medieval castles. Then a trumpet sounded. Escorted by another prince, with our interpreter immediately behind me, I walked between two rows of huge black men dressed only in breech-clouts, ammunition bandoliers crossed over their chests, shiny golden swords crossed over my head, and entered the throne room where sat Prince Faisal. A graduate of Princeton, he said in perfect English: “Welcome, Dr. Moore. Won’t you tell me about His Royal Highness?”

Prince Faisal, though not as visible as Sheikh Id, had much more to say about what transpired on the international scene. Sheikh Id was strictly local. Faisal was in striking contrast to most of the other Arabian men we saw. Not only was he educated at an Ivy League college, but he

was also married to an American lady and was monogamous. When his wife became queen, she introduced education for women, founded a women’s university, and began to make some long overdue changes in Arabian society. At that time, partly because of Faisal, women were not always required to wear a chador. A few years later, with King Faisal’s Queen in charge, the liberation of Arabian women was well under way. Faisal instituted economic and legal reforms. Then the inevitable occurred. Faisal was assassinated. In Arabia, primogeniture is not the custom. Rule (and/or wealth) often passes to a brother or cousin. With such huge families there are lots of choices. Another brother succeeded to the throne.

Although I have not followed the matter closely, I have learned from more recent visitors that Arabia—now 20 years after Faisal, and possibly dominated by Iran—has again reverted to a fundamentalist Moslem posture, the women being shielded and chadored. The immense injustices of their society have become further entrenched. These customs are seen as injustices not only in women’s eyes, but also in the eyes of many of the younger generation of Arabian men and women, especially those who have visited the West. Under King Saud there was a beginning liberalization (rather slow and mostly by default) that was given new impetus and support by Faisal (intentional and well planned but brief). But now has come the retreat to severe social and political, and strict religious, fundamentalism.

Images remain of the sadness of a proud old society, its ruling dynasty unable to cope with the wealth and temptations thrust upon it by a fluke of geology: the Dhahran oil dome. Images too of a sick, primitive, unsophisticated but kindly king overtaken by history.

Doctors and medical scientists fall into that large class of people whose expert knowledge is considered useful to government. This group wends its way to the banks of the Potomac on repeated occasions. In my early days this trip was made via the midnight train to Washington. My ties have been with the Army, the National Research Council, the National Academy of Sciences, the National Institutes of Health (NIH), the Uniformed Services University of the Health Sciences, and the National Aeronautics and Space Administration (NASA). In case that seems like a long and pretentious list, I should remind the reader that I have been at it since 1942 (about 53 years).

In 1952, after my return from Korea as a consultant to the Army, I reported my findings to the Surgeon General. Consequently, he asked me to visit army research units both in this country and abroad to review their research and their role in teaching army medical officers. On the basis of this work, I was asked by the Surgeon General to chair a new committee on the metabolic care of wounds and burns. Part of the job of our committee was to visit such hospital units to review their studies and plans. We journeyed to army medical research units in San Francisco,

Denver, and San Antonio, and to army-sponsored burn units, such as that in Charleston, South Carolina.

The largest unit for the care of burns in the United States was the Army Surgical Research Institute at the Brooke Army Medical Center in San Antonio. This unit developed rapidly during the 1950s and still remains the treatment center where severely burned service personnel are flown from all over the world. As one of the foremost burn units in the world, it has produced many remarkable advances in burn care. Surgeons who later took leadership positions in civilian burn units had studied there, including John Moncrief, Curtis Artz, Everett Evans, Bruce McMillan, Basil Pruitt, and Douglas Wilmore.

Early in its history, the San Antonio Burn Unit was the scene of a disaster when the whole unit was overwhelmed by a bacterium called Pseudomonas aeruginosa. Although this organism rarely causes disease in otherwise healthy people, it can be both invasive and destructive in a debilitated and severely ill burned patient. Once this germ becomes established in a hospital, it is difficult to banish completely because it resides in dust on the floor and walls as well as on bedding, utensils, and even drinking-water vessels unless these articles are all heat sterilized. Pseudomonas adheres to the person and clothing of physicians and nurses unless they are extremely careful.

Those in charge of the San Antonio Burn Unit and our consultant committee were slow to recognize that this severe, localized, self-perpetuating epidemic was due to an especially virulent strain of the bacterium and that patients, personnel, walls, and floors were harboring it. Once confronted, this epidemic was overcome by heroic methods of isolation and the restoration of structural and total environmental cleanliness. This burn unit was not the only one to suffer the blight of uncontrolled Pseudomonas infection. Several others elsewhere in the country developed the same plague and could be cleansed only by equally heroic measures. Our own burn unit at the Brigham was threatened, but fortunately we were able to eradicate the contamination in time to prevent the infection from reaching epidemic proportions. The San Antonio contamination had given us a warning.

As a consultant to the Surgeon General, I was also asked to witness, for the first (and only) time in my life, what I considered to be

unethical experiments on human beings. Several members of our committee and one or two from other consultant groups were singled out to go on a secret mission. We were not told much about it and had to go through a loyalty-security-psychological clearance process even more rigorous than that ordinarily expected for army consultants. After this we were flown to a secret base, the exact location of which we never learned, where antipersonnel gases were being tested on volunteers from among our own GIs.

These nerve gases were not the quickly lethal ones being developed by the armies of many nations at that time. Such deadly poisons could be tested on animals for both offensive and defensive purposes. Instead, these were psychoactive gases that disorient people so they are unable to understand or obey commands, unable to determine direction or purpose. These gases depersonalize troops. Scramble their brains. Knowing what I did about drugs and anesthetics, I realized that in testing such dangerous gases there would be the problem of dose variability, especially since the gases were inhaled. Some of these volunteers could inhale large doses by pure chance with possibly severe or permanent brain damage. And as for the concept of volunteers, this was analogous to the ethical problem of doing experiments on prisoners. Who wouldn’t volunteer if it got you out of prison? These young men got a lot of special perks as well as early discharge from the service in exchange for acting as guinea pigs to test nerve gases, or rather antipersonnel measures.

I was shocked by this. We were told, “An enemy will use it on us so we must know how to protect ourselves and counteract its effects.” This argument is hard to fight. After the flight back to Washington, I slunk home to Boston, shaken and humiliated. I had seen something I was powerless to stop or control and realized it was only a small bit of what might be going on. On many other occasions I had seen the results of bullets and explosives (including nuclear blasts) tested on animals. I was accustomed to the realities of military research. But this was different.

Later on, some of these volunteers exhibited delayed emotional problems and self-destructive behavior. It was hard to know what was cause or effect. I never knew the answer. I suspected that in this instance the medical establishment—stressed by Korea and Vietnam and motivated by an urgent need for defense—had crossed a clear ethical boundary.

Later, too, as I was to learn over the course of several decades, our government has been especially vulnerable to accusations of careless disregard in the handling of the hazards of radiation injury and causes of suspected or real injury. As an institution, our government is prone to cover up or gloss over allegations that discredit either individuals or institutions such as the Army, Navy, NIH, Atomic Energy Commission, or any other large agency. If these matters of potential embarrassment pertain to bodily or psychological damage affecting troops or the public, or miners of uranium, or those living near nuclear plants or test sites, or workers with nuclear material, or patients in a government-sponsored radiation experiment, otherwise sensible officials become pathologically protective. Those “psycho” gases, and radiation exposure in nuclear plants and bomb testing were prime examples. “Truth is the first casualty of war”—but also of certain peacetime activities. Otherwise upright servants of the people become liars or tell their subordinates to lie.

Where there has been harm, or the suspicion of harm, beware a government spokesman or news release. Government agencies will admit a billion-dollar deficit or a billion-dollar cost overrun on an aircraft carrier. But when a person may have been hurt or killed, the reflex of government is to cover it up. If it is radiation that is the root cause of harm to people, even less will be said. There is a blind spot here about which I have become increasingly alarmed and apprehensive. A consultant such as myself, secure in his or her civilian position, must speak out about untruths or errors he perceives. Whether his perception be right or wrong in the eyes of history, if he does not speak out about this, who can?

Another duty of our committee of the Army Medical Corps was to review research proposals for funding. A tension, sometimes bitter, arises between animal researchers and the antivivisectionists. Usually I side with the researchers, but there were exceptions. An example was embodied in one proposal from a prominent medical school that was reviewed on several occasions. Because we were uncertain about the methods being used, I visited the laboratories. I considered those particular experiments on burned animals to be unnecessarily and unacceptably cruel and painful. The animals were not kept under anesthesia. A long and painful healing process often ended in death. How would such arcane and convoluted research help the care of burned people? I was no

antivivisectionist and had done many animal experiments, but based on my reservations here we had the unpleasant duty of cutting off funding for that research completely. I made some bitter enemies; later they came to understand. This decision was decades before raids on labs by antivivisectionists and front-page stories from insiders about unacceptable conditions in animal experimentation.

On another occasion we visited a laboratory directed by a prominent surgeon, working under contract from the armed services, only to find that the work described in the proposals was not being carried out at all. Nowadays this breach would be considered science fraud and would probably attract the attention of the Congress. But at that time we were feeling our way with the review process. We took away the research grant. The “midnight to Washington” sometimes could impose an impressive burden.

Looking back on years of work with the NIH brings to mind a different yet typical experience.

The scene now changes to a neat office building on the campus of the NIH in Bethesda, a few miles north of the district line and across the street from the National Naval Medical Center and the Uniformed Services University of the Health Sciences. A group of 15 or 20 of us, mostly surgeons, would be sitting in a conference room there. With us would be one or two administrators and an executive secretary. At each place at the large table would be a neat pad flanked by several sharpened pencils. Also at each place would be a huge pile of research grants to discuss, copies of which we had already received. Coffee and danish on the sideboard. This scene was repeated hundreds of times every year: a consultant committee to some agency of the government—such as the NIH—meeting to vote on the acceptability for government funding of proposals from research labs all over this country and in Europe. We were determining make-or-break decisions on 100 or 150 research grant proposals seeking support, several millions of taxpayer dollars, for research on surgical topics in the medical schools of the United States and in a few universities abroad.

For me, this scene became a habit about 1956, a time when the NIH university grants programs were expanding rapidly. Specifically, it was the moment of opportunity for our government to support further development and perfection of pump-oxygenators for open-heart surgery as described in Chapter 23. I was working my 3-year stint as chairman of the NIH Surgery Study Section (1958 to 1961).

During World War II, financial support for research on the surgical care of the wounded was channeled through the Office of Scientific Research and Development (OSRD), a collaborative enterprise undertaken under the direction of the National Research Council (NRC), which is, in turn, an operating arm of the National Academy of Sciences (NAS). NAS was founded by Abraham Lincoln at the time of the Civil War precisely for such purposes: to put the scientific brains of the country to work for the common good.

In 1946 at the close of World War II, the OSRD function of channeling federal money to university laboratories was transferred to the NIH. Although OSRD funding for biomedical research during World War II seemed to be as generous as would befit a nation at war, it was but a pittance compared with the budgets soon to be voted annually by the Congress for university research through the NIH. At the peak of NIH funding, outlays for research—i.e., the total voted each year by the Congress for the support of medical research—was often in excess even of that requested by the administration. We were at the threshold of a heyday that persisted through the 1960s and 1970s before a tendency to scale back the annual increases became evident in the 1980s. By the standards of any other nation we are still very liberal in our public support of research.

The Surgery Study Section supported NIH funding for the majority of research undertaken to perfect the extracorporeal pump-oxygenator. This device was essential to the development of the field of open-heart surgery, yet its use now is so routine that it is rarely mentioned as an integral part of heart surgery. We arranged and funded the first international conference on extracorporeal pump oxygenation, bringing together surgeons, physicians, physiologists, biochemists, and mechanical engineers from all over the world to exchange data and ideas and help bring this device to its present state of perfection. It was this piece of machinery

that made open-heart surgery possible and has been essential to the performance of heart transplantation.

A scene from the opening ceremonies of the USUHS on August 25, 1977, will display some of the Washington that we enjoyed. It was a brisk and windy day, bright sun with a few scudding puffball clouds. Laurie and I were sitting with a small group of men and women (most attired in the uniforms of the several services) in the imposing grove of tall and handsome pine trees in the low hills directly southeast of the U. S. Naval Medical Center in Bethesda, Maryland. Behind us was a large brick building, still in the final stages of construction. A naval band was blaring away, too loud and too close. We were there to celebrate the admission of the first class of medical students to the USUHS, the first full-time regular medical school since the American Revolution to be operated entirely by the federal government. It was a remarkable moment. There were speeches. David Packard, formerly Deputy Secretary of Defense, was the chairman of the Board of Regents. The board also included the surgeons general of the three armed services, as well as those of the Public Health Service and the Army Nurse Corps. Members of that board, together with spouses, joined in the celebration. Mr. Packard’s address was one of pride at the accomplishment of building the new university. The President of the University, Anthony R. Curreri, a surgeon of our generation and Professor of Surgery at the University of Wisconsin, also spoke. Jay Sanford was the dean; Norman Rich was the first Professor of Surgery.

During World War I some medical courses had been given at the Walter Reed Army Medical Center to apprise the medical officers of the conditions they would face in France when treating men wounded in trench warfare. Sixty years before, during the Civil War, and again for a short time in the 1890s there had been a semblance of an army medical school in Washington. Walter Reed had been dean.

During World War II the need for medical personnel became more urgent. Medical officers of the Army and Navy (at that time there was no separate air force) would be better able to accomplish their mission

with special training. New sorts of wounds needed new treatments: new conditions of war in desert or tropics, new diseases, and tropical parasites, as well as old diseases typical of overcrowded conditions and poor sanitation.

The government therefore recognized the need to provide an educational setting and postgraduate training for physicians in all the uniformed services (Army, Navy, Air Force, Coast Guard, and Public Health Service). This school was to be under the Department of Defense, also a creation of the postwar years. But it was not until the middle of the Vietnam War that a bill to establish such a medical school finally became law. Congressman F. Edward Hébert of Louisiana was the most vocal and persistent of advocates, so the medical school bears his name. His bill to establish the school had been signed into law by President Nixon in September 1972. A Board of Regents was established in May 1973 by presidential appointment, and an entirely new program of medical education for the armed services was gradually brought to life. I was appointed to the board in 1976 by President Ford.

The original idea was to provide specialized training to meet the needs of the military for physicians and surgeons, medical technicians, corpsmen, and nurses. At that time about 6 million servicemen and dependents scattered all over the world were cared for by the physicians, nurses, and hospitals of the armed services. While it was clear that our new medical school could never provide all the doctors needed for such an immense defense establishment, it could supply at least a few medical leaders committed to a career in uniform.

Now we were gathered to celebrate the admission of our first small class of 32 students—to be the class of 1981—and to dedicate the newly completed building. This was the initial proud step of that federal medical school. Later, when that first class graduated, Lewis Thomas—a leading interpreter of medical science—gave the commencement address. The second class had 62 students and by 1985 classes had increased in size to over 150 men and women, as mandated by the 1972 statute.

The mounting cost of medical education makes it hard if not impossible for many would-be students (and their parents) to afford it. Tuition was on the rise, but in most cases it was still far less than the true cost of educating the student. There were never enough scholarships and

fellowships to take care of everybody. The financial arrangements for medical students at USUHS were (and still remain) unique. Each student is an officer in his or her service of choice, holding the rank of second lieutenant or ensign, and is paid an officer’s salary—a good way to get around the problem of tuition. As you can imagine, the school has many applicants and is able to select an outstanding class.

Clinical courses (for example, in medicine, surgery, pediatrics, or obstetrics) are taught in the Army, Navy, and Air Force hospitals around Washington and around the country, as well as those in the Pacific and in Europe. The Clinical Center at the NIH is also available for teaching fourth-year courses. The students can elect courses in service hospitals hundreds or thousands of miles away.

Even before their first academic courses begin, the students receive field indoctrination in their particular branch of the armed services. If the Army, they might spend those first few weeks working with a tank, infantry, or artillery battalion. If the Navy, their first indoctrination might be in submarines. Most of the students choosing the Air Force option would already be flyers, but now they would be flying with other pilots in a variety of planes.

As befits the intense activities of a service career, physical fitness was always a part of the student mystique at USUHS. Dean Sanford exemplified this aspect of a service-related lifestyle and led mountain-climbing expeditions on the local Potomac precipices. The students were an orderly group. “Regimented,” some critics would carp. That was not our impression. Hair was cut to conform to the dress code. Handsome young men and women well dressed and neat in their uniforms make an appealing sight whether the appeal is humanistic, patriotic, or just plain aesthetic. At commencement, as the students marched to their places, you were reminded of the order and discipline associated with West Point, Annapolis, or Colorado Springs. Quite a contrast to the costume so prevalent among college students of the 1960s and 1970s: untrimmed beard, long hair and headband, sandals, and sloppy jeans (including a guitar).

Periodically, the USUHS has come under fire from the Congress because it seems an expensive luxury to train medical officers specifically to care for the millions of people in uniform or their dependents when

there is no way—beyond obligatory service for a minimum of 8 years—to ensure that they will stay on the job. The cessation of the Cold War and the consequent dissipation of the Soviet threat are likely to erode Congressional support for this medical school. Whether or not the intent of the Congress in establishing the USUHS will in the long run be considered valid depends entirely on the number of graduate physicians who remain in the armed services for significant periods of time beyond their obligation. All these young men and women are potentially leaders in military medical care and organization. If most of them leave the service, the investment is lost. It was our hope that they would remain on duty for a significant service career before giving it up to the temptations of private practice. Although we have only 20 years to go on, initial data from our graduates suggest that the investment is paying off as planned. Visits to army and navy hospitals have reinforced my feeling that this tiny fraction of the huge defense budget was well spent.

For almost two decades the USUHS has been a part of my professional life. Appointment to this board arose from my prior service with the Army Medical Corps as a consultant in Korea and with army research sponsorship, which began 25 years earlier.

As my responsibilities at the NIH began to wind down about 1968, I was asked to become a consultant to one of the Life Sciences Advisory Committees to NASA. The space agency first asked me to join an advisory committee in 1968 when NASA was first focusing on the physiological effects of prolonged space flight. This was on the eve of the Apollo program, one of the greatest feats of manned space flight, the moon walks.

Bentley Glass, physician, physiologist, and leading scientist of the State University of New York at Stony Brook, was asked to chair this NASA Advisory Group in the Life Sciences. He invited me to be a member of that group because of my knowledge of body composition (described in Chapters 13 and 14).

Under conditions of prolonged weightlessness, the human body undergoes massive changes in body composition. There is loss of muscle

mass, blood volume (both red cells and plasma are reduced), cardiac output, and skeletal mass. There is loss (by inactivity) of the blood-vessel reflexes that support our circulation in the upright posture and prevent the pooling of venous blood in our legs. These changes in space are almost entirely due to weightlessness, to lack of gravitational force for the body to resist. Nothing causes loss of muscle like inactivity: think of the size of the muscles in a paralyzed leg or a leg long immobilized in a plaster cast. Travel in a space vehicle is a form of inactivity that affects all the muscles of the body except the heart and diaphragm.

We are accustomed to life in a gravitational ambience of about 1.0 G, the gravitational force as measured on Earth at sea level. Even when we are sitting in a chair, the muscles of the back and neck are keeping us upright, and the arms may be at work. Even in bed, the tone of some muscles is maintained at a resting level, not totally relaxed. In space at 0.0 G (or, more accurately, at microgravity—about 0.001 G), such automatic antigravity exercise is no longer required, and the heart does not need to pump blood uphill to the head. Everything is “on the level.” An athlete getting ready for the season gets in condition by exercise known as “conditioning.” On prolonged space flight the opposite effect is seen, a state rightly called “deconditioning.”

Since measurements of this phenomenon were very much a part of our studies of body composition, we were able to help with advice on how to prevent this deconditioning in space by having the astronauts exercise against spring-loaded resistance devices. You can’t lift weights for exercise when a 10-pound weight can be raised from the floor like a Ping-Pong ball.

Since 1968 I have continued as member of a series of NASA advisory committees in the biomedical sciences, finally ending up as a member of the Committee of the National Academy of Sciences on the Space Station. As we collaborate with the Russian Space Agency in our new space station effort, maintenance of physical conditioning over prolonged periods of travel in space, literally space-dwelling, will be a major research target of the entire effort.

A far more severe threat to astronauts in the high orbits of interplanetary flights is their exposure to space radiation. The orbits of all manned flights thus far, except those to the Moon, have been at altitudes

of 150 to 300 miles, beneath the radioprotective shield of the magnetosphere. This is called low Earth orbit, or LEO. Once emerging from the protective zone of LEO (as on a trip to the Moon and Mars, for example), the spaceship and everyone in it is exposed to severe irradiation from cosmic rays and solar flare emissions. This will be a major hazard on any future interplanetary voyages and has been the main focus of my work on the NASA committees in recent years. In March 1992 I published a review of the available data on this matter entitled “Radiation burdens for humans on prolonged exomagnetospheric voyages.” This is probably the last scientific paper I will ever publish and closes out a bibliography that began with “Studies with Radioactive Di-azo Dyes” in 1943 (described in Chapter 13).

For decades the best way to get to these meetings was to ride via the midnight train from Boston to Washington. The sleeper. Breakfast could be taken in the diner or at Union Station. And then off by taxi to the meeting on Constitution Avenue.

Nowadays, the first plane to D.C. usually leaves Boston around 6:00 or 6:30 AM. I could usually get breakfast aboard the plane (rather sparse), go to the meeting, check in at a hotel late in the day—or stay with a friend—and then after another day or two in the nation’s capital, turn around and come home again. See patients, sort the mail, and wonder if spending that much time away was worthwhile.

Looking back, it seems that 50 years ago all this government consulting was somehow more leisurely and joyous than it is today. Less hassle and less political. More the feeling of a community of scientists joining in patriotic service. Under President Nixon, even appointments to NIH advisory councils became politicized for the first time. Some of the joy of public service disappeared.

The picture on a morning plane to Washington these days (especially the first plane on Monday) is such a sight, such a genre phenomenon, as to invite more artwork and satire than it has received. All the passengers are men (very few women, children, or families). They are clad in charcoal-grey suits, almost a uniform; earnest, sometimes joshing

with each other but usually quite serious. As soon as tray tables can be lowered, they take out their pencils, papers, and calculators. All have leather briefcases or little valet cases. And laptop computers.

Some are going to Washington to sit with committees to some branch of government. Others are seeking government contracts, pleading cases, or lobbying. They have risen early. Their helpful wives have dished out some coffee and maybe toast. Soon they fall asleep over their tray tables, their work and computers laid out before them. A few minutes after takeoff they are roused for a small second breakfast. Back to napping. Then the announcement of the imminent landing. Stuff the work into the briefcase. Slam the laptop closed. Up go the tables. On go the seatbelts. Then the docking. All stand up. As the door of the plane is opened the men at the head of the line start to rock back and forth from side to side; they are beginning to walk out. They rush to a taxi (sometimes to an impressive limousine, the driver in uniform) and off to their jobs.

In its most comfortable period, during the years between 1950 and 1970 or so, travel on the airlines was almost as pleasant for the traveler as the trains had been 10 or 15 years earlier. It was not difficult to get reservations. In the early days at the East Boston Airport (not yet called Logan International) you could park your car right outside the entrance to the airline terminal. You walked across a little gravel parking lot and maybe a macadam roadway, checked your bags, walked outdoors on the tarmac (a British term borrowed by the Americans) to get to the plane, and then climbed a few steps to the downward-slanting tail section. Coming back on that same airline, it was a cinch. If it was raining, well that was just too bad. Back in 1940 I remember seeing a visionary picture of an airplane loading dock in a Popular Mechanics magazine. We wondered then how long it would be before we could actually walk from a terminal into an airplane without going outdoors and upstairs (in the rain). Soon, most of the planes had a third (forward) landing wheel, so they sat in a horizontal position on the ground. When new, this was in striking contrast to the DC-3 and its contemporaries, which rested in a tail-down sag until going fast enough to raise the tail off the ground. Level planes and loading docks helped air travel reach its apotheosis of comfort, about 1975 to 1980.

In the early 1950s, some of the regular commercial passenger aircraft began to provide sleeping berths. On one particular occasion, I was coming back to Boston from Seattle on a night plane. It was a four-engine prop plane with a big round belly, sometimes called a pregnant C-54. The opportunity of sleeping on a berth rather than propped up in a seat looked pretty attractive. The trip was being paid for by a medical society in Seattle. The trip would take 9 or 10 hours. Plenty of time for sleep.

With the props grinding away only a few feet from my ears as a kind of a constant soporific drone, I slept quite soundly. In the morning, I struggled into my clothes (much as in the old-time Pullman upper berth) and tentatively stuck out a foot, still bare. Then with my shirt on, but wearing pajama pants, I swung down to the floor into the aisle. At that moment I was facing toward the cockpit, since I had been sleeping in the most forward of the berths.

Behind me I suddenly heard laughing and was greeted by a nice round of applause, which shook me up a bit. When I turned around I could see that my matin arousal was being monitored by the rest of the passengers, who were seated in an orderly fashion, two by two, on each side of the aisle extending back 10 or 15 rows to the rear of the plane. They greeted my descent from the upper berth as sort of a theatrical performance. My audience totalled about 45 people. Looking at these admirers, I suddenly appreciated my shortcomings. My hair was tousled, my pants unbuttoned, I had no shoes and was padding toward the lavatory a few steps away, razor and toothbrush in hand. Fortunately for me, the lavatory was unoccupied and I could hide in there until I looked a bit more presentable. I then went back to where my berth had been, only to find that there was no place to sit. I was confronted, not with a genial black Pullman porter, but with a rather prim stewardess. This was a period when the appointment of a stewardess involved some overtone of nursing skills. She was thought of not merely as a passenger-handler, but as having some healing or nursing arts in her repertoire. Female pulchritude was still sought in such employment, not yet being regarded as sexist. Because the stewardess had already put the upper berth away and was still tussling with various things on the seats, it was quite difficult for me to extricate my pants, shoes, and socks. When I went back toward the

lavatory to retreat again, somebody had beaten me to it. Occupied. Locked. By now the audience response had reached high levels of laughter, and I wondered if someone like Bob Hope might have done this better than I did. I never hired a berth again. Soon, they ceased to exist.

For doctors who made this trip for so many years, it was most often on a mission as a consultant or committee member. After a couple of days, we would return home laden with reports and briefings that were never read as carefully as we intended. We were anxious to get home for sleep in our own bed with our own spouse, and the next day, back to a different sort of reality: the operating room, students, and rounds. I felt great sympathy for my friends who lived on the West Coast. For them, this task involved, at a minimum, a 2- or 3-day trip. But that did give them lots of time to read!

Looking back on it all I still derive some small satisfaction from realizing that these journeys and government consultations are a part of the citizen’s burden. Patriotism, if you will. The tangible reward is zero. The hours lost from your own work are, over the course of years, beyond measure. There ain’t no glory in it. Few people even know where you have been or why you were away. You give a lot of your own time, of your reserve energy.

In return you receive a lot: you learn about how our government really works and about the medical, surgical, biochemical, and research details of problems we face. You gain respect for the many hard-working, conscientious, knowledgeable, and underpaid men and women who, together, constitute our government. Individually, none of these is responsible for its egregious excesses or abysmal failures. These are more often traceable to upper-level zealotry, selfishness (i.e., pork barrel), or outright stupidity. Our coworkers, even as high ranking as generals and admirals, were the toilers in the vineyard, not the dictators of policy.

Professors profess. They profess to know. Our government needs some of what they know. That is why you get started on that midnight to Washington. For me, this occurred in 1942, and it has never stopped. It is still going on, more than 50 years later. I have no regrets.

If you are a teacher, it is part of your job to get out of your rut and see how others are doing things, what steps are being taken at the frontiers of your science or art, and bring those ideas home. Most certainly this inquisitiveness is important in surgery, where there is a tendency to enshrine even minor local traditions as sacrosanct. Better go see other surgeons and other customs in other places. Autres chirurgiens....

One way of achieving such an interchange was the custom of inviting visiting professors to our own institution to share their expertise. The Brigham under Cushing had begun this “Pro Tem” tradition, meaning the “Visiting Surgeon-in-Chief Pro Tempore.” In the old days, the Pro Tem was invited to come and stay for a couple of weeks. Pretty wearing for all concerned. Then the visit was cut down to less than a week.

Cushing invited many luminaries to visit, including the Russian neurophysiologist Ivan Pavlov and his British counterpart Sir Charles Sherrington. And Sir William Osler. Following in this tradition, we enjoyed being host to many distinguished visitors from abroad. Sir James Learmonth was one of the first. He had been a Scots Jock (i.e., a Scots GI) in World War I, was Professor of Surgery at Edinburgh, and was knighted after operating on King George VI. Then we had Sir Arthur Porritt, later Governor-General of New Zealand and thereafter one of the

first surgical lords. There was Sir Gordon Gordon-Taylor, one of the colorful older generation of London surgeons, as well as the younger generation of brilliant Britons as typified by Charles Rob, who later migrated to Rochester, NewYork, and then Washington, D.C. The visit of James Paterson Ross was described in Chapter 18. And Ivan Johnston of Newcastle. From France we welcomed André Monsaingeon from the University of Paris, from Australia John Ludbrook, and from New Zealand Michael Woodruff. From western Canada Rocke Robertson of Vancouver, later Professor of Surgery and then Vice-Chancellor of McGill University in Montreal. We invited visitors from all over the United States, including some of the senior men who were the very symbols of surgical change during and after the war, including Alfred Blalock of Johns Hopkins and Owen Wangensteen of Minnesota. In a reciprocal fashion, I was invited as visiting professor to many universities in this country and abroad.

While a little learning from abroad is a good thing, the tendency of American professors to spend a lot of time traveling can be pernicious. There was a joke about a friend of mine in Colorado who spent so much time on planes that he was called the “TWA Professor of Surgery.” I tried to hold my own travels in check, but not always with success. At first I traveled solo to Washington, to meetings, societies, other colleges and universities. Later on (after our children had left for college) I told anybody who wanted to have me around that they should ask Laurie to come too. Worked fine. We circled the globe together. One of the pleasures of the academic life.

My first major trip as visiting professor was to the University of London in 1950. They also asked me to teach in Edinburgh, so this was a big trip for us. Laurie came. And then we went to Paris and Italy. On this trip we made personal and family friendships that have lasted all these years.

This was my introduction to the pomp and panoply of the Royal College of Surgeons. The atmosphere of the upper echelons of surgery in London had to be seen to be believed. At home I drove an old broken-

down Pontiac station wagon into the unpaved Brigham parking lot, where I often got stuck in the mud or in a snowdrift. In London at that time, leadership mandated a Rolls-Royce (or a Bentley) and a chauffeur. Most of the ruling class of surgeons were also important potentates in national organizations and many were, sooner or later, knighted. About 30 years later a group of us Yankees were in London to visit with the four surgeons who were members of the House of Lords, so our traveling group had a chance to have a tea party with the surgical lords in the House of Lords and witness some of their quaint customs.

That first visit was only 5 years after the war and the hospitals were still pretty well broken down. There had simply not been time (or funds) to start reconstruction after the bombing and the fires. The National Health Service (NHS) was established in 1948, still brand new. It was possible for practicing surgeons and teachers in the universities to have only a fraction of their week occupied by NHS activity, so there was still free time for practice, research, and teaching. There was a virtual absence of organized departmental surgical research as we knew it and of research on large animals. Antivivisectionists in Britain had won their battle at the turn of the century. The familiar American animal laboratory where research and teaching could be carried out on dogs, cats, pigs, sheep, cattle, or monkeys simply did not exist. Only one animal research laboratory existed in London, and it was conducted under strict licensing arrangements by the Royal College of Surgeons. This was the Buckston Browne Research Farm, where Roy Calne did his epic experiments on kidney transplants in dogs using 6-mp (described in Chapter 20).

Among other things, it was this restriction that prompted so many young British surgeons to come to America. Over 50 young men from the United Kingdom worked with us at one time or another, many of them later assuming leadership positions at home.

In some ways the clinical traditions of British surgery, of operations and surgical care, contrast with ours. British surgeons are apt to pride themselves on speedy operations. They are more impulsive, possibly less prone to search out the root cause of error, seemingly less rigorous in aseptic technique, more authoritative. And the residents are more in awe of their seniors than they are here. Yet the two traditions are remarkably similar in basic surgical philosophy, and the cross-fertilization

(dating back centuries) has been very intense since 1945. If I or my family should be taken ill and require major surgery elsewhere, I would accept Canada or Great Britain interchangeably as the best. If I found myself in some of the other nations on this Earth, I would flee in terror (if still able to run).

The most illustrious figure in the history of British surgery was Joseph, Lord Lister. By the peregrinations of his career, he could claim three cities as home: London, Glasgow, and Edinburgh. In turn, all three cities claim and celebrate Lister as their most famous son. Lister was the successor, in the mid-nineteenth century, of that paterfamilias of all surgical research, the Scots-born Londoner John Hunter, who lived and worked a century before. Laurie and I attended the Lister celebration in Glasgow in 1965, where I received an honorary degree, along with my long-time friend and associate, Bert Dunphy, former Brighamite, then Professor of Surgery at the University of California at San Francisco.

To visit Guy’s Hospital and see the cornerstone bearing the date A.D. 914 is a lesson in humility. The oldest of our hospitals in the United States are only now about to celebrate their 200th anniversaries. Our traditions in surgery and academia trace more strongly back to the British Isles than to any other antecedents, although the British tradition was heir to some strong influences from both France (in the early part of the nineteenth century) and Germany (in the middle and latter parts of the nineteenth century).

Our first official visit to French surgery occurred in the early 1950s. André Monsaingeon, who had come to work with us at the MGH in the late 1940s, was now back in Paris as Professor of Surgery at the University of Paris, at l’Hôpital Paul Brousse, south of the city. Traditions of medicine and surgery, teaching and research, are very different in France. As an example, some of the French medical schools will admit as many as 1,000 students to the first-year class. The entrance examinations are very generalized; the student’s name, age, or sex are not specified. Each has a number. From this huge egalitarian class (which would be impossibly expensive in this country), only a few are selected to go on to

the second year. That initial intake of students is really an elaborate screening process to select those who should be permitted to advance.

The French Academy has an old tradition dating back to the great French teachers, such as Professor Louis, and the early surgeons epitomized by Dupuytren and Napoleon’s surgeon, Larrey. One of the established traditions of this academy is that those who attend a meeting proceed to sip their cognac or drink their coffee and carry on conversations while the speaker is also speaking. This is very distracting to us Americans. I was asked to give a speech about some of our work in surgery. After I staggered through some fractured French that must have been acutely painful to the fine-tuned ear of the audience, André, who knew all about this work, took over and delivered the rest of my address, using my lantern slides. Yet even upon hearing his elegant French, the audience continued to eat, drink, and converse. This studied indifference might be a bit upsetting to the unwary. I assumed they were bored to death. Wrong. When it was all over, they asked a lot of questions, clearly demonstrating that not only had they listened to the lecture, but they had actually read some of my papers!

While London dominates much of British culture, it gets a lot of competition from Oxford and Cambridge. The Scots, with their university medical schools and hospitals, will never admit to any dominance by London at any time, in any connection, or even as competition. In France, Paris so completely dominates the intellectual and scientific life of the country that to the casual visitor it is hard to understand where the rest of the country fits in.

In the United States, the position of professor in a field such as medicine, pediatrics, or surgery is not celebrated except by those associated with academia and often times by few of those. In Britain, the professor is ranked in a sort of midposition. But in France and Germany, Monsieur le Professeur occupies a position of great eminence, and some of them have egos to match. We went to a formal dinner in Paris given by one of the most prominent surgeons in France. While I was busy trying to understand cocktail-hour French and possibly construct a few acceptable sentences, Laurie was quietly observing the decor. She later told me that there were six portraits and no fewer than 15 busts of

our host in his apartment (abutting La Place de l’Etoile and l’Arc de Triomphe).

All three of the Scandinavian countries have a tradition of pleasant human relationships, fine surgery, and trenchant science. Yet the three great countries are quite distinct.

Sweden is by far the largest (about equal to Denmark and Norway combined). The Karolinska Institute in Stockholm is the dominant biomedical research institution of Scandinavia and for a time received almost as much financial support from the National Institutes of Health as did many major universities in the United States. It is the source and scene of the Nobel ceremony. On its 150th anniversary I was invited to the Karolinska as the representative of American surgery and was asked to speak on behalf of the visitors from abroad.

The Danes are filled with good humor, good science, and a remarkably liberal tradition despite the terrible Nazi occupation. Professor Husfeldt was at that time the leader of Danish surgery. He had been active in the anti-Nazi resistance during the war, narrowly escaping with his life, and had supervised the passage to safety of thousands of German Jews through an underground transport system. He was widely recognized and revered for this role. I was flattered to be made an Honorary Fellow of the Royal College of Surgeons in London in 1967 at the same meeting where that honor was also conferred on Husfeldt.

Several Danish scholars came to work with us, including Bent Friis-Hansen in pediatrics, Knud Olesen in cardiology, and Helge Faber in endocrinology. The Danish residency system in surgery had such an inflexible pattern of promotion that it was not easy for them to get away to study abroad.

Norway is the smallest of the Scandinavian countries in population, has the longest coastline, and suffered the saddest and most brutal repressive occupation by the Nazis during the war. Carl Semb was Professor of Surgery in Oslo and a great sailor. His wife was a little bit overweight. They both joked over the fact that this was why he put her on the windward rail in his sailing dinghy and they won lots of races. Egil

Amundsen, a relative of the great polar explorer, was a frequent visitor to our department and to the Department of Physiology. At one point I was asked to be visiting professor at the University of Tromsö, the only medical school in the world north of the Arctic Circle. We took a boat up the west coast of Norway and spent a delightful week in Tromsö. It is dark there about 6 months of the year and is regarded as a hardship post. Many of the faculty rotate to the south to Bergen or Oslo to bask in a little sunshine from time to time. For those of us who live in lower latitudes, it may seem surprising to go to Bergen or Oslo for a southern sunshine holiday. But such is Tromsö.

At the time of one of our visits to Norway, our friend Fisher Howe, then a member of the State Department, was chargé d’affaires at the U.S. Embassy in Oslo. He asked me to speak there on the subject of the role of the U.S. government in American medicine. Most Europeans are critical of the United States for not having a broader system of healthcare coverage for the population. I pointed out that we did have several programs. One covered about 6 million people (the armed forces, dependents, and retirees) and another, 28 million people (the Veterans Administration). The total is considerably more than the entire population of Scandinavia! But of course, despite this evidence of our size, I agreed with their basic point: we do not provide coverage of all our people for the financial burden of illness.

Our visits to Germany were mainly to Heidelberg and Munich. We never did get to Berlin. Professor Fritz Linder of Heidelberg had become a close friend of many American surgeons. He was made an Honorary Fellow of the Royal College of Surgeons in London at the same time I was. No German had been elected to honorary membership since before World War I. Feelings ran deep considering the thousands upon thousands of British soldiers who lost their lives fighting the Germans in two wars, not to mention the tonnage of bombs so recently dropped on London. So it came as quite a wrench (and the cause of some rather touchy speech-making) when Fritz Linder was offered this honor. He typified the new and warm relationship among West German science,

western Europe, and the United States that slowly emerged two decades after World War II.

Visiting Munich in the 1980s, I recalled my first visit there 50 years before as a college student (in 1934). That was Hitler’s first year. We were in Munich at the time of the Brownshirt rebellion when General Roehm and his followers sought to topple Hitler and his Blackshirts. After some maneuvering but not much gunfire, Hitler won. When they confronted each other near Munich, Hitler handed Roehm a loaded revolver. Roehm could have shot Hitler or himself. He shot himself. In his book on life as a Nazi bureaucrat, Albert Speer stated that this was the moment when he realized that Hitler was a criminal, yet Speer was trapped and remained in the Nazi government almost to the very end.

The Munich of our first postwar visit (1953) had been reduced to rubble by the Eighth Air Force. Even the place where the Nazi guard had an eternal flame burning to commemorate Hitler’s first publicly violent demonstration (known as the beer-hall putsch) had long since disappeared. And with it the two uniformed, heel-clicking, goose-stepping Nazi Blackshirt guards with fixed bayonets, who guarded it when I was there as a college student.

While in Munich we took the opportunity to visit the famous library. One of the great anatomy books of all time is the Fabrica of Andreas Vesalius, published in 1543. Vesalius was Professor of Surgery in Padua. The illustrations of Vesalius’ dissections were drawn by an artist (Jan Calkar) who was a pupil of Titian. These woodcuts persisted for 400 years. In the 1930s the New York Academy of Sciences had borrowed them, dusted them off, and reprinted a whole new edition using special acid-free paper and modern ink. Those precious woodcuts were then returned to the library in Munich. Some time in early 1945 that library was destroyed by an Eighth Air Force raid. During our visit we went to the library to learn what we could about the fate of the Vesalius woodcuts. The librarian was acutely aware of this tragedy and told us that the plates were probably deep under ground, buried in the rubble, if they had not been consumed by flames.

Though we visited Greece two or three times, we made only one major trip to the Middle East, in 1961. This was at the invitation of the United States Information Agency to teach and lecture in several countries. We visited Greece, Turkey, Lebanon, Syria, and Egypt. It was at the time of Nasser, when Egypt and Syria were united in a fragile political union: the United Arab Republic. There was a reasonable state of peace in the Middle East. We could drive without incident from Lebanon to Damascus across the Golan Heights. Jewish students attended the American University of Beirut. Neither before nor since has there been such a period of peace in the Middle East. It was on this visit that we met William Taylor, the ARAMCO physician in Dhahran whose friendship led to my visit to Arabia and Ibn Saud’s visit to Boston (Chapter 26).

In the Arab world, autopsies are virtually unheard of. It seems immoral to introduce transplantation or cardiac surgery into a country where autopsy is forbidden and the surgeon cannot root out the causes of error or death. If an operation about which little is known is carried out and the patient dies, an autopsy is ethically mandated. If there is no way for the surgeon to find out what went wrong, it would not be ethically acceptable to perform the procedure in another patient. And yet in the Arab world, they do just that. They seem to get away with it. But at what cost? Surgical research as we know it is absolutely nonexistent in those countries. We often worry about the inappropriateness of introducing our advanced technology in developing countries. But how about teaching our science where there is no ethical or scientific standard of morality to give it validity? Some of the least developed countries are most anxious to establish transplantation or cardiac surgery. Whether or not they should do it, they surely will. Like so much technology transfer, teaching this type of surgery in such cultures is superficial and ineffective. It is like selling aircraft to people who don’t know how to maintain them or presenting an ocean-going yacht to someone who has never piloted a sailboat. Only more dangerous. Problems of cultural difference run deep, and for the first time I began to feel them keenly. Why teach transplantation or heart surgery if the first 175 patients die and there are no autopsies? And no one cares?

We did not visit Israel until much later (1970) when we attended a large transplant meeting where I was to describe our early studies on liver transplantation. Israel stands like an island in the Middle East, an island of Western culture. In Israel, surgical research, teaching, publications, societies, and autopsies are all either part of the Western and American tradition or closely allied to it. While we can be proud of this important outpost in that part of the world, we must learn to respect the differences, of which there are many.

For any traveler in medicine or science, the two island continents of Australia and New Zealand occupy a special place. Their scientific traditions have a historical basis in both Great Britain and the United States. The common language and a common spirit of congeniality, humor, athletics, and sports—and ethics—binds these nations strongly to ours. I was visiting professor at the University of Dunedin in New Zealand and later in Melbourne, Australia.

While we were in Australia, our host (Ross Sheil, formerly of our staff) decided to take us sailing in Sydney Harbor. Sydney has a large, beautiful, and protected harbor, completely landlocked. We went out in a little tender from the Royal Yacht Squadron, and there moored in front of us were two large sloops. One was immediately recognizable as Gretel, the Aussie 12-meter competitor for the America’s Cup. Right next to it, almost as impressive, was an 8-meter sloop. Our host said, “Franny, which one of these do you think we are going to sail?” I replied, “I have no idea, but either one of them would be a first for me.” We boarded the 8-meter. They immediately gave me the tiller. Up went the sails. Out came the cocktails and hors d’oeuvres, and we set off through Sydney Harbor, Australian style. I had to ask people about the buoyage system and try to avoid running into battleships, freighters, and ferries. There was a good breeze, and we moved along briskly. We had no power on board. Finally we came to an isolated beach, sort of a city park, maintained for yachtsmen. Here I “shot” a small buoy. I was proud of my skill (or luck) in being able to do this with reasonable success considering the strangeness (to me) of this large yacht. We then rowed ashore for a

picnic on the beach. Surrounded by surgeons of Australia and New Zealand, some of whom had trained at the Brigham, many in charge of transplantation in their own local units, we had a great time. There was a kookaburra bird, which looks something like a kingfisher but about six times as large, screaming in one of the nearby trees. With the best of ornithologic intentions I held up a little piece of ham. The kookaburra came swooping down, snatched the ham, and flew off. The surgeons immediately jumped on me and said I should never have done that, because I was more apt to lose a finger than the ham.

In New Zealand I enjoyed the company of Gus Frankel, the professor at Dunedin, and through him spotted a young surgeon, Murray Brennan, who seemed willing enough when I suggested he might come to Boston to work with us. He came, married a beautiful American surgeon (one of our interns), raised a large family, and soon became Head of Surgery at the Memorial Sloan-Kettering Cancer Center in New York. Quite an import!

In India I was struck by the amusing but confusing admixture of British and American traditions. According to British tradition, all would-be surgeons had to go to London and pass the examinations of the Royal College of Surgeons. Merely to sit for these examinations was quite an honor. One heard about surgeons whose credentials included the phrase “Royal College of Surgeons, England—failed.” Unlike the British College, the American board system of examinations follows the completion of the residency and, because of these prerequisites, is as good as closed to people coming from abroad. Nonetheless, many Indian surgeons have done fine work in various departments in this country, including ours, in both clinical work and research.

Many of the Indian population had been undernourished for many years, and I was struck by how small the people were compared with the average size of American patients. Often the disease process is far advanced by the time the surgeon is called in. Here is where one sees primary cancer of the breast that has spread all over the patient’s breast and chest, like a great crab, as the ancients perceived in naming it cancer.

Hernias, which in this country are usually the size of a grape or, at their largest, an egg, here often descend into the scrotum and can reach the size of a football.

The professor of surgery at Banaras, Narsing Udupa, had worked with us for several years. He asked me to be visiting professor there. Laurie and I had a wonderful adventure. Banaras is also called Varanasi because it is situated along the west bank of the Ganges, bordered by the Vara and the Nasi Rivers. It is the only city in the world where the smog and foggy conditions are due to the accumulated smoke of saffron cloth and human bodies being burned in the ghats on the west bank of the Ganges. I noticed that the intensive care units of several of the hospitals conveniently situated on the sacred west bank of the Ganges, near the ghats. Not a topic you would bring up over tea.

Our visit to Thailand was part of the same journey as that to India and included Bangkok as well as Chiang Mai, where the professor of surgery was Okas Balankura, who had worked with us for a couple of years. Up at Chiang Mai the weather was clear and cool, since it is higher—in the mountains—and far removed from the stifling sea-level tropical humidity of Bangkok.

They have many unique problems in Thailand, one of which is tetanus (lockjaw). Tetanus is so rare in the United States that many American surgeons have never seen a case. In the rural parts of Thailand there were many unlicensed folk-nurses or self-styled physicians with no education or training. They did not understand cleanliness or sterilization. For all diseases they administered antibiotics by intramuscular injection with a long needle. A large fee was charged. Penetrating deep into muscle, these long needles were the ideal way to introduce an anerobic infection such as tetanus. On one ward I saw 12 patients with tetanus. Some cases were rather mild, but in one or two the disease was very severe, and prolonged periods of general anesthesia had been required to prevent lethal convulsions. We were told that, with time, most of these patients recovered.

In 1981, I was invited to visit China and was asked to bring three other members of my staff. While I could be relied upon to lecture on metabolic care, nutrition, and liver transplantation, the Chinese also wanted someone to teach about kidney transplantation, another who would cover intensive care, and a third, blood-vessel surgery. All these were new aspects of Chinese surgery. They had done their first kidney transplant only 2 years before, in 1979. The Chinese were beginning to encounter arteriosclerotic blood-vessel disease, that is, hardening of the arteries, so common for generations in the United States and Western Europe. No one knows quite why this disease was appearing in China for the first time at this period. The Chinese were beginning to need intensive care units and were becoming interested in the biochemical and physiological aspects of surgical care. To our surprise, one of our hosts, Professor Tseng Hsien-chiu, told me frankly that the government was difficult to deal with. I was a little surprised that he could state this so frankly. He said, “Building an intensive care unit in China is like trying to grow roses in concrete.” However, he had managed to build a small unit in Beijing that was well equipped and provided good care for the few patients it could accommodate.

When we first arrived in Beijing we were ushered into the main library of the University of the National Academy of Medical Sciences. During colonial days this had been called Peking Union Medical College. Then it was given a communist title of the People’s Republic. Shortly after we were there, the old name was restored, a historic reversal, insofar as this was contrary to the usual communist antagonism toward prior colonial policy. When we were introduced, the librarian displayed a brand new copy of my book on metabolic care with my picture, and handed me a pen to autograph the book. A photographer then took a picture of the event, with Laurie standing at my side. For the aging author of a book then 25 years old, this was flattery in the extreme.

Our fellow China travelers were all from our department and included Nathan Couch in vascular surgery, Herbert Hechtman in intensive care, and Nicholas Tilney in transplantation. Just at the last minute our hosts sent us a cable and told us to bring our wives. Our small group

certainly got special treatment and had a chance to learn about Chinese medicine and surgery and visit many Chinese patients, in great detail and with a minimum of fanfare or persiflage.

Our visit took place only 5 years after the wind-down of the Cultural Revolution, which had shaken everything to its roots and was now being referred to as the greatest disaster in Chinese history. A notable superlative. Our host, Dr. Tseng, now Professor of Surgery at Beijing, had during the Cultural Revolution been assigned to a province just northeast of Tibet where he dug in manure fields and made irrigation ditches. He and two or three of his colleagues quietly started a small hospital there. At the time of our visit they were still helping to run that hospital 2,000 miles away in a rural land of peasants and few modern conveniences. It no longer had to be kept a secret from the government.

The Chinese smoke cigarettes excessively. Maybe this is the cause of their vascular disease. Every morning, when starting hospital rounds, we attended a little sit-down ceremony with the director of the hospital and possibly the mayor. In front of each of us was a cup of steamy hot water with green tea leaves floating on top. When the leaves got soaked and sank to the bottom, the brew was ready to drink. Four cigarettes had been placed on the saucer and you were supposed to smoke them. The Chinese admired the fact that most Americans did not smoke any more and acknowledged that smoking was a health problem in which the Chinese had made no progress whatsoever, whereas the United States somehow had.

Our host, Professor Tseng, died of carcinoma of the lung only a year after our visit. He was a far-sighted leader of surgery, and his death was a tragic loss to Chinese surgery. His son studied at Johns Hopkins and later became a member of the faculty of Harvard Medical School. Tseng’s wife, Qin-sheng Ge, is a distinguished endocrinologist who visits us here on occasion. One of their grandchildren is named Francis Moore Tseng. Zhu-ming Jiang, one of Dr. Tseng’s staff, has been a research fellow in our lab and that of Doug Wilmore on several occasions.

While we were in China, official enthusiasm for acupuncture was already on the wane. According to our host, publicity about acupuncture had been advanced during the Cultural Revolution because it appeared to be anti-Western, was contrary to conventional teaching, and was consid-

ered peculiarly Chinese. For my own part, I was always impressed with the nature of acupuncture’s effects. Operations around the face and chest could apparently be carried out under acupuncture anesthesia alone. This success sent a message about the nervous system that we did not understand. To explain this, people liked to mutter something about gate theory (how sensations from one irritant could block out sensations from another, even pain). There was little hard evidence to back up such ideas. Within 2 years of our visit I was disappointed to find that the Chinese were no longer doing research on acupuncture. The special unit in Shanghai had been closed. In the United States, research on acupuncture had largely been abandoned. Although there were always plenty of people to defend it, there was precious little insight into its use. Acupuncture is something we should learn more about but seem now to have stopped the effort.

Despite my defense of acupuncture as requiring more study, I was disillusioned to see it being used in China for everything from headache to asthma. A patient with old poliomyelitis and a withered, useless limb would be treated by acupuncture, hoping it would make her better and bring back the kilograms of missing muscle. The patient usually felt better, we were told, but all the doctors recognized that there had been no change. Even the Chinese had a limit on the wanton use of acupuncture; it did cost something after all; even in a communist state, economic reality must sometimes rule. There was a rule that no patient could come in for acupuncture more than five times.

A famous American journalist, James Reston, had undergone an abdominal operation in China a few years previously for acute appendicitis. Our friend and host, Dr. Tseng, had been the surgeon. The American press got the idea that the operation was conducted under acupuncture anesthesia. I had been doubtful about this, since even at that time the Chinese pointed out that the muscle relaxation so necessary to abdominal surgery was rarely attained with acupuncture. Now we got the straight story. Dr. Tseng told us that regular Western-style anesthesia had been used, and that the acupuncturist had been called in only to help ease postoperative gas pains. Dr. Tseng was one of the many Chinese surgeons we met who spoke realistically (and disparagingly) about acupuncture. He made it clear that even in the case of Mr. Reston he was not sure the

acupuncture helped much and noted wryly, “Gas pains always go away anyway.”

Although the events of Tienanmen Square in 1989 were unforeseen during our visit in 1982, roots of discontent were already strong. There was a clear desire on the part of the university community—not only the students—to shake off a restrictive and vengeful government. And yet, when that uprising came, many university people we knew rather surprisingly opposed it. Some of our friends were among that conservative group, along with the majority of Chinese. While they might have agreed that there was some justification for the democratic movement, to them, stability of the Chinese government, culture, and economics was far more important than democratic reforms at this difficult time. Now a few years later (1995) there may be traces of some slight liberalization even among the Chinese intelligentsia. But precious few.

While it is typical for travelers to recall their trips abroad with sentimentality and nostalgia, our visits to many of the universities in this country have given us equal pleasure, and the experiences have been just as instructive.

One of the pleasures of academic life is that you meet people from all over the United States and the world. Wholly aside from teaching, research, or sharing new knowledge, this eclectic brotherhood makes the academic life enjoyable. It makes for notable memories to operate with a strange surgeon in a strange country and despite difficulties to find that you both share the same basic language of anatomy and surgery.

Of memorable visits in this country, I will select one to tell here because of its special nostalgia. In Chapter 3 I told about how one of the surgeons who influenced me as a child was Frederick Christopher, a leading surgeon of Evanston and Winnetka. He had taken care of me because of that injured knee. He was the author of one of the first textbooks of minor surgery and later of a standard large surgical text, now edited by David Sabiston of Duke University. It was therefore a thrill for me to be asked to give the first Frederick Christopher Memorial Lecture at the Evanston Hospital about 40 years later. Quite a few friends of mine from

high school had gone into medicine and came to hear the talk. Others came because they also had been cared for by Dr. Christopher. I told of the pleasure of growing up there and of having Christopher as my surgeon. I ended by showing a slide of that picture from his book showing my injured left knee at the age of 14.

This brought down hoots and hollers from the audience. After the meeting, I was inundated by friends who had grown up in Winnetka. They showed me pictures from the same textbook, pictures that Christopher had taken of their left ear, their fractured finger, or their facial burns. Of such is the fellowship of patients.

Our visits on this continent have ranged from Bangor to San Diego, Seattle to Tampa, Halifax to Vancouver. Always congenial, always hospitable, always something to learn and surely to tell about on your return. Of such is the fellowship of surgeons.