The Bank has always operated in the black, though its operating budget has grown from $5,000 in 1942 to $144,300 in 1951, and finally to more than $1 million yearly at the present time. The staff has grown from one nurse, one technician, and a part-time physician in 1942 to more than one hundred technicians and nurses and secretaries at present.

  By definition, an organ is a mass of specialized cells serving some specific function. According to this definition, blood is an organ, though one does not often think of it in this way.

  As a developing organ in the embryo, blood is formed from the same tissue which also differentiates into cartilage, connective tissue, and bone. This helps explain why, for example, blood is formed in bone marrow.

  In the adult man, blood consists of five quarts of liquid, accounting for 7 per cent of adult body weight. This makes it, on a weight basis, a respectably large organ-much larger than either the lungs (1 per cent) or the liver (2 per cent). The functions of blood are suitably complex, ranging from transport of oxygen and nutrients to defense of the body against infection.

  If blood is an organ, a blood transfusion is an organ transplantation. It is not idle to think of transfusions in this way, for nearly all the problems of modern organ transplantation were first met, and solved, in dealing with blood transfusion. Only our familiarity with modern transfusion makes us forget that it is, in fact, a transplant-a gift of vital cells from donor to recipient.

  No one knows when the first transfusion was performed, but it was certainly a long time ago, for the efficacy of blood was highly regarded in ancient times. In early accounts, it is not clear whether the blood was transfused or drunk, since both methods were considered useful. Celsus, in Roman times, refers to treatment of epilepsy by drinking the hot blood from the cut throat of a gladiator. The Mongols, living in a horse culture, often drank horse blood for sustenance.

  The idea of intravenous injection is also old. Ovid relates that Jason was helped by Medea with an injection of "succis" into his jugular vein.

  Behind the early interest in transfusion was the quite logical notion that an illness involving blood loss was best treated with blood replacement. Early materials for this were primitive-needles made of quills and bone, tubing formed from bladders or leather. In many cases, animal blood was transfused to human beings, often with the addition of semen, urine, and other substances thought to be invigorating.

  It is not surprising that patients often died from this procedure. Donors often died, as well. In a famous instance, Pope Innocent VIII received a transfusion from three young boys in 1492. The donors as well as the recipient expired within a few days.

  In the eighteenth century, when better materials were available and more careful observation the rule, it became clear that certain patients benefited from transfusion but others did not. This early notion of the "transfusion reaction" evolved slowly, culminating in Karl Landsteiner's discovery in 1900 of A, B, and O blood groups. This represented the first clear, unequivocal statement that all blood was not the same. For more than a decade after Landsteiner's work, there was no practical clinical method of differentiating blood groups. The search for such techniques is a direct forerunner of modern tissue-typing methods for transplantation of other organs.

  Just as the matching of donor and recipient was a problem, so was storage of the organ. Untreated, blood clots soon after it is drawn. It was not until 1916 that blood could be kept refrigerated for two weeks in glass bottles, with the addition of anti-coagulating substances. And it was not for more than twenty years after that that clinical blood banking began on any scale in this country. There was no important improvement in storage techniques until 1952, when glass bottles were replaced by plastic bags, which preserved blood elements much better.

  More recently has come the ability to store frozen blood. This single technical capability has solved several traditional banking problems, and indeed is now integral to the MGH function: most open-heart cases are done with frozen blood [Dr. Charles Huggins, an MGH surgeon, was one of the pioneers in making frozen blood practical for clinical use].

  Formerly, all blood had to be used within three weeks. Now it can be stored at -120° F. for five years or more. In the past, patients had to be matched to their own blood type. Now, the freezing-thawing process washes out serum antibodies, which means that type O frozen blood can be transfused to anyone, regardless of his blood type. The need for the bank to stock many different blood types is therefore reduced.

  And, finally, there is evidence that the risk of hepatitis, a traditional problem with transfusions, is reduced when frozen blood is used.

  There are, of course, some drawbacks to frozen blood. It is more expensive at the present time. Also, some blood components, notably platelets, which are important to clotting, are lost and must be supplied separately. But there are easy techniques for this.

  In fact, the products of the modern blood bank are increasingly sophisticated. In 1942, the bank produced only two products-whole blood and plasma (the liquid portion without the cells). But it is now possible to give whole blood, or packed red cells without plasma, or platelets; it is possible to give plasma, or only the protein from the plasma, or only specific parts of the total protein without the others. Each of these specialized blood bank products is becoming increasingly important to the conduct of modern medicine.

  What has all this meant to surgery? As it has become more scientific and more complex, a certain amount of the drama and flair, the spectacle that Warren remembered, has disappeared-or at least become muted, until it is hardly recognizable.

  On Saturday mornings at the hospital, surgical clinics are held for students in which patients are presented pre-operatively and then the students are invited to watch the procedures from the several overhead viewing galleries. This teaching exercise is the last remnant of a proud tradition of surgical spectacle. Dr. E. D. Churchill, former MGH Chief of Surgery, gives the following account:

  The display of operations at the Hospital on Saturday mornings continued well into the 1920's. Unusual cases were assembled so that the senior surgeons on duty could have an impressive list of operations scheduled for the amphitheater. The two services, East and West, vied with each other in trying to stage the better show. In the Surgical Building, opened in 1900, the display reached major proportions. When the morning's list was a long one, an operation would be started in a small room and then the entire outfit trundled like a troupe of gypsies into the pit of the amphitheater, where the crucial phase of the procedure was demonstrated to the visiting doctors. The surgeons would be allotted, say, fifteen minutes. Whether or not the operation had been completed, at the expiration of the allotted time the tents were folded, the troupe moved off stage to complete the operation elsewhere, and a new act took over… Great weight was placed on the speed and daring of the operator… Tension mounted when some prima donna showed reluctance to withdraw from the spotlight and overstayed his time to hold the audience spellbound in an ad lib recounting of his surgical prowess.

  The prowess of the surgeon has steadily increased since then, to the point where reconstructing a nearly severed hand is, if not commonplace, at least nothing to get very excited about.

  And if, in this age of television, the surgeon shows more flamboyance than is scientifically necessary, more sense of drama than is medically indicated, he can at least be excused for upholding the traditions of his calling-and, in a deeper sense, the facts of his life.

  Sylvia Thompson. Medical Transition

  Flight 404 from Los angeles to boston was somewhere over eastern Ohio when Mrs. Sylvia Thompson, a fifty-six-year-old mother of three, began to experience chest pain.

  The pain was not severe, but it was persistent. After the aircraft landed, she asked an airline official if there was a doctor at the airport. He directed her to the Logan Airport Medical Station, at Gate 23, near the Eastern Airlines terminal.

  Entering the waiting area, Mrs. Thompson told the secretary that she would like to see a doctor.

  "Are you a passenger?" the secretary said.

  "Yes," Mrs. Thompson said.

  "What seems to be the matter?"

  "I have a pain in my chest."

  "The doctor will see you in just a minute," the secretary said. "Please take a seat."

  Mrs. Thompson sat down. From her chair, she could look across the reception area to the computer console behind the secretary, and beyond to the small pharmacy and dispensary of the station. She could see three of the six nurses who run the station around the clock. It was now two in the afternoon, and the station was relatively quiet; earlier in the day a half dozen people had come in for yellow fever vaccinations, which are given every Tuesday and Saturday morning. But now the only other patient she could see was a young airplane mechanic who had cut his finger and was having it cleaned in the treatment room down the corridor.

  A nurse came over and checked her blood pressure, pulse, and temperature, writing the information down on a slip of paper.

  The door to the room nearest Mrs. Thompson was closed. From inside, she heard muffled voices. After several minutes, a stewardess came out and closed the door behind her. The stewardess arranged her next appointment with the secretary and left.

  The secretary turned to Mrs. Thompson. "The doctor will talk with you now," she said, and led Mrs. Thompson into the room that the stewardess had just left.

  It was pleasantly furnished with drapes and a carpet. There was an examining table and a chair; both faced a television console. Beneath the TV screen was a remote-control television camera. Over in another corner of the room was a portable camera on a rolling tripod. In still another comer, near the examining couch, was a large instrument console with gauges and dials.

  "You'll be speaking with Dr. Murphy," the secretary said.

  A nurse then came into the room and motioned Mrs. Thompson to take a seat. Mrs. Thompson looked uncertainly at all the equipment. On the screen, Dr. Raymond Murphy was looking down at some papers on his desk. The nurse said: "Dr. Murphy." Dr. Murphy looked up. The television camera beneath the TV screen made a grinding noise, and pivoted around to train on the nurse.

  "Yes?"

  "This is Mrs. Thompson from Los Angeles. She is a passenger, fifty-six-years old, and she has chest pain. Her blood pressure is 120/80, her pulse is 78, and her temperature is 101.4."

  Dr. Murphy nodded. "How do you do, Mrs. Thompson."

  Mrs. Thompson was slightly flustered. She turned to the nurse. "What do I do?"

  "Just talk to him. He can see you through that camera there, and hear you through that microphone." She pointed to the microphone suspended from the ceiling.

  "But where is he?"

  "I'm at the Massachusetts General Hospital," Dr. Murphy said. "When did you first get this pain?"

  "Today, about two hours ago."

  "In flight?"

  "Yes."

  "What were you doing when it began?"

  "Eating lunch. It's continued since then."

  "Can you describe it for me?"

  "It's not very strong, but it's sharp. In the left side of my chest. Over here," she said, pointing. Then she caught herself, and looked questioningly at the nurse.

  "I see," Dr. Murphy said. "Does the pain go anywhere? Does it move around?"

  "No."

  "Do you have pain in your stomach, or in your teeth, or in either of your arms?"

  "No."

  "Does anything make it worse or better?"

  "It hurts when I take a deep breath."

  "Have you ever had it before?"

  "No. This is the first time."

  "Have you ever had any trouble with your heart or lungs before?"

  She said she had not. The interview continued for several minutes more, while Dr. Murphy determined that she had no striking symptoms of cardiac disease, that she smoked a pack of cigarettes a day, and that she had a chronic unproductive cough.

  He then said, "I'd like you to sit on the couch, please. The nurse will help you disrobe."

  Mrs. Thompson moved from the chair to the couch. The remote-control camera whirred mechanically as it followed her. The nurse helped Mrs. Thompson undress. Then Dr. Murphy said: "Would you point to where the pain is, please?"

  Mrs. Thompson pointed to the lower-left chest wall, her finger describing an arc along the ribs.

  "All right. I'm going to listen to your lungs and heart now."

  The nurse stepped to the large instrument console and began flicking switches. She then applied a small, round metal stethoscope to Mrs. Thompson's chest. On the TV screen, Mrs. Thompson saw Dr. Murphy place a stethoscope in his ears. "Just breathe easily with your mouth open," Dr. Murphy said.

  For some minutes he listened to breath sounds, directing the nurse where to move the stethoscope. He then asked Mrs. Thompson to say "ninety-nine" over and over, while the stethoscope was moved. At length he shifted his attention to the heart.

  "Now I'd like you to lie down on the couch," Dr. Murphy said, and directed that the stethoscope be removed. To the nurse: "Put the remote camera on Mrs. Thompson's face. Use a close-up lens."

  "An eleven hundred?" the nurse asked.

  "An eleven hundred will be fine."

  The nurse wheeled the remote camera over from the corner of the room and trained it on Mrs. Thompson's face. In the meantime, Dr. Murphy adjusted his own camera so that it was looking at her abdomen.

  "Mrs. Thompson," Dr. Murphy said, "I'll be watching both your face and your stomach as the nurse palpates your abdomen. Just relax now."

  He then directed the nurse, who felt different areas of the abdomen. None was tender.

  "I'd like to look at the feet now," Dr. Murphy said. With the help of the nurse, he checked them for edema. Then he looked at the neck veins.

  "Mrs. Thompson, we're going to take a cardiogram now."

  The proper leads were attached to the patient. On the TV screen, she watched Dr. Murphy turn to one side and look at a thin strip of paper.

  The nurse said: "The cardiogram is transmitted directly to him."

  "Oh my," Mrs. Thompson said. "How far away is he?"

  "Two and a half miles," Dr. Murphy said, not looking up from the cardiogram.

  While the examination was proceeding, another nurse was preparing samples of Mrs. Thompson's blood and urine in a laboratory down the hall. She placed the samples under a microscope attached to a TV camera. Watching on a monitor, she could see the image that was being transmitted to Dr. Murphy. She could also talk directly with him, moving the slide about as he instructed.

  Mrs. Thompson had a white count of 18,000. Dr. Murphy could clearly see an increase in the different kinds of white cells. He could also see that the urine was clean, with no evidence of infection.

  Back in the examining room, Dr. Murphy said: "Mrs. Thompson, it looks like you have a pneumonia. We'd like you to come into the hospital for X rays and further evaluation. I'm going to give you something to make you a little more comfortable."

  He directed the nurse to write a prescription. She then carried it over to the telewriter, above the equipment console. Using the telewriter unit at the MGH, Dr. Murphy signed the prescription.

  Afterward, Mrs. Thompson said: "My goodness. It was just like the real thing."

  When she had gone, Dr. Murphy discussed both her case and the television link-up.

  "We think it's an interesting system," he said, "and it has a lot of potential. It's interesting that patients accept it quite well. Mrs. Thompson was a little hesitant at first, but very rapidly became accustomed to the system. There's a reason-talking by closed-circuit TV is really very little different from direct, personal interviews. I can see your facial expression, and you can see mine; we can talk to each other quite naturally. It's true that we are both in black and white, not color, but that's not really important. It isn't even important for der-matologic diagnoses. You might think that color would be terribly important in examining a skin rash, but it's not. The history a patient gives and the distribution of the lesions on the body and their shape give important clues. We've had very good success diagnosing rashes in black and white, but we do need to evaluate this further.

  "The system we have here is pretty refined. We can look closely at various parts of the body, using different lenses and lights. We can see down the throat; we can get close enough to examine pupillary dilation. We can easily see the veins on the whites of the eyes. So it's quite adequate for most things.

  "There are some limitations, of course. You have to instruct the nurse in what to do, in your behalf. It takes time to arrange the patient, the cameras, and the lighting, to make certain observations. And for some procedures, such as palpating the abdomen, you have to rely heavily on the nurse, though we can watch for muscle spasm and facial reaction to pain-that kind of thing.

  "We don't claim that this is a perfect system by any means. But it's an interesting way to provide a doctor to an area that might not otherwise have one."

  Boston's Logan Airport is the eighth busiest in the world. In addition to the steady stream of incoming and outgoing passengers, there are more than 5,000 airport employees. The problem of providing medical care to this population has been a difficult one for many years. Like many populations, it is too large to be ignored, but too small to support a full-time physician in residence. Nor can a physician easily make the journey back and forth from the hospital to the airport; though only 2.7 miles away, the airport is, practically speaking, isolated for many hours of the day by rush-hour traffic congestion.

  The solution of Dr. Kenneth T. Bird, who runs the unit, has been to provide a physician when the patient demand is heaviest, and to provide additional coverage by television. The system now used, called Tele-Diagnosis, is frankly experimental. It has been in operation for slightly more than a year. At the present time, eight to ten patients a day are interviewed and examined by television.