The Marvels of the Human Hand

The Marvels of the Human Hand





In the darkness of a mother’s womb a tiny, ivory-colored embryo enters its fourth week of life.  Within the tightly curled, motionless organism, scarcely two inches long, millions of new cells are growing at an enormous rate.  From the side of the reck region sprouts a pair of “buds”.  Rapidly they elongate into three segments.  The extreme outer segment assumes a paddle shape.  Five lobes appear on the edges of the paddle.  Muscles, tendons and nerve fibers develop.  By the third month of pregnancy, the little flipper’s miniature fingers flex spasmodically.  A human hand has been formed.

Months later, when the baby is delivered, these little fingers will clutch and pluck at the hands of the obstetrician with startling insistence.  From then on, the hands of this human being, directed by the brain, will chiefly determine how this life differs from the lives of all other creatures on earth.

No other part of the body is so intimately associated with human behavior.  With our hands we work, play, love, heal, learn, communicate, express our feelings, construct our civilizations and create our works of art.  The hand and our emotions are so linked that, for most of the world’s peoples, clasped hands symbolize faith, love and friendship, while the clenched fist is the unmistakable expression of human strength and resolution.

How and when during the immense span of evolutionary time did this extraordinary appendage originate?

Amazingly, the fin of the fish is the forerunner of the human hand.  As fish crept out of the sea and developed into air breathing amphibians, their fore fins developed into instruments for crawling, gripping, creeping; and through millions of years subsequent evolution their basic four-limbed artichetecture persisted.  Watch goldfish in an aquarium.  The delicate motion of the fins just behind its head as they fan the water to regulate its movements is controlled by a set of muscles, which are the rudiments of our intrinsic hand muscles.

Once of the most complex instruments of the entire body, the hand is an intricately engineered mechanical device composed of muscle, fat, ligament, tendon, bone and highly sensitive nerve fibers.  It is capable of performing thousands of jobs with precision.  To make the simplest grasping motion, and array of muscles, joints and tendons all the way from shoulder to fingertips is brought into play.  Taking a spoonful of soup involves more than 30 joints and 50 muscles.

The hand is packed full of bones, eight in the wrist, five in the palm, and 14 in the fingers of one hand.  The ligaments, cords of stringy material, hold all these bones together at the joints.  The tendons, tough fibers that guide hand and wrist bones and link them to the muscles that operate them, control finger motion.

The thumb, operating independently of the other four fingers, is the busiest and most important of all the drifts.  Because of the thumb’s unique ability to cross over and link up with any one of the other fingers, we can get along with one thumb and one other finger, or even the stump of a finger.

The rest of the fingers are markedly different in strength.  The middle finger is usually the strongest, followed by the index finger; the fourth finger is considered by the teachers of music and typewriting to be the less least responsive to training because of an innate muscular weakness; the little finger is weakest of all.

The size of a person’s hand is not significantly related to the strength of its grip or whether it will be fast or slow, deft of clumps.  Among musicians, physicians, artists, athletes and others who depend on their hands to earn living, there is an infinitive variety of stubby fingers, slender fingers, large hands and small hands.

Human fingers can be trained to perform astonishing feats.  The flying fingers of a master pianist can strike 120 notes per second.  With two fingers, a skilled surgeon can tie strands of thread into tight knots inside the human heart.  A circus performer so strengthened the index finger of his right hand by years of patient effort that he can balance himself on its tip.

Every walking moment we obtain a great deal of information about the things we touch by the “feel” of them.  This is possible because the skin of the hand is not like the skin of an other part of the body.  While extraordinary tough, it is also wonderfully elastic and incredibly sensitive.

The skin of the back of your hand actually stretches by almost half an inch when you grip or squeeze something; simultaneously, the palm inside is shortened by half and inch.  Beneath the thick skin of the palm is a buffer of fat which protects the vital tendons and blood vessels of the hand while the outer surface is being subjected to the tremendous friction created by scraping, twisting, gripping and clenching motions.

The palm of the hands, and particularly the fingertips, are equipped with special sensory apparatus.  A piece of finger skin smaller than a postage stamp contains several million nerve cells.  Of the surface of the skin are ridges formed by papillae.  These are dotted with myriad pores and nerve endings, which detect the temperature and texture of anything we touch. [Fingerprint identification is based on the fact that the whorl patterns created by these papillae are never identical in two people]

The greatest natural enemy of the human hand is cold, because bloodless joints in which the temperature drops more quickly than it does in blood filled muscles take up most of the finger.  That is why you can skate of ski all day in zero temperature without covering your face, which is full of muscles richly supplied by warm blood, while without gloves your fingers grow painfully numb in minutes.  Finger joints, like all other body joints, are bathed in a colorless, viscous lubricating fluid [synovia], which provides a smooth, gliding action when we bend an elbow or a finger.  When this fluid gets cold, it thickens and finger joints stiffen.

Because of its intricate arrangement of nerves and muscles, the hand is highly vulnerable to injury.  Injuries to wrist, fingers and hands account for almost one half of the total casualties in industrial accidents.  All lacerations of the hand are potentially dangerous because holders of virulent organisms swam over the things we touch daily.  The thick skin of the hand provides an impregnable barrier to these bacteria.  But if a scratch of puncture permits then to gain entrance, infection may follow swiftly.

Our hands deserve careful treatment.  As tools of learning, working and communicating, they can be considered the fundamental vehicle of human thought—partner with the brain in forever separating man from the rest of the animal kingdom.



I’ve Lived With Cancer

I’ve Lived With Cancer




One morning I stretched in bed and felt a pain in my right breast.  I touched the spot with my fingers; there was a tiny lump, about half the size of an olive.  I lay there for a minute thinking.  I was 37 years old.  What a terrifying coincidence.  Mother had been 37 when she had her operation for breast cancer.  I wasn’t sure my lump was anything serious, but I remembered how it had been with Mother.  She was the sort of person who believed it a disgrace to be ill.  She waited too long to see the doctor.  Ger operation hadn’t cured her; the cancer recurred in the uterus, and the second time they didn’t operate.  They treated her with radium, but that didn’t work either.  She died when I was 19, a senior in college.

With these memories crowding in one me, I wanted to see a doctor right away.  My husband Hod (a nickname for Horace) and I, with our two little girls, had just moved to Seattle, and we didn’t know any doctors there.  After a bad experience with obstetrician who diagnosed the lump as “just nerves,” I went eventually to an internist.  He felt the lump and send me immediately to a surgeon.  The surgeon told me the lump ought to come out the next day.  He would have it examined on the spot by a pathologist.  If it turned out to be cancer, he would go right ahead and do a radical mastectomy; remove the breast and all surroundings tissue likely to be invaded by cancer, including some muscles and the lymph nodes under the arm.  He knew about my mother and wasn’t about to take any chances.  I was pretty sure it wasn’t cancer.  I may have prayed about it.  Raised a Presbyterian, I had married a Mormon.  Not wanting a house divided, my daughter and I had studied Mormon faith and been baptized the preceding year.

I knew the bible quotation: “Is any sick among you? The prayer of faith shall save the sick,” we asked some of out Mormon friends, elders in the church, to come to the hospital and pray.  They came, put their hands on my head and asked the Lord’s blessing, and prayed for my recovery.  It was a simple, spontaneous act, not words read out of a book.  But in this time-honored ceremony.  I knew I had been blessed—that there had been communication with Our Lord.

The next day, when I was taken to the operating room, both Hod and I were quite calm.  When they didn’t bring me out after a few hours, he knew that they must have found cancer.  He says he didn’t worry, and I believe him.  He has a calm faith in God, and he trusted our doctors—and he has always made me feel the same way.

My friend thought when I woke up after the operation was that there was a ten-ton truck on my chest.  This was the pressure bandage put on to keep fluid from accumulating.  “We’re sorry,’ a doctor said, “but we had to do the radical.”  I was pretty groggy from the anesthesia, but even so I was shocked.  Remember, I was only 37—that seems very young to me now, 16 years later—and I was proud of my body.  I knew what the alternative was, though, and the doctors cheered me by saying that they had got out all the cancer in one piece of tissue.  As far as the surgeons could tell, I was free of disease: “You might as well worry about being hit by an automobile,” he said.  “As to think that you will die of cancer.”

But what really convinced me that I was going to live was a peculiar experience I had a day or two after the operation.  I was lying in bed, quite alone, when I heard a voice say, “You are going to be fine.”  It’s possible that I was still feeling the effects of drugs, but I heard that voice as clearly as I’ve ever heard anything in my life.  It dramatically renewed my faith, gave me strength and tranquility.

After nine days I was able to go home.  Hod came and got me.  He acted as though I had just got over a bad cold, or something equally trivial.  That night we watched a television verity shoe with a line of chorus girls wearing low-cut gowns.  I began to cry.  Hod turned to me and said, “and what are you crying about?”  It made so mad that I quiet crying—and I’ve never cried since.  What he said may seem heartless, but he was under doctor’s orders: tender, loving care was great, but sympathy would only get me feeling sorry for myself.

I was very touchy at first.  The doctor said, “You must have something to help you bathe; otherwise you might lose your balance and fall.”  When I protested, “You don’t mean you want me to let my husband see me!” he just laughed and said, “Of course I do.”  And Hod was so unconcerned about the scar that I began to get over my embarrassment.  About four weeks after the operation, I went to a department store for my prosthesis—a false breast worn in a brassiere.  The woman in the lingerie section was merry understanding, and the prosthesis was quite comfortable.

After a radical mastectomy you have to work to recover the use of your arm.  It is painful, because the muscles have been cut; but if you don’t exercise they heal in a stiff and awkward way.  So I did what the doctors ordered: walked my fingers up the wall, waved my arms, everything to get the motion back.  I love golf, and was especially anxious to get back to it.  There were some twinges as I began swinging a club, but I kept at it.  When I first went out to the course, I was rather nervous.  But I took a full swing and something tense me relaxed as that white ball flew into the sun.  It was a nice drive, straight done the fairway.

I was even more nervous the first time I put on a bathing suit at a friend’s pool.  Would my scar, which went rather high in my neck, embarrass the others?  Well, nothing risked, nothing gained.  It was hot, and I wanted to swim.  So I walked out, trembling a little inside, and dived into the pool.  Nobody even noticed.

As the years passed, the operation receded from by thoughts.  The girls grew up and married.  Hod and I had a wonderful time.  Of course I had the checkups the doctors ordered, including chest X-rays and the Pap test, every six months at first and then every year.  But there were no further problems.  I had long ago considered myself cured when I discovered a lump in my left breast as I was taking a shower.  I reported directly to my surgeon.  “I don’t know what it is.” He said, “So we’ll operate and find out.  With your history, even if the lump is not malignant, I will remove the breast.  But I’ll not do a radical unless the lump is malignant.”

Two days later they operated.  The lump was not malignant—but underneath he did find a spot of cancer.  When I came out of anesthesia, the doctor told me this—and that he had had to do the radical.  I wasn’t feeling so flippant, but my retort was, “Hurray, now I match!”  I now felt that my troubles were behind me.  The pathologist’s report was negative, meaning that the cancer had been confined to the one spot.  So I was concerned more about regaining use of the left arm as soon as possible, and seeing my new grandson, than about the threat of future disease.  Actually, the second operation was easier to take, both emotionally and physically, than the first—and I was playing golf within two months.

After moving from Seattle to Salt Lake City, I went to see dermatologist about a lingering ear infection.  He took a biopsy and told me there was local cancer-cells involvement.  “Please don’t be alarmed,” he said.  “It’s not metastasis [spreading] of the breast cancer, just a basal cell skin cancer,” But it had got into the cartilage, and needed some plastic surgery so, I entered the hospital.  As a precaution, the surgeon ordered a regular checkup, including chest X-ray, before we went to the operating room.  While I was still unconscious, he told Hod that the X-ray had disclosed a walnut-sized lump in my right lung that would have to come out.  “How are we going to tell her? He asked.  Hod said, “Just tell her.  She can stand the truth as well as I can.”

They gave me five days to recover from the ear operation, and then we went back to surgery for the lung.  It was a much longer and more difficult operation than the mastectomies, and more painful afterward.  For three days I was in intensive care.  But there was good news from my doctor.  The pathology report showed that the cancer—it was definitely metastases of the breast cancer—had been confirmed to that single tumor which he’d removed with the middle lobe of my right lung.

Nevertheless, I began to feel resentful.  I knew I’d been lucky, but I was getting a bit tired of being so lucky so many times, perhaps because I was older, 51.  But after six weeks—a month at hoe—the doctor said I was recuperating perfectly and could go with my husband to a convention in Coronado, California.  It was beautiful there, sunny and warm, and I began to feel strong again.

For a year I was fine, traveling with Hode, playing golf, visiting our grandchildren.  And them I had an attack of pneumonia.  During a series of sputum tests, cancer cells were found.  This means that there is cancer in my chest.  They’ve been giving me radiation treatments to reduce fluid accumulation, and now chemotherapy has been started.  The situation is not good, but I know that I’ve been helped before I believe my doctors when they say there is a good chance of arresting the spread of the cancer.

People often ask me if my cancer is hereditary.  The doctors say no, although they think there may be a hereditary tendency in some families for some forms of cancer.  Since my mother and I both had breast cancer, this is clear warning to my daughters, one doctor told me.  They should be extra careful as taught by the American Cancer Society.

Another question that comes up shy, after all I’ve bee through; I’m not angry or depressed.  My answer is: if the doctors give you every chance to live a normal life, well, why not does it?  They’ve always been honest with me.  They’ve said frankly in the past that they don’t know when or if another form of cancer, of another metastasis, will show up.  But I can’t see sitting around the moping.

I’ve lived a full, happy life through three major cancer operations.  I’ve watched my daughters grow up and seen three grandsons born since the first tumor.  And I’ve not been living in fear.  On the contrary, I’m more fearful about getting abroad an airplane than I am about undergoing anesthesia.  Hod and I have had a good life together; I feel we’ve had a present of 16 marvelous years—more than some have in their entire lives.  As for the future—nobly knows that except God.  And I have faith in Him, just as I have always had.


The Right Arm of Eddy Knowles

The Right Arm of Eddy Knowles




Everett “Eddy” Knowles, Jr., a merry, freckled, red-haired boy of 123, stood just off the roadbed and watched the Boston & Marine gravel train grinding slowly past Gilman Square in Somerville, Massachusetts, a suburb of Boston.  It was about 2:20 p.m. May 23, 1962.  Eddy was on his way home from Northeastern Junior High School, and had decided to have a fling at forbidden fruit—hooking a ride on freight.

As a gravel-laden gondola car moved slowly past him.  Eddy pulled himself to the steel step and grasped the handrail.  He hung there in triumph, all five feet and 90 pounds of him.  The spring breeze eddied through his jacket and cotton shirt as the freight groaned eastward.

A few seconds later the world went black for Eddy.  His leaning body slammed full force into a stone abutment supporting the Medford Street overpass.  His right arm cracked, and he dropped into the roadbed, crushing his thumb and the first two fingers of the left hand.  For a minute he laid there, a small-bewildered heap, until the train passed.

He was sure he had broken his right arm, the arm that had so far earned him a 3—1 winning record as a Littler League pitcher.  A smear of blood spread on his shirt just below the shoulder where the jacket had been torn.  Supporting his right arm with his mangled left hand, he struggled to his feet, climbed a steep bank and started home. 

As Eddy shuffled past the back loading platform of the Handy Card & Paper Co., Norman Woodside, the foreman saw the bloody, bedraggled figure and shouted to Richard Williams, a press operator, ‘Grab him!’ Williams laid Eddy on the wooden platform while Woodside phoned the Somerville police.  Woodside returned with Mrs. Alice Chmielewski, a clerk, who tried to put a rag tourniquet on Eddy’s arm.  Suddenly, she felt faint.  At the place she sought to apply the tourniquet, there was nothing but space.  Eddy Knowles had walked more than 100 yards, mostly uphill, clutching an arm that had been severed from his body.

Mrs. Chmielewski pushed some rags against the shoulder stump in an effort to stanch the bleeding.  “I got to get out of here,” moaned Eddy.  She held him gently and wiped the sweat from his forehead.  Eddy didn’t cry.  Indeed, he was not to shed a tear for the entire day of his ordeal.

A police squad car arrived in two minutes, and by 2:40p.m Everett Knowles, Jr.,had the good fortune to be wheeled into Massachusetts General Hospital, one of the finest in the United States.

As emergency ward administrator Ferdinand Strauss and his assistant, Michael Hooley, wheeled Eddy toward the emergency operating room, Hooley, asked Eddy his name, address, phone number, religion.  The boy replied clearly.  Hooley now put a complex system into operation.  One call went to the Knowles home; another to the patient-index center in the basement where 1,500,000 names are filed, luckily, Eddy had been a patient there before.  Within five minutes his medical record with his blood type reached the operating room.  Eddy already was receiving 250 cubic centimeters of plasma through a ‘cut down’ in his leg.  Now, the first of the six pints of whole blood he would receive flowed into him through the transfusion tube.  “My arm hurts.” Eddy told the doctors.  “Is it going to come off?”

Nurses Mary Brambilla and Francis Brahms lifted Eddy from his litter to the operating table.  Nurse Brahams cut away Eddy’s clothes with scissors.  Then, they all saw it: Eddy’s right arm lay three or four inches from the shoulder stump.  Not a single thread of skin bridged the gap.  “Will my arm be all right?”  Can you save it?”  Asked Eddy.  Dr. S.B.Litwin, a duty surgeon, nodded.  “Yes, son,” he said.  But at that moment nobody knew.

Dr. L.Henry Edmunds, Jr., the duty surgeon in charge now gave brisk, routine orders: tetanus shot, atropine, injections of penicillin and streptomycin, a sedative shot, pulse taking, blood pressure.  Eddy’s pressure was low, his pulse 120, and he was cold, sweaty—all indications of shock.  Hank Edmunds noticed on encouraging detail.  Eddy’s right-arm artery protruded almost an inch from his damaged flesh and, with each pulse, it throbbed and dilated—but no blood emerged.  It is one of nature’s miracles, this self-sealing quality of a severed artery.  In a young person especially, the vessel’s elasticity is so great that it closes within few seconds of rupture.

Dr. John M. Head, staff surgeon, and Dr. John F. Bruke consulted with Edmonds.  They all noticed that the lone arm, while bruised and damaged, was fairly clean.  Edmunds ordered Nurse Brambilla: “Put that arm on ice.”  Mary Brambilla filled two basins with crushed ice from the ward kitchen’s ice-making machine and placed the arm on them, then packed ice-filled bags around it.

At Edmond’s side now were a number of doctors, including 30-year-old Dr Ronald A. Malt, the resident in surgery and perhaps the most important man Eddy Knowles was to see that day.  These physicians conferred in the corridor.  Never in medical literature had they read of a case of a major limb successfully reattached to the body.  But Eddy and his severed arm appeared ideal for am attempt.  Each step that would be necessary—rejoining veins, arteries, bone, muscle, skin—had been performed routinely for years.  Could they all be done atones?

As the doctors talked, Father L. Chanel Cyr, duty chaplain at the hospital, administered extreme unction to Eddy.  Then Eddy’s father, a meatpacking employee, who worked nights and had been asleep at home when the phone rang, arrived.  Physicians explained the situation.  Would Mr. Knowles send to a reattachment operation?  Knowles signed the release.

Dr. Malt asked Dr. John Herrmann, his assistant in surgery, to take the arm upstairs to Operating room No 5.  There Dr. Herrmann scrubbed, donned a surgical gown, and wet to work.  First he fished out the arm’s three major nerve trunks and the torn blood vessels.  They appeared reasonable intact.  Placing a syringe in the artery, he flushed the blood channels with heparin, and anticoagulant, with antibiotics and with a solution approximating the body fluids.  The antibiotics severed to kill any grantee of lockjaw bacteria that might be starting.  There were no lacerations on the arm.  The bone was broken and jagged, one side longer than the other, but it was not crushed.  Then Dr>Herrmann injected a radiopaque solution into the artery.  A technician took X rays to determine whether there were any blood-vessel blocks.

Eddy Knowles, meanwhile, was wheeled into the “White 3” anesthesia induction room.  Here at 3:40p.m. Dr. Joan Flacke injected a muscle relaxant into Eddy’s leg and gave him an intravenous dose of thiamylal, a sedative.  “I just thought of something,” said Eddy to her.  “My family was going on a vacation in a couple of weeks, and now I guess I’ve spoiled it.”

Malt looked at the X-ray plated of Eddy’s arm.  The limb appeared to be fine.  No blood clots, no obstructions appeared.  It was 4:05p.m. When Malt reached his crucial decision: they would try to sew back the severed arm of Eddy Knowles.  Malt ordered Joan Flacke to begin anesthesia.  Then he phoned Dr. Robert S. Shaw, an expert in vascular surgery who was working in another hospital building.  “Bob,” said Malt, “there’s a boy here with his arm off, and I think we’ve got a chance to put it back on.”  Shaw came, on the run.

Under great overhead light in OR 5, Dr. Flacke fitted a mask over Eddy’s face. The boy began to breathe a mixture of halothane, nitrous oxide and oxygen from three tanks.  He fell quickly into a sound sleep.

Judy Moberly, the scrub nurse, felt queasily for the first time in months of watching operations.  The sight of an arm on one table and a boy on another had strangely upset her.  “Do I have to watch?” she asked.  But then, as soon as the arm was brought close to Eddy, she was no longer disturbed.

Around the boy now stood three doctors, two nurses, three anesthetists and two orderlies.  The glassed balcony above them was crowded with a score of doctors and nurses, drawn there as word spread through Massachusetts General that a limb was to be reattached.

Eddy’s right side was propped up, the bloody stump irrigated with salt water and draped with gray linens.  The Shaw directed the initial step, the sewing of the veins.  These had to be connected first, so the blood would have a way to get back to the heart when the artery was repaired.  The arm has two outer veins and one deep plexus entwined about the artery.  Ignoring the outer veins, Shaw selected two veins from the intern network.  With forceps, he gasped the minuscule curved needle attached to green but hardly visible Dacron 6-0 thread. Through a vein he pushed the needle, let loose, picked it up on the other side and pulled.  He did that again and again, 30 stitches to the vein.

It was painstaking work.  Save for the occasional asides of the doctors, muttered though their gauze masks, the room was hushed.  Malt’s job required excruciating patience.  He had to hold Eddy’s arm so firmly that not the slightest movement would occur.  Occasionally, Herrmann helped with this.  One little tilt, and the delicately stitched veins would rip.  When the two veins were reunited, the doctors joked a bit, to crack the tension.

Now Shaw tackled the brachial artery, still self-sealed and throbbing with each heartbeat.  This task was easier, for Eddy’s artery was large—about two-thirds the size of a lead pencil.  Still, the procedure was complicated and took 45 minutes.  Anatomists, of the suturing of blood vessels, were completed just three and a half hours after Eddy fell form the train.

And now came the moment of truth.  While Malt still held the arm tightly, Shaw removed the artery clamp.  Blood rushed down the arm.  People in the balcony stopped talking.  Not a word was spoken around the operating table.  Everybody watched.  Slowly, the waxen limb began to regain its flesh coloring.  A glow seemed to envelop the arm.  The doctors wanted to cheer.  In the balcony, there were exclamations of joy.

“My,” said Malt, “its nice and pink, isn’t it?” Judy Moberly, the scrub nurse, felt the hand.  It is warm.

In the huddle of surgeons now were Dr. Bradford Cannon, a plastic-surgery specialist, and Dr. David C. Mitchell, an orthopedist.  Now it was time to repair the bone.

Consulting with other bone experts and with Malt, Mitchell decided the bone would have to be reinforced.  If not held securely in place, it might snap and tear the blood vessels again.  There are many shapes of stainless-steel rods for intramedullary fixation, as the profession calls it.  Mitchell tried several of these, forcing them into the marrow of the bone, but wasn’t satisfied.  At last, he and Malt settled on the Kuntscher nail, which in cross section is roughly the shape of a cloverleaf and grumps firmly.  They measured the length required—six and a quarter inches.  Malt drove the nail part way up the marrow of the stump bone with a stainless-steel mallet.  Then Mitchell held the arm and forced it onto the rod.  It was 8p.m.

Next job: nerve suture.  The doctors struck a snag here.  They couldn’t find all the nerves in the stump, and they couldn’t be sure how badly damaged the located nerves were.  The smallest scar on a nerve end could thwart full healing, giving Eddy a lifelike but useless arm.  With an eye on the clock, because Eddy already had been on the operating table four hours, Malt made another one of the scores of decisions made that day.  He decided to postpone nerve rejoining for a later operation.

Malt now removed dead tissue to block infection.  Normally this would have been done first, but the doctors postponed it because, until circulation was restored, they couldn’t be sure how much would ultimately be dead.  Next: the muscle.  Malt jointed the muscle with 12 large stitches of catgut.

A skin graft was clearly called for now, since a large, raw wound showed.  But Malt, in still another decision, ruled against an immediate graft.  A graft would take 45 minutes, and there was little time.  It was now past 10p.m., with much work still to be done.  A dry dressing was placed on the patched arm.  Then Eddy was fitted with a spica cast covering both his shoulders and down to the hip tops and holding the rejoined arm firmly, crooked at the elbow.

Eddy’s left hand still had to be cared for.  Dead tissue was cut away from the smashed thumb and two fingers, and a skin graft taken from Eddy’s right foot was applied.

It was almost 1 a.m. when Eddy was wheeled into the recovery room, eight and a half hours after the operations started.  As he emerged from unconsciousness, Eddy smiled at Joan Flacke.  “How’s my broken arm?” he asked.  Then he thought something.  “Next time,” he said, “just give me the gas.  I don’t like those needles.”

Eddy stayed in the recovery room until daylight, and then was wheeled into a private room on the 12th floor.  Although Eddy and his arm were one again, the doctors’ vigil had just begun.  When days passed with no sign of infection, they breathed more easily.  On the fifth day they took a large piece of skin from Eddy’s right thigh and grafted it onto his arm in two places.  On the 12th day they changed the cast, and again on the 15th day, June 13, Eddy went home to his family’s two-story frame house on Dell Street in Somerville.

Eddy Knowles, at age 30, is doing well.  His recovery has been good, and his hobbies include weight lifting and tennis.  He has held various jobs, among them, delivering 200-pound slabs of meat and cross-country truck driving.  All in all, a very remarkable, productive life for Everett Knowles, jr., once a brave little boy who never cried, and who helped to blaze a new trial in medical science.  Suture of Right upper Extremity.” Ronald Malt called it in his laconic one-page official report.


Immunotherapy: Medicine’s Most Exciting Frontier

Immunotherapy:  Medicine’s Most Exciting Frontier


Of all fields of medical research, none is so full of promise as immunotherapy—the manipulation of the body’s natural defense system to make it fight off diseases, which have previously overwhelmed it.

Consider the California boy who suffered recurrent episodes of infection, including several bouts pneumonia, abnormal bleeding, an enlarged spleen and loss of hair.  He was born with an immune system so impaired that it offered no defense against certain disease organisms.  After injections of a substance called “transfer factor”’ every six months, the boy was kept free of infection for 48 months.  Extracted from the Shiite blood cells of healthy individuals, transfer factor is capable of temporarily transferring specific immunes response from on person to the faulty immune system of another.

By a similar manipulation, an eight-year old Florida girl whose body for years was encrusted with disfiguring sores caused by a chronic fungus infection has became a clear skinned child.

An estimated ten million Americans have diseases for which immunotherapy bay be of use.  The diseases include cancers, arthritis, rheumatic heart disease, certain kidney ailments, a number of infectious diseases and multiple sclerosis.  In addition, many of the millions who suffer from allergies may ultimately benefit.

Once thought to be involved only in defense against infection, the immune system is now known to be considered with recognizing and combating all types of foreign materials that threaten the body’s integrity, including cancer cells, which probably develop many times throughout life.  There are at least two types of lymphocytes [a variety of site blood cells] those that act by themselves ad those that synthesize antibodies.  They make up the two major combative forces of the immune system.  The first type of lymphocyte can learn to recognize disease organisms and other foreign materials and, once having learned, can remember and react to the any time they reappear.  Among other reactions, these lymphocytes can release substances, which direct big scavenger cells—macrophages—to attack enemies.  Usually, it takes 4 to 48 hours for a lymphocyte corps to congregate at an intrusion site.

Meanwhile, the second force, the antibodies—protein molecules known as immunoglobulins—may attack.  The immune system turns out specific antibodies to fit specific antigens [foreign materials that provoke immune forces] almost the way a key fits a lock, and the fit inactivates the antigen.  Antibodies circulate in the blood and can act within five seconds; some need help from a complex group of substances in the blood called “complement” which can split apart invading bacteria, viruses and other foreign materials.

One immunologic manipulation—vaccination—has been used since Dr.Edward Jenner discovered it as a weapon against smallpox in 1796.  In recent years, attempts to transplant kidneys and other organs have given tremendous impetus to further study of other manipulations.  Early on, the body—attacked and sloughed off because their foreignness aroused and the immune system quickly rejected transplanted organs.  Powerful drugs, employed in anticancer therapy, were used to suppress the immune system, but then patients were left wide open to deadly infections.

The phenomenon noted among early transplant patients was that suppression of the immune system made them more prone to certain types of cancer.  Did immune system play a role in preventing cancer?  In 1950s, it was discovered that the surfaces of cancer cells contained antigens not present on normal cells, and that these could arouse the immune system.  Doon, a surveillance theory, which is still debated, was developed; normal body cells are always, in small numbers, turning malignant, and a major job of the immune system is to search them out and destroy them.

Some years ago, DR. Edmund Klein, chief of dermatology at Roswell Park Memorial Institute, Buffalo, New York, began studies testing cytotoxic drugs [drugs that kill cells] on skin tumors.  Some to these chemicals combined with tissue materials, resulting in highly antigenic compounds that aroused the patient’s immune system, causing it to attack the tumor.  An agry red reaction occurred at the site, and before long the tumor disappeared as normal tissue grew in to resurface the area where tumor had been.  Here was the first clear evidence that the immune system could destroy a cancer.  Later, Klein and his team of researchers went on to show that separated components called ‘lymphokines’ [which are produced by a group of white blood cells] could bring about similar reactions against tumor.

Over the years, Dr. Klein found that, at least in skin cancers, immunotherapy could eradicate lesions in more than 70% of patients, with no recurrences for up to 15 years.  New skin tumors, however, did occur, but at a greatly diminished rate.  Klein and his co-workers found that immunotherapy could ferret out and eliminate skin cells not yet malignant but on they’re way to becoming so.  When the oblivious skin cancers were treated, a dozen or more other tiny areas, previously unnoticeable, reacted.  They proved to be pre-malignant or in very early stages of malignancy.  “We found,” says Klein, “that the immune system was a lot smarter than we were and could combat tumors we didn’t even know existed.”

From researchers around the country and abroad come other reports that science is taking its first uncertain steps on the route to immunotherapy for cancer.  In the early 1970s and M.D. Anderson Hospital and Tumor Institute in Houston, for example, Dr Evan M. Hersh and colleagues have used BCG, the tuberculosis vaccine, to treat 300 patients with malignant melanoma [a kind of skin cancer].  Some had had surgery before treatment and were disease-free.  In these patients, the BCG clearly prolonged the disease-free interval, compared to controls.  In others, who could not be treated surgically because their cancer had spread, chemotherapy plus BCG, compared with the results of chemotherapy alone, prolonged the remission and length of survival.

At a 1972 National Institutes of Health conference on immunotherapy, Dr Sol Roy Rosenthal and other investigators from the University of Illinois reported on a Chicago study: from 1964 through 1969, only one death from leukemia was recorded among 54,414 children up to six years of age who had been vaccinated at birth with BCG against tuberculosis.  In contrast, 21 deaths from leukemia were reported among 172,986 children of similar age and race who had not been vaccinated—a rare more than six times as great.  A controlled stud has now been set up nationwide by the Children’s Cancer Study Group to investigate BCG as a vaccine against leukemia.

Few investigators believe that the chemicals they are using experimentally today will be the ones in use five years hence, to that immunotherapy alone can be expected to conquer a cancer that has become well established.  They see the immunolic killing of such tumor cells as a kind of “numbers game.”  Each immune agent has a certain limited capacity to stimulate the immune system.  So, when a cancer is well established immunotherapy may be the most effective after the tumor load has been lightened by surgical removal of the primary tumor, or after regression has been induced by chemotherapy.

Once the most fundamental discoveries about the immune system are that it sometimes defeats itself by producing a substance that blocks its own 


Thoughts of a Brain Surgeon [From Reader’s Digest 1981. November.]

From the frontiers of science and the far horizons of personal courage, these stories of medical triumphs and miracles will reaffirm your faith in the awesome powers of the human spirit. Dramatic victories and human triumphs.


Thoughts of a Brain Surgeon  [By ROBERT J. WHITE, M.D.]

She was a lovely little girl, six years old, exceptionally pretty, bright, happy.  But our studies showed a large tumor in her brain.  Operating, I found the hemisphere markedly enlarged by giant cyst associated with the tumor.  I started in after the fluid—filled mass and. Disaster!  Suddenly the hemisphere collapsed and the large vessels on its surface ruptured, flooding my operating field with blood.

My colleagues and I struggled to stem the torrential flow, but we were losing the battle.  Gloom settled on us.  With my fingers, I held little pads of cotton tight against the hemorrhaging vessels, striving desperately to control the bleeding.  At last I succeeded.  I dared not to release my fingers; all I could do was pray while the child was transfused.

As I waited, I felt terribly inadequate, humble.  Who was I to be engaged in such awesome work, to think it was my responsibility, and mine alone, to remove this ugly growth from this little girl’s brain—the tissue substrate of her highest functions, her wonderful personality, her intelligence, memory, emotions, free will?  This area where we were operating, that was where she was, it was who she was.

Half an hour passed.  The operating room was alive with a terribly quiet tension.  No one, including me, believed I could lift my fingers from the pressure points without releasing another river of blood.  I kept applying digital pressure and preying, praying to God to will the necessary strength into my hands.

And then, quite suddenly, I felt relaxed.  I knew I had done all was in my power to do, and I was full of comfortable certainty that I could proceed.  Somehow God was in the room with us.  Carefully, slowly, I released my pressure on the vessels, one finger at a time.  There was no bleeding until all my fingers were free.  Then one vessel began to bleed, but it was easily controlled.

It took 4 ½ hours to remove the tumor.  I stayed close to the little girl’s bed for the next week.  Her wounds healed well; no re-hemorrhaging, no neurological deflect, no brain damage.  The result was all that had been hoped for, and the girl today is normal, happy teen-ager.

In 1974 I operated on a young boy who had suffered two massive brain hemorrhages—the result, studies showed, of a small tumor at the very center of his brain.  The hemorrhaged areas were badly infected.  The lad became comatose; he was dying.  We placed tubes into both sides of the brain and literally washed out the brain cavity with cold antibiotic solutions—a revolutionary new technique of our own devising.  Later we placed the boy on a respirator, a breathing machine, and reduced his body temperature.

For weeks the fight for life continued.  I kept praying, not only for the boy and his parents but also for the strength to sustain the entire medical team in the sad and exhausting case.  Then, almost imperceptibly and for reasons not yet clear, the boy began to improve.  After a fortnight we removed the cooling blanket.  Another two weeks and we were able to remove him from respirator, then to remove the drainage tubing from the brain.  Now, in my daily meetings with the distraught parents, I began suggesting the possibility that their son might survive, even if incapable of anything resembling a normal life.  Yet, unaccountably, he continued to improve.  By the time we discharged him, I was able to describe him as a spastic with severe mental retardation—far better than we had dared hope.

Several months later, the parents brought the boy back to me for an examination.  I am still astounded at what I found: he was in all respects completely, utterly normal—happy, active child.  The tumor is still there, in the center of his brain—we continue to keep a close watch on it—but it has caused no further trouble nor has grown.

If I seem to be saying that I have witnessed miracles that is not what I believe.  To be sure, I have been in many extremely dangerous operating-room situations—several of them apparently hopeless—in which to my amazement the patient has survived and prospered.  But I see nothing “miraculous” about these successes.  I don’t think they would have occurred without the combined hest efforts of all the medical professionals in that, I believe; it would not have been achieved without Divine help in making the decisions and in the actual technical performance.

Many research scientists seem to lose faith as their knowledge increases.  For me, the opposite has occurred.  My experiences with my patients, and in my neurological research trying to unravel the mysteries of the brain, have put me more than ever I awe of the brain.  And I am left with no choice but to acknowledge the existence of a Superior Intellect, responsible for the design and development of the incredible brain-mind relationship—something far beyond man’s capacity to understand.

Just think about this wondrous organ, the human brain.  The most sophisticated computer man will ever build will not match the complexity, efficiency and performance of this gelatinous mass of tissue weighing approximately three pounds.  With its topography of small hills and narrow valleys crisscrossed with red and blue streams, one-brain looks much laid any other.  But somewhere in there is what makes each of us unique.  For the brain contains the mind, the relationship between the container and its contains, science knows very little.

I am convinced that the brain is the repository of the human spirit, the soul.  Therefore, to me the brain is a holy place.  Still, it is subject to injury and illness, and sometimes it is necessary for us to enter and search its depths for tumors, hemorrhages, and infections.  To work in this area strikes me as an almost religious undertaking, and one demanding the highest of human skills.  I need a very solid set of beliefs to sustain me in such work.

I recall a lovely, long-ago spring day when I was called to a veteran’s hospital for consultation in the case of a man in his early 30s who had a malignant brain tumor.  His room was full of colorful, homemade get-well cards, several with pictures on them of a beautiful little dark-haired girl, and her repetitive plea; “Get well soon, Daddy”; “Come home soon”; “I miss you so much” But as I studied the young man’s records and examined him, I knew he would not be going home again.

My depression was profound.  I would mot want to try to weather such moments without the realization that understanding is beyond me, without faith that the patient and all involved with him are moving ahead, that they happen now to be center stage in a grand drama of time and space in which each of us figures significantly.

For me, the practice of medicine and religious faith are inextricably interwoven.  I prey a great deal, especially before and after surgery.  I find prayer satisfying.  I feel there are immense resources behind me, resources I need and want.

I knew great and good men among my colleagues who seem able satisfactorily to explain things to themselves in terms of mathematics and chemical formulas, and are comfortable in assuming that what is not explainable today will come clear as science continues to progress.  Yet the notion that human life is nothing more than a chance confluence of complex molecular biology and electrical activity strikes me as a defiance of logic.

From purely scientific standpoint, it seems to me the human brain-mind is so far beyond anything science have ever developed that a Superior Intellect-Creator is demanded to explain the uniqueness and individually of the human being.  No matter how much we learn about brain, we can never expect to explain the mind completely.  And I have to believe all this had an intelligent beginning that someone made it happen.  I can’t accept the proposition that at random points in time such substantial entities as intelligence, personality, memory and the human body just sort of fell together.

I also find it unreasonable to suppose that the brain death those powerful entities of intelligence, personality and memory simply cease to exist.  Far more reasonable to believe that the essence of us escapes from a container, the brain, which no longer is capable of supporting us, and finds support in a new dimension.

As to what becomes of the essence of us at brain death, I can’t presume even to speculate.  I can only say that logic leads me inescapably to faith—faith that the uniqueness, the individuality, of the human being lives on in this concept we call the soul.


How Anesthesiologists Save Lives

How Anesthesiologists Save Lives


Summer was always a fearful season in the days before polio vaccines. One of the worst epidemics occurred in Copenhagen, Denmark, in 1952.  Victims of paralysis began arriving at Beldam Hospital in mid-July.  Up to 50 new patients, mostly children, poured in every day, as many as a dozen with clogged lungs and in need of breathing assistance.  There weren’t enough iron lungs of cuirass (chest-size) respirators to go around and even with the breathing machines, 80 percent of the breathing-paralysis patients died.

The frantic doctor in charge, H.A.C.Lassen, had an inspiration.  He called in Dr. Bhorn Ibsen, a free-lance anesthesiologist working at another hospital.  Lassen knew that anesthesiologists had had to become experts I keeping patients breathing during surgery, but nobody had ever thought of applying their expertise outside the operating room.

Dr. Isben’s first patient was a 12-year-old girl, paralyzed and gasping for breath, literally drowning in her own secretions.  He asked a surgeon to do a tracheonomy—that is, to make a hole directly into her windpipe.  Isben inserted a plastic tube and pumped her lungs clear of fluid, then attached a simple anesthesia apparatus to her neck—a Y-shaped tube, canister of oxygen and a breathing bag.  But he used the breathing bag to squeeze a mixture of air and oxygen into he lungs, instead of an anesthetic.  Soon the child’s body relaxed.  Her skin became pink.  She was kept on the breathing device until she could breathe for herself.

From them on, all new patients with breathing paralysis—total of 318—were given a tracheotomy and the same kind of breathing apparatus.  Every medical student in Copenhagen volunteered to squeeze the breathing bags by hand, in eight-hour shifts.  Whereas 26 of 30 patients had died on the old respirators, 200 of the 318 lived—and 175 recovered enough breathing capacity to leave the hospital.

This dramatic death-to-life reversal made medical history.  Doctors all over the world realized that they had a new life-saving resource in the mastery of artificial ventilation by anesthesiologists.

Today the anesthesiologist is being called in every breathing emergency, from birth to attempted suicide.  For example, if a mild anesthetic commonly given to mothers during childbirth anesthetizes the baby so that he cannot begin to breathe, an anesthesiologist may put a plastic tube into his windpipe and give him lifesaving oxygen.  Should a emphysema victim be struck with bronchitis or pneumonia—and be dying from exhaustion in his efforts to get oxygen—and anesthesiologist will breathe him by machine for a few hours, of even days, giving his body vital rest.  The anestheologist also gives artificial ventilation to heart-attack victims with total cardiac arrest; to tetanus patients whose breathing is strangled by a muscular spasms; to people who have taken overdoses of barbiturates, which temporarily paralyze the nerves controlling breathing.

Ventilation is just one of the lifesaving skills mastered by anesthesiologists since surgical anesthesia was first demonstrated, practically, with either by dentist William Morton in 1846—an event since equated with such medical milestones as the discovery of vaccination by Edward Jenner and the introduction of antiseptics by Joseph Lister.  Over the years, specialists in anesthesia have come a long way from the guesswork application of either and nitrous oxide to the precise control of dozens of powerful drugs that may be inhaled, injected, given orally or rectally.

Anesthesiology is now one of medicine’s most versatile specialties.  The anesthesiologist can take away consciousness of obliterate feeling locally, paralyze the body and relax the muscles, control the blood flow and reduce blood pressure to prevent bleeding, even largely suspend the body’s needs for oxygen by cooling.

Most patients never see the facemask through which the inhalants are breathed.  Asleep by the time they reach the operating anteroom, they remember only the premeditations—the tranquilizer or barbiturate and morpheme injection administered an b\hour before the operation, plus a belladonna-like drug which stops tissue from secreting fluid, giving the surgeon a dry “field” to work in.

Although the anesthesiologist’s surgical patients are unconscious most of the time he is with them and have little notice of his role, most leading surgeons recognize that anesthesiology has extended their skills into fields that would have been inconceivable a few years ago.  Dr. Roald Grant, surgical consultant to the First marine Division in the Koerean war, said, “Our front-line hospitals were as effective as their anesthesia.  When they had an anesthesiologist to keep the severely wounded alive, the surgeons could make their repairs.  Without the anesthesiologist, many of the wounded would have died.  The same thing was true in Vietnam.”

Surgeons often ask anestheologist whether a patient can stand anesthesia and a long operation.  And it’s not uncommon during surgery for the anesthesiologist to warn that a patient is weakening and that the operation should be stopped.  Several years ago, a surgeon was operating on a cancerous intestine in Columbia-Presbyterian Medical Center in New York City.  His plan was to remove part of the colon and much surrounding tissue.  The patient’s blood pressure sank to 70/50 during the surgery—too low—and, on the anesthesiologist’s advice, the surgeon closed the abdomen without completing his planned procedure.

“The patient’s electrocardiogram didn’t look right,” Dr. Emmanuel M Papper, then head of the anesthesiology at the center, told me.  “We couldn’t be sure, because we couldn’t put electrodes on his chest—they would have interfered with surgery.  But when we could do a full EKG, we found he’d had a heart attack on the table.  Interposing surgery gave him a chance to recover.”  The surgeons finished the operation later.

Such teamwork, supported by a wide range of new anesthetic drugs and electronic controls, has made formerly impossible surgery commonplace.  I once saw a surgery-anesthesiology team do two open-heart operations the same date at Columbia-Presbyterian.  The first patient was a 70-year-old man with a leaky heart valve.  He went to sleep quickly with little premeditation, and was kept asleep on a very low dose of halothane (a modern inhalant that has largely replaced ether—it is non-explosive, and doesn’t leave patients nauseated) and nitrous oxide.  Catheters were inserted into a vein and an artery in his groin to measure blood pressure, and a tube was slipped into his windpipe for later ventilation.

A special stethoscope was put into his esophagus less than a half-inch form his heart.  This was connected to an earpiece worn by the anesthesiologist molded to his ear so that he can wear it without discomfort for hours, leaving the other ear open to hear the nurses and surgeons).  Through this, the anesthesiologist can listen to both the heart and the lungs (like a drumbeat with an organ background) and detect the first signs of emergency.

During the ensuing four-hour operation, surgeons inserted tubes into an artery and a vein connected to the blood –oxy-generating machine—the “heart-lung” machine—that would cleanse and oxygenate the patient’s blood.  Then they cut into the heart, removed the bad valve and successfully replaced it with a man-made one.

The second patient was a 14-month-old infant with a hole in the wall inside his heart.  He was overactive and fearful, so the anesthesiologist, Dr. Richard Patterson, decided not to show him the face mask.  Instead, he called for an odorless, but explosive, gas—cyclopropane [often used because children can’t smell it, and so don’t panic].  Everyone in the room was grounded; all electrical equipment was turned off.  As De. Patterson moved the open end of the gas tube near the baby, the child began to breath the gas, his movements slowed and he fell asleep.  Now a mask was slipped over the tiny face, and a mixture of halothane and air replaced the dangerous gas.  The hole was quickly repaired.

In the both cases, the anesthesiologist was in charge of the patient’s blood volume.  He had a panic-type thermal bag with chilled pints of the proper type of blood.  Some of this was used to prime the oxygenating machine.  His assistants weighed blood-soaked sponges during the operations, and he would ask the surgeon how much blood was leaking inside the incision so that blood replacement could be estimated exactly.

In the case of an infant, the thimbleful of lost blood is the equivalent of a hemorrhage in an adult [a baby has less than a pint of blood in his body; and adult has a six quarts], and, in replacing blood, too much is as dangerous as too little.  Excess can overload the heart.  After each operation Dr. Patterson and the surgeons went along as the patient was wheeled into an intensive-care room.  In many hospitals, this room is now under the supervision of an anesthesiologist.

Such close control of patients before, during and after surgery has saved countless lives, and has, infect, made death from surgery of anesthesia a rarity.  Of some 20 million surgical operations done under anesthesia last year in the United States, it is estimated that one patient in each 4500 operations died of surgical caused, and one in 10,000 of anesthesia.

Anesthesia’s first and basic role—the suppression of pain—has led to new knowledge of pain; where it originated, how it travels, and how to block it locally.

The anesthesiologist now treats patients outside the operating room who suffer amputation stump pain or the chronic pain resulting from such diseases as angina pectoris, advanced cancer, Parkinson’s disease.  “Chronic pain is a disease,” said Dr Papper.  “If the pain can be relieved without damaging the patient, he’s considerably improved, even if not cured of the basic illness.”

One morning at an outpatient clinic in Liverpool, England, I watched an anesthesiologist treat several patients.  One was a woman suffering the agony of advanced cancer.  The doctor felt for the source of the pain in her back, pressing with his fingers until the patient said, “there.”  He plunged a long hypodermic needle into the spot for a trial injection.  For an instant she stiffened; then, after a few minutes, she smiled.  “Feels better already,” she said.

“We use lignocaine, a form of Novocain,” the doctor told me.  “When the dentist gives it to you, you feel local number ness for an hour.  But if we can put it directly into a nerve that transmits pain—which may be quiet far from where the pain is perceived—it may work for months.  We don’t know why.”

One of the doctor’s patients comes in about once every two years with back pain.  He hobbles in bent over, barely able to move.  A half—hour later, he strides out, erect and smiling—and doesn’t come back for another two years.

“Our results aren’t often so dramatic,” the anesthesiologist said to me.  “We don’t have a one-shot cure.  If the injection doesn’t work, we may try killing some nerves with alcohol of phenol.”

With all that anestheologist can do to save lives and relieve pain, you’d stink the specialty would be booming.  It hasn’t boomed in the United States.  One reason is lack of research money.  Few outstanding leaders—the men who inspire students to enter the specialty—have thus been attracted to anesthesiology.  And only a handful of medical centers offer enough exposure to anesthesiology research and training, of give anestheologist full recognition for the entire can do—or the authority to do it.  In these places, spirit is high.  But, generally, anestheologist has image trouble, woven among doctors—many of who still tend to regard them as technicians, subordinate to surgeons.

In Great Britain, anestheology is a leading medical specialty, attracting nearly 10 per cent of all doctors—as against only 3 percent in the United States.  We have about 12,000 doctors trained in anesthesiology; we need thousands more.  To bridge this gap, in some hospitals general practitioners may give anesthesia; other hospitals use specially trained nurses.

There are programs, some government-financed, to make up our deficit in anesthesiologists.  But closing the gap will take years.  Meanwhile, more knowledge of the work that anesthesiologists do in and out of operating rooms will help build the morale and numbers of these overlooked specialists who save so many lives.