The Best Hope of All

SURGERY

(See Cover)

The grey-gowned figure in charge looks like a visitor from another planet. Between skull cap and mask, his head sprouts a startling pair of binocular spectacles. His hands move with confident precision and his even voice snaps with authority, but his very words seem part of an alien language--a communication designed solely for his colleagues:

Fours on Frenchies, please. Twos on threes . . .

Let's get those little bleeders up there. Give 'em a little current!

Suction! Suction!

Swift yet unhurried, the tense drama of the operating room plays itself out as Dr. Francis D. Moore, surgeon in chief of Boston's Peter Bent Brigham Hospital, removes a breast afflicted with cancer.

Yet for all its otherworldly air, that drama is utterly human. Silent, motionless, unconscious, and all but invisible under her surgical drapes, the leading actor is the human patient.

Under the bright lights that illuminate the surgical incision with brutal clarity, the achievement of the surgeon and his assistants becomes one of the greater glories of science. Man may strain ever farther into space, ever deeper into the heart of the atom, but there in the operating room all the results of the most improbable reaches of research, all the immense accumulation of medical knowledge are drawn upon in a determined drive toward the most awesome goal of all: the preservation of one human life.

Hospital Truism. In hospitals all over the U.S., surgeons now make a routine performance of lifesaving procedures so radical that they were almost unimaginable a few years ago. There is hardly a place in the human body that surgeons have not been, hardly an operation too daring for themi to perform; yet the surgical patient can face his ordeal with more confidence than he ever could before. Per haps the proudest measure of the surgeon's success is the built-in assurance of today's hospital truism: "If they can operate, you're lucky."

That grisly hospital cliche, "The operation was successful but the patient died," is as out of style as the street clothes worn in the 19th century operating room. Even as the men-in-white of the 1930s have switched into the soft greys and greens and blues of today's surgical gowns, they have learned to do more than mere knife work: now they know what can go wrong both before and after an operation; they know how to take care of the whole patient. Their patients' lives are guarded by a vital fund of knowledge born after a long-overdue marriage of surgery and medicine.

"Why in God's name is there such a great difference between a physician and a surgeon?" cried the great 13th century physician Gilbertus Anglicus. And after seven centuries, his plea has been answered. Ever since medical science and surgery began keeping house together, they have inherited one bonanza after another from rich uncles to whom they did not know they were related: nuclear physics, polymer chemistry, rheology (flow of liquids), gas dynamics, cybernetics, electron microscopy. Out of a rich harvest of intelligence from the physical and biological sciences, surgeons have learned how to use heart-lung machines, artificial kidneys, X-ray cameras to take pictures inside the heart--a whole host of machines that could never have been made or used until the biochemistry of the body itself was understood.

With their new machines and new skills, surgeons know practically no limits to the range of patients they can help. Operations once regarded as foredoomed to failure and fatality if attempted in the very young, in the aged, or in those seriously weakened by illness are now carried out on the youngest of babies or on the oldest and sickest of patients.

Repairing Nature. For a child born a "blue baby," the surgeon's probing hands delve into the innermost recesses of the heart, open up valves that nature has botched, and sew in patches where nature has left something out. They put artificial valves into hearts scarred by rheumatic fever. In an old man's belly, they implant an electrical pacemaker, the size of a railroad conductor's watch, with electrical leads to spark a faltering heart. They thrust a thin tube through the brain and freeze to death a tiny bundle of nerve cells to relieve the tremors of Parkinson's disease. They take a beam of fierce laser light and aim it into the eye to cement a detached retina back into place.

They remove a kidney from a healthy donor and transplant it into a patient who would otherwise die of chronic kidney failure. And to make such a transplant work, they wash out the body's liquid wastes, rebalance its acids and alkalies, lower its potassium--biochemical feats no less remarkable than all their surgery.

Abdominal Drain. On the average, one out of eight operations today is of a type that could not have been done at the end of World War II. At the Brigham recently, there have been as many as ten such new operations a week. Notable among them, besides the kidney transplants: open-heart procedures to repair mitral and aortic valves, removal of aneurysms from brain arteries and the aorta, insertion of pacemakers for the heart, removal of both adrenal glands to check a spreading cancer, removal of a cancerous pancreas, and placement of an "abdominal drain plug" for periodic washing out of the body's metabolic poisons. Several of the most promising and significant forms of today's advanced surgery are shown in color on the following pages.

Already able to treat some types of atherosclerosis (the deadliest form of hardening of the arteries), surgeons are confident of finding effective ways to deal with this disease where it wreaks its greatest destruction--in the coronary arteries of men in their prime. Soon they will open the skull to correct an ever wider variety of brain-artery defects and to remove tumors, while patients are chilled to a temperature of 42DEGF. and their hearts are stopped for as long as an hour.

However drastic the operation he undergoes, today's patient knows an intensity of care unheard of a few decades ago. Instead of being purged, and carried dehydrated and half dead to an operating theater to be dosed with chloroform or ether, he is gently sedated hours before the operation. The actual anesthesia, usually with a mixture of gases including cyclopropane or halothane, is far easier on him. He is not nearly so likely to suffer shock. All the while, from preoperative preparation through postoperative care, his surgeon watches over his welfare.

The Great Man. The very thought of such surgical treatment becomes possible because the split that separated surgeons from the rest of medical science has been closed for good. Gone is the era of the "great man" in surgery, dominated by the European Geheimrat system. The great man seldom saw the patient before an operation. He arrived early at the hospital, scrubbed up and donned a gown that left a length of striped pants showing below. He operated swiftly, with never an unnecessary stroke of the scalpel or a needless word to his assistants and nurses.

Usually, when he had cut out what had to be cut out, he departed, and left an assistant to close the surgical wound. If he ever saw the patient again, it would be on "grand rounds," when he would expatiate on the case loudly and authoritatively to surgeons in training.

European medicine and surgery, for all their shortcomings, were still the world's best until the 1930s. and an American who aspired to greatness in surgery went to Europe for training. The U.S. remained a medical outpost. Its own great man was Johns Hopkins University's William S. Halsted (1852-1922), who nurtured a frontiersman's egalitarian ideas: residents in surgery (M.D.s who have finished their internship and are in specialist training) should be encouraged to use both their hands and their heads. The most brilliant product of Halsted's revolutionary residency system was the great brain surgeon

Harvey Gushing, who was named the Brigham's first surgeon in chief in 1912.

Direct Action. Though the first tentative beginnings of the courtship between surgery and medicine can be traced back to Cushing's work on the pituitary, no man has done more to effect the marriage than Dr. Francis Daniels Moore, 49, and few have done nearly so much. When Gushing retired from the Brigham in 1932, Moore was still a Harvard undergraduate, fascinated by anthropology. At the end of his junior year, he switched to medicine, and four years later to surgery. By then Frannie Moore's personality was emerging, and he has no difficulty in explaining his choice of specialty: he likes direct action, and it seemed to him that of all the doctors the surgeon was the one who acted most directly for the patient and had the most intimate contact with him.

Three days after he got his B.A. (cum laude) in 1935, Moore married Laura Benton Bartlett, a childhood friend from Winnetka, 111. They settled in Brookline, where they have raised a family of five. Moore got his M.D. (cum laude) in 1939. It was an exciting time in surgery. New theories, new techniques were being developed. Daring decisions were being made. American surgery was poised to leap ahead as Europe's medical centers lost some of their best brains to Hitler's anti-Semitism and to World War II.

Preparing himself to be a leader in the American advance, Francis Moore went straight into a nine-year progression through intern, resident, and assistant in surgery at Massachusetts General Hospital. There, in 1942, he was one of the surgeons who treated survivors of the Cocoanut Grove nightclub fire. That holocaust, in which 500 died, emphasized surgery's need to know far more about a burn victim than the state of his skin grafts--to know what is happening to his emotions and to a dozen of his body chemicals.

Heavy Water. With Dr. Oliver Cope, then his chief, Moore studied the anemia of bum victims and their liability to blood clotting in their veins. But to understand any one of these mechanisms, young Dr. Moore realized, demanded understanding of broader and more fundamental subjects. What is the body's normal content of such common components as water, sodium and potassium? What changes occur after injury or surgery? Astonishingly, no one knew how to measure the amount of water in the human body.

Dr. Moore had an idea. (He found out years later that somebody else had had the idea before him, but had not pursued it.) Why not make use of some of the techniques of nuclear physics and inject into the patient a carefully measured dose of heavy water (D20, the oxide of deuterium, the nonradioactive isotope of hydrogen)? When the D20 and the body's ordinary water (H2O) were thoroughly mixed, the dilution of the heavy water would show the body's total water volume. All this was easier said than done; it took 2 1/2 years to get results that satisfied Moore's meticulous demands. Today, with the aid of radioactive tritium and an ultramodern scintillation counter, the job can be done in minutes.

Big Blue Book. In the midst of such work, which he calls "a chemical dissection of the body by isotope dilution,'' Dr. Moore was named simultaneously to two of the most honored posts in U.S. surgery: surgeon in chief at the Brigham and Moseley Professor of Surgery at Harvard Medical School. It was 1948. and Dr. Moore was all of 34. But this was in the new American tradition. Gushing had been only 43 when he took the twin jobs. Of equal rank. Dr. Edward D. Churchill was only 35 when he became a full Harvard professor and a chief surgeon at the big (950-bed). old Massachusetts General Hospital. Dr. Owen H. Wangensteen was 32 when he was named head of surgery at the University of Minnesota.

By 1952, Moore was ready to publish The Metabolic Response to Surgery, a slim (156-page) volume, listing Margaret R. Ball, his chief lab technician, as coauthor. Despite its unimpressive size and its coldly scientific title, the book became a surgical landmark. And it was only a beginning. What Moore calls his "big blue book" appeared in 1959. Metabolic Care of the Surgical Patient, a six-pound omnibus of 1,011 pages, would be monument enough for most men; it is a basic and irreplaceable text for modern surgeons. But Moore is still enlarging the dimensions of his monument. W. B. Saunders Co. has just published The Body Cell Mass and Its Supporting Environment (helpfully subtitled "Body Composition in Health and Disease"), with Dr. Moore as lead-off man among the six coauthors.

Back of all his research is the question that Dr. Moore asks himself: What is surgery? He answers that. "Surgery has assumed responsibility for the entire range of injuries and wounds, local infections, benign and malignant tumors, and many of the pathologic processes and anomalies which are localized in the organs of the body. The practice of surgery is the assumption of complete responsibility for the welfare of the patient suffering from these conditions." The statement ranges widely, but surgeons defend it jealously.

The American College of Surgeons--which, like the Brigham. is celebrating its 50th anniversary this year--is composed of specialists who believe that the exercise of their art or craft requires concentrated training. The A.C.S. now has more than 25,000 fellows (21,000 in the U.S.), but by latest estimate, nearly half of the nation's 90,000 family doctors engage in what they call "minor surgery." Some go on to intermediate or even major surgery, though the A.C.S. insists that "there is no such thing as minor surgery--there are only minor surgeons."

Good v. Great. Given the proper training, most surgeons are competent. Many are extremely good, and a few are great. What makes the difference? "To be great." says the Cleveland Clinic's Dr. Donald B. Effler. "a surgeon must have a fierce determination to be the leader in his field. He must have a driving ego, a hunger beyond money. He must have a passion for perfectionism. He is like the actor who wants his name in lights."

Almost as if determined to live up to that definition even while an undergraduate, Francis Moore wrote both book and music for the Hasty Pudding's 1934 show, Hades, the Ladies, and played a male lead. He now plays many leads: as the one man ultimately responsible for all the surgery done at the Brigham by scores of highly trained surgeons; as secretary of Harvard's joint surgical departments, covering five hospitals; as director of a many faceted research program. There is even a trace of the thespian in the way he lectures--never still, always holding the students' eyes as well as their minds, somehow managing to draw a laugh with such lines as "the brain is an island in an osmotically homogeneous sea."

Like a Pianist. The great surgeons' egoism is reflected in a selective amnesia. Practically any one of them, asked to name the three greatest living surgeons, has difficulty in thinking of two others. Individualists down to their physical characteristics, great surgeons show that even their skilled hands need be of no particular design. Like a pianist's, they may be long and slender or broad and powerful. Dr. Moore's are of medium proportions, kept limber by playing piano duets with his children on paired Steinway grands.

Geared to a revolution in which every advance seems to make his job more complicated, no surgeon can hope to become master of all the mechanical aids that are available. The best and most important work he does is almost always a team effort. But there in the operating room, his team on hand, his patient anesthetized, all the surgeon's knowledge must be instantly available for decisions upon which life depends. "At a given instant," says the Mayo Clinic's famed Heart Surgeon John W. Kirklin, "everything the surgeon knows suddenly becomes important to the solution of the problem. You can't do it an hour later, or tomorrow. Nor can you go to the library and look it up." Because of his own contributions to surgery's body of basic knowledge, his phenomenal ability to recall the right things at the right time and to make the right decision in the operating room or at the patient's bedside, Francis Moore ranks as one of "the half-dozen greatest surgeons.

Knife in the Heart. Perhaps partly by chance, but largely because of Moore's drive and leadership, the great eruption of pioneering progress that is still continuing at the Brigham began soon after he took over as chief. Says one of its most articulate surgeons: "This little place, with only 284 beds, has made more contributions to progress, per brick and per patient, than any other hospital in the world."

The toughness of the human heart and its ability to withstand intrusion had made a deep impression on Brigham Surgeon Dwight Harken during World War II, when he removed shell fragments from servicemen's hearts. His main postwar concern has been with heart valves, especially mitral valves that have been damaged by rheumatic fever. In 1948, he was one of a few bold surgeons who first dared to slip a finger, with a tiny surgical knife at the tip, into a beating heart to separate the leaflets of a mitral valve partly closed by scarring.

But some mitral and aortic valves are so badly damaged and distorted that they are beyond repair. If he could take a piece of metal out of the heart, Harken wondered, why couldn't he put one in? Then he could replace an irreparable valve. When heart-lung machines were perfected, the way was opened for valve replacement. By now. Dr. Harken has implanted 47 heart valve replacements and many hundreds of similar heart valve operations have been done across the U.S. Human Substitute. Aside from Dr. Harken's work, most of the pioneering in heart surgery has been done away from the Brigham, though some of it only a block away at Children's Hospital. There in 1938, Dr. Robert E. Gross led the way toward heart surgery with his pioneering patent-ductus operation (to shut off a vessel that is necessary during fetal life, but should close automatically soon after birth). He followed this with a more daring operation in 1946 to remove a narrowed section of the aorta--a crippling and potentially fatal defect with which some babies are born. Baltimore's Dr. Al fred Blalock opened the field for surgery directly on a malformed heart with the first blue-baby operation, which he devised in 1944 with Pediatrician Helen Taussig.

After Philadelphia's Dr. John H. Gibbon Jr. did the first successful operation in which the patient's circulation and breathing were taken over completely by his heart-lung machine (1953), variant machines appeared at several medical centers. One of the most successful was built at the University of Minnesota, where Surgeon C. Walton Lillehei had already gone so far as to use another human being as a heart-lung substitute in a cross-transfusion hookup. Heart-lung machines are now so good that at least one operation once rated impossible has become standard in many medical centers: total correction of Pallet's tetralogy,* the most common cause of blue babies.

If an infant has a condition so severe as to be an immediate threat to life itself, there is now virtually no lower limit to the age at which surgeons will move in. Dr. Gross has operated on 300 premature babies, one of whom weighed only11 Ib. 14 oz. Houston's Dr. Denton A. Cooley. 42, another bold vanguardsman in this field, regularly schedules four operations a day. By now, he has done 450 major operations on infants less than a year old. He will put even these tiny patients on the heart-lung machine if necessary, though he prefers not to. Either way, baby surgery is far safer than it used to be, says Dr. Cooley.

Digestive Cripples. At the opposite end of the life scale, where a whole group of other surgical emergencies are concentrated, Baylor University's professor of surgery. Dr. Michael E. DeBakey, has developed a series of operations to restore full circulation to the brain when there is critical narrowing in an accessible artery in the neck. His colleague, Dr. Cooley, did the first operation to remove an aneurysm (a thin, ballooned-out section) from the left ventricle, the heart's main pumping chamber. He tried putting a patient on the heart-lung machine two years ago while he removed a "pulmonary embolism," a usually fatal blood clot in the pulmonary artery. Now. with three successes logged, Cooley believes the procedure should be made generally available, with disposable oxygen kits ready in all major hospitals.

Ironically, an old. familiar operation has stirred some of the sharpest surgical controversy. In the American Journal of Surgery, Dr. Moore recently inveighed against the various stomach-cutting operations that have been tried as "cures"' for duodenal ulcer. "The removal of a large segment of normal stomach for a disease in the duodenum," he wrote, "is not only crippling, but wanting in elegance of rationale." Dr. Moore, who drives himself hard and ignores any possible effects on his own digestion, insists that the basic cause of ulcers is still unknown. The dazzling variety of stomach operations devised between 1886 and the mid-1900s. says he, made many "digestive cripples." may have caused more ulcers than were ever cured, and killed too many patients. The first great advance in ulcer treatment, says Dr. Moore, came in 1943, when Chicago's Dr. Lester R. Dragstedt reported that cutting the vagus nerves (vagotomy) would keep the stomach from producing the excess acid that eats a hole in the wall of the duodenum. Dr. Moore's prescription for a duodenal ulcer severe enough to require surgery: Cut both vagus nerves, but cut out no part of the stomach --only enlarge its outlet.

But adventurous surgeons have devised still other ulcer treatments. From the fertile mind of Minnesota's Wangensteen came the idea that chilling the stomach, by running a coolant solution through a swallowed balloon, might stop bleeding from ulcers in the stomach itself. It did. Then with his surgeon son Stephen, Dr. Wangensteen reasoned that actually freezing the stomach wall might cripple the acid-producing cells and thus keep acid from spilling into the duodenum. It does, at least for several months. After that, says Dr. Wangensteen, the procedure can be repeated--though in any but expert hands, it may be dangerous.

Pressure Boosters. In another area of contention, surgeons still argue about the cause and treatment of "irreversible shock." a condition in which the blood pressure falls dangerously low. A whole generation of doctors has treated this kind of shock with adrenaline and noradrenaline because those drugs are blood-pressure boosters.

No wonder the results have been so bad, complains Minnesota's Dr. Richard C. Lillehei;* there never has been any evidence that pressure-boosting hormones relieve shock caused by blood loss or infection. The basic problem. Dr. Lillehei believes, is a drop in the amount of blood available for circulation. He recommends giving massive doses of hydrocortisone. or of phenoxybenzamine, a new drug not yet released for general use. Neither drug increases blood pressure, and they may even lower it, but both increase blood flow to the body's smaller blood vessels.

Singular Insight. Surgeons are virtually unanimous in believing that the most exciting and promising new area now being opened to them is the field of transplantation. After this momentary agreement, they promptly offer a thousand differing opinions on how soon transplantation of an organ from one human being to another will become a daily routine instead of the headline-heralded event that it is today. They are equally diverse in their views as to how surgery will eventually overcome the fact that all animals, and especially man, are designed to resist any invasion of foreign protein from any creature except an identical twin. (The major exception is the cornea, which has no blood supply. Paradoxically, blood transfusion itself is a transplant, but it tides the patient over, despite eventual rejection of white cells.)

The surgeons of old had some success in using part of a man's own arm to rebuild a nose or ear, but as early as 1597, Gasparo Tagliacozzi of Bologna wrote with great insight that "the singular character of the individual entirely dissuades us from attempting this work in another person, for such is the force and power of individuality." Three centuries later, Charles Claude Guthrie and Alexis Carrel learned the wisdom of this judgment. With great virtuosity, they proved that organ grafts between animals were surgically possible. Guthrie even succeeded in grafting a second head onto a dog; more constructively, he and Carrel learned how to stitch together the ends of small, slippery blood vessels so that they would neither leak nor become clogged by clots. But for all their dexterity, the scientists did not solve the problem of getting organ grafts between two individuals to take.

Then, in 1953, Britain's Peter Brian Medawar pinpointed the "rejection phenomenon." It is, he proved, a display of the same immune mechanism that enables a healthy body to beat down a virus infection by developing antibody against the foreign protein. Against a second invasion, the body reacts faster. It is the same with grafts: the first may be rejected slowly, but a second one from the same donor is turned down more quickly.

"By the Way. . . ." When Dr. Willem J. Kolff visited Boston in 1947 with the design for an artificial kidney to filter waste products from the blood, he had no idea that he was laying the foundation for today's flurry of kidney transplants.

Dr. George W. Thorn, the Brigham's physician in chief, and Surgeon Carl W. Walter modified Kolff's early model, which he had built in secret during the Nazi occupation of The Netherlands; and for patients whose kidney failure was only temporary, the contraption was a lifesaver. But it could not keep alive those whose kidneys had failed permanently. In 1951, in a desperate effort to save these patients, Brigham surgeons decided to go ahead and transplant kidneys without waiting for the mysteries of immunity to be dispelled. But all those "unprotected"' transplants eventually failed.

One day in 1954 a doctor phoned the Brigham from Northboro, Mass., and begged Dr. John P. Merrill to put Richard Herrick, 24, back on the artificial kidney because both of his own kidneys were failing catastrophically. As he was about to hang up, the Northboro doctor added: "By the way, this patient has an identical twin." Physician Merrill immediately grasped the significance of the opportunity. Dr. J. Hartwell Harrison removed Twin Ronald's healthy left kidney. Dr. David Hume implanted it in Richard's flank, and it took, though Richard died this year of heart disease. Of 19 other identical-twin transplants, 17 made a good start. But over the years, three patients have died of recurrent kidney disease. "So now we know," says Dr. Moore, "that the critical factor is glomerulonephritis [a form of kidney inflammation involving the small capillary loops or glomeruli], and that these people have a tendency to get the same disease again, and it attacks the transplanted kidney."

In an effort to stave off the immune reaction, Brigham surgeons have done ten transplants after irradiating the recipients' whole body. But only one nonidentical twin survives. Now Surgeon Joseph E. Murray and his colleagues are relying on drugs alone to suppress the immune reaction, and all of their last four patients who received transplants are still living. So is one of an earlier group whose operation is now a year old. His kidney came from a cadaver.

X-ray the Transplant. Now at the Medical College of Virginia, Dr. Hume has begun kidney transplants with modified techniques. First, Dr. Hume removes both of the patient's diseased kidneys, to lower blood pressure and to guard against infection and especially against glomerulonephritis. After the operation, Dr. Hume doses the transplant itself with X rays, on the theory that if antibody-loaded cells are moving in to attack the kidney, they will be concentrated around the target. One important thing, says Dr. Hume, is to get the replacement kidneys fresh. Most cadaver kidneys are. in effect, "in shock" for several hours before they can be transplanted.

A University of Colorado team headed by Dr. William R. Waddell also takes out both diseased kidneys first. But the Denver surgeons go farther: they remove the recipient's thymus and spleen as well, on the theory that these glands are headquarters for rejection mechanisms. The Denver group has made seven non-twin transplants in five months, and guardedly reports that so far, all the recipients but one are doing well.

Block the Rejection. Medical men who hate eager chatter about "breakthroughs" because it raises false hopes in patients are willing to make one exception. They concede that it will indeed be a major breakthrough when a way is found to tune down the immune mechanism just enough so that a transplant will take and the patient will still have a defense against infectious diseases.

The moment a method is found to control the immune mechanism in man, there will be a flood of transplants of many organs. The kidney has been favored up to now, because one kidney is enough for anyone, and everyone with a healthy pair is a potential donor. Even so, the kidney may not prove to be the easiest or the most wanted transplant. The pancreas, source of insulin, would be a boon to a diabetic. Dr. Moore is already making experimental transplants of whole livers between dogs. In Denver, two months ago. Colorado General Hospital and Veterans Administration Hospital surgeons attempted the first human liver transplant, from a girl of ten. who died of a brain tumor, to a boy of three. The boy died of profuse bleeding.

A lung or a heart would be technically more difficult to transplant, and some surgeons object that those organs probably would fail because they would be deprived of their nerve supply. Not so, says Stanford University's Dr. Norman Shumway, whose team has put a dog on the heart-lung machine, removed her heart, stored the heart in cold salt water for seven hours, then put it back. The arteries and great veins were reconnected, but the nerves were not. The mongrel has since had a litter of eight pups, with no evident strain on her nerveless heart.

But would anybody in his right mind dream of cutting out a human heart? Yes, say the Stanford enthusiasts. In certain cases, it may be the best way to give some newborn children a chance of normal life.

Babies born with transposition of the great vessels--the aorta where the pulmonary artery ought to be, and vice versa --now face a problem for which there is no true cure. Why not cut out the baby's heart, ask the Stanford men. turn it around and sew it back so that the two sides of the heart exchange jobs?

Doing Without. Dr. Richard Lillehei says flatly: ''We don't need all the nerves that nature has supplied." As proof, he cites vagotomy in man, and Shumway's dogs. Other surgeons have long since demonstrated how many more supposedly vital parts the body can do without. Thanks largely to medicinal hormones that replace its own supply, the body can function adequately without: the master pituitary gland in the brain, both adrenals, the thyroid, the thymus, spleen, pancreas, gall bladder, one hemisphere of the brain, the gullet, much of the stomach, anywhere from a few inches to several feet of small bowel, the colon, rectum, one lung, one kidney, one testicle, one ovary, one breast, the prostate gland.

Where all the spare parts for an expanding program of human transplantation will come from is still uncertain. But Dr. Moore is investigating how long tissues survive after what is generally regarded as death. And adventurous surgeons are searching for other answers; some are confident that if natural organs are in too short supply, inventive men will devise artificial parts to replace nature's. The day may come when the Tin Woodman of Oz, who wanted someone to build him a working heart, may not seem like such a hopeless case after all.

No Hands? Men like Francis Moore, who are advancing the frontiers of biochemistry, expanding man's knowledge of his own metabolism, often seem to be peering even beyond the future of successful transplants to a time when they will know enough not to have to use a knife at all, to a time when they will realize the hyperbolic hope expressed by Harvey Gushing: "I would like to see the day when somebody would be appointed surgeon somewhere who had no hands."

"Surgery," says Heart Surgeon Kirklin, "is always second best. If you can do something else, it's better. Surgery is limited. It is operating on someone who has no place else to go." But today, patients who have no place else to go are vastly more fortunate than their predecessors. To virtually all of them, surgery offers more hope than it ever did before. And to many of them with heart defects or in need of transplants--those for whom there never was any place else to go--surgery now offers the first and the best hope of all.

-Named for the French physician who described what he thought were four malformations that -- no one knows why -- occur together.

There are, in fact, only three malformations: instead of arising only from the left ventricle, the aorta has outlets from each ventricle; the pulmonary artery or valve is narrowed; there is a hole in the wall between the ventricles. What Fallot thought was a fourth malformation, enlargement of the right ventricle, is a result of these three. It subsides when they are corrected. Youngest of three noted brothers, sons of Minneapolis Dentist C. I. Lillehei (still active in practice at 70): Heart Surgeon C. Walton Lillehei is 44; James, 38, specializes in lung physiology; Surgeon Richard is 35.

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