HISTORY
The Shah’s Spleen: Its Impact on History
Leon Morgenstern, MD, FACS
The spleen had never before played a major role in shaping
human history. Failing hearts, damaged brains, or organs
pierced by assassins’ bullets had all occupied center stage in
their time. In 1979, a diseased spleen provoked a serious
conflict between The United States and the newly formed
Islamic Republic of Iran, reverberations of which are still in
play today. In the dramatic evolution of that conflict many
other countries played lesser but significant roles. Medical
professionalism was challenged in a multinational arena,
involving dozens of doctors. In the central role of a hapless
patient in need of urgent surgical treatment was the re-
cently deposed Shah of Iran, Mohammad Reza Shah
Pahlavi.
Mohammad Reza Pahlavi became the Shah of Iran in
September 1941 at the age of 22, after the forced abdica-
tion of his father, Reza Pahlavi, founder of the Pahlavi
dynasty. Unlike his father, who had a strong, despotic de-
meanor, the new Shah assumed the role of a benevolent
despot, whose goals were to modernize the country and
guide it into the 20th century. Within 10 years into his
reign, the oil industry was nationalized, education was up-
graded by building schools, libraries, and institutions of
higher learning, and women’s suffrage was instituted. The
country’s infrastructure was strengthened and the plight of
the Iranian people was unquestionably improved.1
Politically the Shah was decidedly pro-Western in inter-
national relations. Physically he was handsome, urbane,
and outwardly a healthy and active individual, twice escap-
ing assassination attempts and twice surviving crashes in
aircraft he was piloting. Early in his reign it seemed that his
monarchy would fare well under him. But the Middle East
is noted for its constantly seething discontent, and Islamic
extremists continuously challenged the stability of his
reign. In October 1971, undeterred by the gathering
storm, the Shah put on a lavish celebration at the ruins of
ancient Persepolis, marking the 2500th anniversary of the
Persian Empire. If anything, the pompous scale and extrav-
agant cost of the event did nothing but exacerbate the
growing threat to his rule.
Disclosure Information: Nothing to disclose.
Received September 2, 2010; Accepted October 27, 2010.
From the Department of Surgery, David Geffen School of Medicine at Uni-
versity of California, Los Angeles, Los Angeles, CA.
Correspondence address: Leon Morgenstern, MD, FACS, Cedars-Sinai Med-
ical Center, 8700 Becker Blvd, Becker Building - Suite 216, Los Angeles, CA
90048.
© 2011 by the American College of Surgeons
Published by Elsevier Inc.
In early 1974, The Shah’s spleen entered the picture.
While vacationing on the isle of Kish in the Persian Gulf he
noticed an unusual swelling in his left upper abdomen. He
had been water-skiing (a favorite activity) and the swelling
was probably rendered more prominent in the posture as-
sociated with that sport. Back in Tehran, his physicians
determined that the swelling was an enlarged spleen and
summoned urgent consultation with the French hematol-
ogist Dr Jean Bernard, well known for his expertise in he-
matologic disorders, particularly lymphoma. Dr Bernard
chose to take with him his young pupil, Dr Georges
Flandrin. So began the keeping of a secret that remained
well guarded for the next several years. Even the invitation
was deceptive. They were invited ostensibly not to examine
the Shah, but one of his aides. On their arrival it was made
clear that the patient was the Shah himself.
The French doctors examined the Shah and confirmed
the presence of splenomegaly. They also detected some cer-
vical lymph node enlargement. Blood studies, including
bone marrow, established the diagnosis of chronic lym-
phatic leukemia. Although the doctors recommended a
cervical node biopsy for a tissue diagnosis as well, the Shah
balked at the idea of a surgical procedure. Anxious to spare
the Shah from the anxiety likely to be induced by the word
cancer, the Shah’s personal physician convinced the visiting
French doctors to tell the Shah that he had Waldenstrom’s
“disease.” The Shah accepted this diagnosis and only
learned of his true diagnosis several years later. The Shah,
his doctors, and his personal aide all agreed that there was
to be no disclosure of any information even suggesting
malignancy to anyone. The Shah’s condition was to be kept
a well-guarded secret from everyone, even his wife, the
Queen Farah. She was to learn of the diagnosis, to her
dismay, several years later.
The French consultants initially recommended observa-
tion only. Several months later they prescribed a regimen of
chlorambucil to keep the disease in check. Although he
adhered to the chemotherapeutic regimen initially, the
Shah proved to be an inconsistent and noncompliant pa-
tient. On one occasion he even took the wrong medication
as a result of a prescription refill error, also a consequence of
the conspiracy to keep the diagnosis secret. In 1975, the
doctors were called again to meet the Shah in Zurich, Swit-
zerland. There they found that the spleen was enlarging and
recommended that the dosage of chlorambucil be in-
creased. They also advised that the Shah desist from phys-
ical activities such as skiing, a sport he was inveterately fond
ISSN 1072-7515/11/$36.00
260 doi:10.1016/j.jamcollsurg.2010.10.014
Vol. 212, No. 2, February 2011
of. They insisted that his condition be monitored by more
frequent blood counts and examinations. Dr Bernard, then
aged 67, designated this task to his younger colleague, Dr
Flandrin. So began a traveling routine for Dr Flandrin, well
cloaked in secrecy, which would involve his seeing and
examining the Shah every 5 or 6 weeks as well as collecting
blood samples for examination in France. By the time the
Shah left Tehran in 1979, Flandrin had made 35 trips to see
his patient, a round trip distance of more than 5,000 miles,
equivalent to traveling 7½ times around the world. It was
only the beginning of his later transcontinental journeys to
follow the Shah in the turbulent odyssey that was to ensue.
In 1977, Queen Farah was informed by Drs Bernard and
Flandrin of the true diagnosis of chronic lymphatic leuke-
mia, but the Shah himself still thought he had Walden-
strom’s “disease.”
The political situation in Iran had begun to deteriorate
seriously in 1978 with increasing popular sentiment
against the monarchy, fueled by the rise of Islamic extrem-
ism. The Shah’s benevolent despotism had also become less
benevolent and his secret police force, “Savak,” was feared
and despised. As the position of the Shah weakened, he
ostensibly received assurances from US official sources that
he would be welcomed in the United States if he had to flee
Iran. In 1979 he did indeed have to flee, in the wake of a
violent wave of strikes and riots, against which he refused to
use military force. The year 1979 was then to be a calami-
tous year in which he would seek refuge in 7 countries,
suffer constantly declining health, undergo 4 operations,
and experience rejection by both governments and doctors
in a maelstrom of complex political and medical decisions.2
On January 16, 1979, encouraged by the United States
government, the Shah and his entourage departed Tehran
in a Boeing 707 piloted by the Shah himself. At the time of
their departure the Shah clung to 2 unrealistic assump-
tions. One was that the departure was for a temporary
“vacation” and that he would be recalled by popular senti-
ment as he had been after a similar coup in 1959. The other
was that his invitation to come to the United States was a
firm commitment that he could rely on. Delaying his trip
to the United States, he chose instead to accept invitations
from President Anwar Sadat of Egypt and King Hassan II
of Morocco to visit their countries. He first stopped in
Aswan, Egypt, where he received a hospitable and fittingly
royal welcome from Anwar Sadat and his wife Jehan. In
Aswan, Dr Flandrin visited the Shah for his regular exam-
ination and laboratory studies. The visit to Egypt was a
short one and was followed by a visit to Marrakech, Mo-
rocco, where he enjoyed the hospitality of King Hassan II.
There he was again visited by Dr Flandrin, faithfully keep-
ing vigil on his peripatetic patient. This idyllic stay in Mo-
Morgenstern The Shah’s Spleen: Its Impact on History 261
rocco ended somewhat abruptly and unpleasantly after sev-
eral weeks, when the government of Morocco decided
(with encouragement from the government of France) to
request the Shah to leave.
The sudden need to depart Morocco posed an urgent
and unexpected problem.3 Events in Iran had gone from
bad to worse. On February 14, 1979, Valentine’s Day, a
mob had broken into the American Embassy in Tehran and
committed mayhem. By the time they were dispersed, an
American marine sergeant was missing and the embassy
staff was severely shaken. This development changed the
attitude of the United States government, then under Pres-
ident Jimmy Carter. The Shah was told, to his great con-
sternation, that his planned settlement in the United States
was not “convenient” at the time, considering the unstable
situation in Tehran. So the Shah was left as a man without
a country. He was refused safe haven in Switzerland,
France, Italy, England, Jordan, and other countries that
might have been suitable choices for him. Only Paraguay
and South Africa indicated their willingness to take him,
but they were not acceptable to the Shah. Declining health
was also an issue. Photographs of the Shah in Egypt and
Morocco showed him appearing increasingly gaunt.
The Shah’s twin sister, Princess Ashraf, came up with a
tenable solution by suggesting a temporary haven in the
Bahamas, a Caribbean island nation with a salubrious cli-
mate and a relatively safe environment. To facilitate this
move, the Shah’s friend, Henry Kissinger, the former US
Secretary of State, flew to the Bahamas to negotiate with
the Prime Minister there. The Bahamian government
agreed to issue a visa to the Shah, but only on the condition
that he stay on Paradise Island, a small island adjacent to
Nassau, where a small beach house was available. When the
negotiations were complete, The Shah left Morocco on
March 30, 1979, for his next refuge, a very small beach
cottage on a tiny island in the Atlantic, lodging decidedly
unfit for a king.
The 10-week stay in the Bahamas was an ordeal for the
Shah and his wife Farah. The quarters were cramped, the
humid climate uncomfortable, and the isolation boring.
The Shah was depressed by the increasingly horrible news
from Iran, the unaccustomed nonregal existence, and per-
haps most important of all, his worsening health. He had
discovered an enlarged lymph node in his neck that occa-
sioned another visit by Flandrin, who aspirated the node
and sampled the Shah’s bone marrow. The news was not
good. The presence of immunoblasts indicated a transfor-
mation of the leukemia from a chronic, less threatening
stage to an acute form that required more aggressive treat-
ment, including radiation and possibly surgery for the
splenomegaly. The chemotherapy was changed from
262 Morgenstern The Shah’s Spleen: Its Impact on History
chlorambucil to the stronger drug combination of vincris-
tine, procarbazine, nitrogen mustard, and prednisone. Be-
cause this was given by weekly infusion, more visits by
Flandrin were necessary. He advised the Shah that it was
time for him to be hospitalized for more intensive diagnos-
tic and therapeutic measures. That would have meant re-
vealing the long kept secret of the Shah’s illness. Although
the Shah agreed that it might eventually be necessary, he
believed that it was neither the time nor the place for that to
be done.
Meanwhile, intense efforts were being made in Washing-
ton to find the next haven for the Pahlavis because their stay
in the Bahamas was limited by their expiring visa and the
lack of suitable medical facilities. Involved in these efforts were
Henry Kissinger, the former secretary of state, Zbigniew
Brzezinski, the national security advisor, President Jimmy
Carter, Hamilton Jordan, the President’s chief of staff, and
David Rockefeller, a long time friend of the Shah. The
United States was still out of the question considering the
state of affairs in Iran and the precarious status of the re-
maining Americans there. Kissinger finally made a crucial
personal call to the President of Mexico with a plea to admit
the Shah to that country. Kissinger’s request was received
favorably and it was a solution that the Shah found accept-
able. With only 2 days remaining before the expiration of
the Bahamian visa, Mexico granted him a 6-month tourist
visa.
In Mexico, a suitable lodging was found in Cuernavaca,
a city 30 miles west of the capital, known for its beauty and
pleasant climate. A house called the Villa of Roses, more
suitable to the royal taste, was available there and the Shah,
Queen Farah, their Great Dane dogs, and their retinue of
servants settled in comfortably for a several-month stay. In
Washington the debate continued about the feasibility of
allowing the Shah’s entry into the US, a promise that had
been graciously made previously but then rudely broken.
That debate came to a head only 4 weeks after their arrival
in Mexico, when the Shah’s health took a drastic turn for the
worse. Flandrin visited him several times and adjusted the dose of
chemotherapy. Mexican doctors, called in for the Shah’s onset of
fever and jaundice, diagnosed malaria. At this point the
decision was made to call in an American consultant,
given the increasing complexity of the medical problems.
With the advice of the David Rockefeller staff, the physi-
cian chosen was a New York internist, Dr Benjamin H
Kean, well known for his prominent Park Avenue practice
and his subspecialty in tropical diseases.4 In late September
1979, Kean arrived to visit and examine the Shah. He was
astounded by what he found. As he put it, “the Shah had
become a sad, shrunken figure.” He was deeply jaundiced
and obviously cachectic. Kean quickly excluded the diag-
J Am Coll Surg
nosis of malaria and instead suspected obstructive jaundice,
possibly due to bile duct obstruction, but when he wished
to have some blood samples taken the Shah refused without
the concurrence of his “French doctors.” “Flabbergasted”
at the mention of “French” doctors that no one had ever
mentioned to him before, Dr Kean withdrew from the case
as diplomatically as he could and flew back to New York.
Again the Queen called Dr Flandrin to come to Mexico.
When Flandrin arrived, one glance at the Shah told him
that the Shah had to be hospitalized. At the time, the Shah
was adamant in his refusal to consider the United States, so
piqued was he at American behavior toward him. Again Dr
Kean was summoned to Cuernavaca, this time to meet with
Dr Flandrin. Dr Flandrin disclosed to him that the Shah
had been known to have lymphatic cancer for 5 years but
had consistently refused a proper workup. This was the first
time that Kean learned of the diagnosis of lymphoma. Both
he and Flandrin agreed on the need for the proper imaging
studies that were available in nearby Mexico City, but the
Shah balked at such a move because of the language diffi-
culties and some doubts about hospital arrangements there.
Dr Kean said that he favored an American hospital and that
there were at least 7 cities in the US with world-class med-
ical centers where such studies could be done. Though the
Shah was embittered by what he considered his betrayal by
the United States he reluctantly agreed. Dr Kean’s choice
was New York Hospital in New York City, where he was on
staff, knew the doctors, and was well acquainted with the
facilities. He suggested that the process for moving the
Shah to New York begin immediately. Dr Flandrin, origi-
nally in favor of hospitalizing the Shah in Mexico, agreed
that the facilities in the US would be better. He then with-
drew from any further care of the Shah, a duty he had
performed faithfully and at great effort for the past 5 years.
Dr Kean now assumed the role of the Shah’s personal phy-
sician. He made the request through government channels
that the Shah be admitted without delay to the US for
hospitalization at New York Hospital and awaited permis-
sion to see this accomplished.
The news that the Shah was suffering from cancer, that
he needed urgent treatment, and that Kean had recom-
mended his immediate admission to New York Hospital in
the United States hit Washington like a bombshell. The
situation in Tehran had deteriorated even further. The Pres-
ident and key members of his staff were still divided on the
advisability of admitting the Shah to the US for fear of
provoking even more anti-American violence in Iran. Pres-
ident Carter was especially fearful of such a consequence,
but finally conceded that for humanitarian reasons the US
could no longer refuse the Shah admission. Permission was
granted for admission to New York Hospital. Whatever the
Vol. 212, No. 2, February 2011
reaction in Tehran would be, it would have to be accepted
because decency and principle demanded it.
The Shah and his party left Mexico for the US on Oc-
tober 22. On arrival in New York he was admitted to New
York Hospital and very quickly underwent a CT scan. It
showed that the jaundice was due to common bile duct
obstruction by gallstones. The spleen was also enlarged to
many times normal size. The problems were now 2-fold:
biliary tract disease and the worsening lymphoma. For the
treatment of the former, the surgeon chosen was Dr Frank
Glenn, well known for his contributions to surgery of the
biliary tract; for the lymphoma, the oncologist of choice
was Dr Morton Coleman, a senior oncologist at the med-
ical center. Therein lay the genesis of another problem. The
biliary tract operation was arranged, without the knowl-
edge of Dr Coleman, for October 24. Dr Coleman favored
splenectomy, but this was not in the operative plan, to the
consternation of Dr Coleman. The operation was a chole-
cystectomy and common duct exploration. The surgeons
also excised a cervical node for examination. Had the
spleen been removed at the time, as urged by Dr Coleman,
this story would be nearly over. Dr Glenn’s rejoinder to Dr
Coleman’s request to also perform a splenectomy was “Tell
Mort, he’s a braver man than I.” Considering the risks at
the time, the surgeon’s judgment was probably the wiser.
Because the spleen was not removed, however, the worri-
some odyssey of the Shah in search of treatment was des-
tined to continue.
Histologic examination of the excised node confirmed
the malignant transformation of the relatively indolent
chronic lymphatic leukemia into a more malignant lym-
phoma. The terminology of the diagnosis at the time was
histiocytic lymphosarcoma, now called large cell lym-
phoma. That bad news was more or less suspected from the
observed clinical course, with progressive enlargement of
the cervical nodes and the increasing size of the spleen.
What was not expected, but disclosed on a postoperative
T-tube cholangiogram, was the presence of a retained gall-
stone within the common bile duct. For treatment of this
complication, the Shah’s physicians summoned Dr H
Joachim Burhenne, a noted radiologist from British Co-
lumbia, Canada. He had devised a nonoperative means of
removing retained intraductal stones by snaring them in a
wire basket introduced through the T-tube tract under ra-
diologic control. He accomplished this successfully and
once again the Shah’s treatment was on course. Because he
was still too debilitated for chemotherapy, it was decided to
begin radiation therapy of the cervical nodes at Memorial
Sloan Kettering Medical Center, where superior facilities
were available, just across the street from New York Hospi-
tal. Initially, the hospital authorities at Sloan Kettering,
Morgenstern The Shah’s Spleen: Its Impact on History 263
fearful of a possible terrorist attack and unwilling to be
involved in the controversial status of the Shah, balked at
accepting him for treatment there. But they relented and
treatment of the diseased nodes by radiation was begun.
For privacy and for security reasons radiation was admin-
istered at odd hours in the early morning or late evening,
when the Shah could be transported safely through the
tunnel connecting New York Hospital and Memorial Sloan
Kettering Medical Center. It was a difficult and unpleasant
regimen for all concerned. During the tunnel transport his
wife Farah accompanied the Shah. The nodes responded
well to the radiation and receded. Now the spleen, growing
larger and beginning to cause symptoms of hypersplenism,
required removal.
On November 4, the political volcano in Tehran erupted
in a violent and not wholly unexpected fashion. An unruly
mob of militant students overran the American Embassy
and took 66 American hostages prisoner. This overt act of
hostility and belligerence shook the American government
to its very core. It also meant a new predicament for the
ailing Shah. It was his presence in the United States that
had precipitated the attack on the embassy and his contin-
ued presence could only make matters worse. It immedi-
ately became obvious that the Shah was no longer comfort-
ably welcome in the US, and the sooner his departure could
be arranged the better. During his entire hospitalization,
the stance of the United States government had been no-
ticeably cool and distant. Now it was urgently interested in
his leaving the country as soon as possible, feeling that his
presence in the US jeopardized the fate of the hostages in
Iran. The Shah himself, humiliated by the inhospitable
atmosphere and unwilling to bear the blame for any harm
to the hostages, offered to leave the country as soon as his
condition permitted and arrangements could be made. He
was now 1 month postoperative; and the retained bile duct
stone had been removed on November 27. Dr Kean de-
clared him fit to travel. But where?
Return to Mexico was the obvious choice because he had
been an invited guest there before and had left only for
medical treatment in the United States. His Mexican visa
was still valid and the Shah was pleased with his environs
there, both physically and politically. However, from Mex-
ico came the stunning and unexpected news by cable that
“The Shah is not welcome in Mexico . . . . His presence is
becoming a threat to our national interest.” Return to Mex-
ico was out. Once again the Shah was a man without a
country and once again to the United States fell the oner-
ous task of finding a haven for a deposed monarch that no
country was anxious to receive. Although President Sadat
extended a gracious invitation for him to return to Egypt,
the choice was unacceptable because of the concern that it
264 Morgenstern The Shah’s Spleen: Its Impact on History
might destabilize relations with other Arab states. As an
interim solution Washington offered the Shah a temporary
site where he could recuperate while the search went on.
The site offered was Lackland Air Force Base near San
Antonio, TX and the Shah had little choice but to accept.
The Shah and his company left for Texas on December 2.
In his memoirs5 the Shah described the departure from
New York Hospital as resembling a “‘getaway’ scene from a
1930’s gangster film. About fifty heavily armed FBI men
guarded all the doors and exits and were posted in the
streets and the inside hallways.”
The Lackland Air Base was an Air Force training facility
that the Shah had some familiarity with, because Iranian
pilots had trained there. The arrival at Lackland in the early
morning was almost as comedic as the departure from New
York. For security purposes the Shah and Queen Farah were
escorted to the psychiatric wing in the Base Hospital, where
the windows were barred and the atmosphere was one of
incarceration rather than lodging. When the Queen, feel-
ing uncomfortably claustrophobic, objected strenuously,
they were moved to a small apartment in the Officer’s
Quarters, which, though cramped, was more acceptable.
The royal couple and their 2 Great Dane dogs settled in and
the Shah resumed his recuperation, regaining some of his
strength and energy. The ordeal of his splenectomy still lay
ahead. During the latter part of his stay at Lackland he was
examined by Air Force doctors. They found that the spleen
had continued to grow larger and laboratory tests indicated
worsening of his hematologic status. They recommended
splenectomy without too much further delay. Dr Kean also
visited and agreed that splenectomy was urgently indi-
cated. As a temporizing measure the dosage of chemother-
apy was increased.
Meanwhile, Washington was increasingly anxious to
have the Shah leave the country as quickly as could be
arranged and continued exploring the few choices avail-
able. Panama, then under the rule of the dictator General
Omar Torrijos, had previously offered the Shah a haven but
the Shah had refused this as a possibility. Now Washington
began to vigorously pursue this as a choice again and began
energetic diplomatic activity to make it a reality. When
General Torrijos agreed to provide Panama as a haven, a
number of high placed dignitaries were dispatched to Lack-
land to convince the Shah that Panama was a good solu-
tion. There the excellent facilities of Gorgas Hospital in the
Canal Zone would be available for his medical care and
suitable living conditions could be arranged. Dr Kean con-
curred that this was acceptable. Although not enthusiastic
about the choice, the Shah ultimately agreed. After a 14-
day stay at Lackland Air Force Base in Texas, the Shah and
his party were flown to Howard Air Force Base in the Canal
J Am Coll Surg
Zone, arriving on December 15. Lodgings were chosen on
Contadora Island, one of an island chain in the Pacific off
the coast of Panama, 30 miles from Panama City. There
they moved into a house owned by the American ambassa-
dor and were under constant heavy guard by a force, inter-
estingly enough, headed by Colonel Manuel Antonio
Noriega, later to become notoriously famous in his own
right for more nefarious activities.
The major medical problem for the Shah at Contadora
was the increasingly urgent need for splenectomy. Where,
when, and by whom would it be done? Answering these
questions involved an array of physicians on a multina-
tional scale that did more to confuse than clarify the issue.
Panamanian physicians, supplied by General Torrijos, su-
pervised his day-to-day care. Dr Kean flew in from New
York to act as his personal physician. The Queen called
Georges Flandrin to come. The surfeit of physicians was
not in the Shah’s best interests. What ensued resembled a
Marx Brothers comedy except that its overtones were
fraught with tragic overtones for the Shah. Dr Flandrin and
the Panamanian physicians were in favor of a splenectomy
performed by Panamanian surgeons in a private Panama-
nian hospital, The Paitilla Hospital in Panama City. Dr
Kean disagreed, requesting instead that an American sur-
geon, Dr Michael DeBakey, at the Gorgas Hospital in the
Canal Zone, perform the surgery. He invited Dr DeBakey,
who promptly agreed and flew to Panama with his own
team, prepared to do the surgery at Gorgas. The Panama-
nians then insisted that the operation be done at the Paitilla
Hospital. Dr DeBakey finally agreed that he would do it at
the Paitilla hospital. But then the Panamanian doctors be-
lieved that it was denigrating to have the operation by a
foreign surgeon when they were capable of doing it them-
selves. One of the Panamanian doctors even called Dr
DeBakey an “itinerant surgeon” in a deprecatory way. The
Shah himself called the medical deliberations a “soap op-
era.” Finally all the doctors involved agreed to sit down and
decide on the definitive arrangements for the operation. At
that meeting the conferees reached the consensus that Dr
DeBakey would lead the operative team at the Paitilla hos-
pital. Although at the time this seemed to be a solution, Dr
DeBakey then asked that the operation be delayed for 2
weeks because the Shah had a respiratory infection. In re-
ality it was a ruse by Dr DeBakey to withdraw altogether
from any arrangements in Panama. He, Dr Flandrin, and
the Shah all agreed that the operation should not be done
there under any circumstances. By the time the “smoke
cleared” the Shah still had his spleen, the spleen required
urgent removal, and the new problem was to get out of
Panama. (This version of the events in Panama has been
simplified to the extreme. What actually happened and
Vol. 212, No. 2, February 2011
who said what to whom varies from source to source,
which is not surprising considering the huge cast of
characters: doctors, politicians, diplomats, family mem-
bers, and others.)
There was another urgent reason for the Shah to leave
Panama. The Panamanian dictator Torrijos was secretly ne-
gotiating to have the Shah arrested and extradited to Iran.
With plans for the operation off and the prospect of extra-
dition brewing, Queen Farah phoned her friend, Jehan
Sadat, in Egypt asking her for help and advice. Jehan Sadat
quickly answered that the Pahlavis should come to Egypt
without delay. In this advice her husband, President Anwar
Sadat, readily concurred and said he would dispatch the
presidential plane to bring the Shah to Egypt. When the
news of the Shah possibly leaving Panama for Egypt
reached Washington, it set off a frantic and intense effort by
the United States government to persuade him to remain in
Panama, but the Shah was determined to leave. To summa-
rize the complex events that transpired, suffice it to say that
the Shah, his Queen, his dogs, and his entourage barely
escaped from Panama on the afternoon of March 23,
bound for Egypt on a chartered DC8. They arrived in
Egypt on the following day after a refueling stop in the
Azores. At the airport, the Sadats greeted the Shah and the
Queen warmly; Mrs. Sadat was struck by the Shah’s wan
appearance and obvious weight loss. Later, the Shah was
taken to the Maadi Military Hospital just outside of Cairo
to await his long delayed operation.
With the Shah ensconced in a hospitable environment,
his medical consortium was quick to follow him there.
From Texas on March 26 came Dr Michael DeBakey with
a team of 6 assistants and suitable surgical equipment for
the long delayed operation. From Paris came the ever-
faithful Georges Flandrin, summoned to Cairo by Queen
Farah. And from New York came Benjamin Kean, who had
assumed the role of the Shah’s personal physician. Also
provided by President Sadat was a group of Egyptian phy-
sicians to provide whatever help was needed. It was a for-
midable array of talent for one patient. Hardly fitting was
the hospital itself, described by Dr Kean as a “hygienic
disaster area” and a “fourth rate” hospital.
The operation was performed at 8:00 PM on March 28,
4 days after the arrival of the Shah in Egypt. In the operat-
ing room, the operating table was placed in a position so
that the Shah’s head could point toward Mecca for the
most favorable outcome. Dr DeBakey opened the abdo-
men through a long midline incision, exposing the now
massively enlarged spleen, estimated by Dr DeBakey to be
10 times normal size. According to Dr Kean, the spleen was
easily delivered and removed in a procedure that took 80
minutes. The abdomen was closed without drainage.
Morgenstern The Shah’s Spleen: Its Impact on History 265
Examined in the pathology laboratory, the spleen
weighed 1,990 g. It was obviously riddled with tumor. A
liver biopsy also showed diffuse tumor involvement, unlike
the observation of a normal looking liver at the time of the
Shah’s cholecystectomy 6 months earlier.
There were some unusual aspects to the operative scene,
if written accounts are to be believed. Queen Farah, the
Shah’s sister Princess Ashraf, the Shah’s children, and other
interested observers watched the operation on a closed tele-
vision monitor in a room adjoining the operating room.
After the splenectomy, Crown Prince Reza took “hun-
dreds” of photographs of the excised spleen from all angles
in the pathology laboratory. Unfortunately none of these
were destined to document the event because the film was
defective.
Dr DeBakey was pleased that the operation had gone
well and expressed optimism in assessing the Shah’s prog-
nosis.6 He said that in view of the improved bone marrow
picture and the absence of retroperitoneal nodes, the Shah
could do well with chemotherapy. Dr Kean did not share
his optimism, having seen the extensive involvement of the
liver with tumor. President Sadat expressed his apprecia-
tion by awarding Dr DeBakey the First Order of the Re-
public. In Iran the Ayatollah Khomeini derided the Egyp-
tian role in the Shah’s treatment as another Satanic plot. In
Egypt, the Muslim Brotherhood fomented riots that led to
bloodshed.
The Shah’s response to the operation was good. By the
morning after the operation he looked “remarkably well,”
according to Kean. When informed of the pathology find-
ings, Queen Farah wanted the truth withheld from the
Shah, but DeBakey insisted on full disclosure, which he
made at a press conference. Both Kean and DeBakey were
in favor of delaying chemotherapy until the Shah was in
suitable condition to tolerate it. Notwithstanding this ad-
vice, chemotherapy was begun by the Shah’s Egyptian doc-
tors even before the Shah’s discharge from the Maadi Hos-
pital. He left there about 2 weeks after the operation to
convalesce at the Kubbeh Palace, an elegant guesthouse in
Cairo reserved for heads of state and other distinguished
visitors. Initially recovery seemed to be going well but it
was soon marred by the onset of fever, nausea, vomiting,
and pain in the left upper quadrant of the abdomen. X-rays
showed a left pleural effusion, which was tapped and
yielded infected pleural fluid. Dr Flandrin, now back in
Paris, was contacted about the Shah’s turn for the worse.
On hearing the findings he suspected that the Shah had
developed a subphrenic abscess and advised that Dr
DeBakey be called to see him. There then ensued the in-
volvement of a dismaying multiplicity of doctors that was
certainly not in the best interests of the patient. Princess
266 Morgenstern The Shah’s Spleen: Its Impact on History
Ashraf requested that the Shah be seen by Dr Morton
Coleman, the New York oncologist who had been con-
sulted during the Shah’s stay in New York. Dr Coleman
was determined that he could treat the Shah’s lymphoma
with aggressive chemotherapy, an approach for which he
was noted. On arriving in Cairo, however, and examining
the Shah, he also believed that the Shah had a subphrenic
abscess and agreed with Dr Flandrin that Dr DeBakey
should be called to see him. At the end of April, Dr
DeBakey flew from Texas to Cairo and evaluated the Shah’s
condition. He did not concur that there was a subphrenic
abscess based on his examination, commenting also that his
own work on subphrenic abscess was “classic.” He attrib-
uted the Shah’s symptoms to the chemotherapy and ad-
vised that the dosage be reduced. Another month passed
and the Shah’s symptoms continued to worsen to the point
where he could no longer eat. Faced with the confusing
array of differing opinions, Queen Farah, in desperation,
called Dr Flandrin to return to Cairo from France, where
he was on vacation. When he arrived in Cairo, Flandrin was
distressed at the deplorable state in which he found the
Shah. Coleman and Flandrin were now certain that the
Shah did have a subphrenic abscess that had to be drained.
Kean, following the developments from New York and
called by the Shah’s aide, was on the verge of returning to
Cairo. Queen Farah and Princess Ashraf were at logger-
heads at who should treat and how to treat. Drs Coleman
and Flandrin disagreed bitterly on the management of the
Shah’s lymphoma. Finally, when the Shah’s condition ap-
peared increasingly desperate, Flandrin called a surgeon
from Paris, Dr Pierre-Louis Fagniez, to operate on the Shah
for a subphrenic abscess. On opening the abdomen, Dr
Fagniez drained a liter and a half of pus containing rem-
nants of necrotic pancreas. It was a dismaying aftermath to
the long delayed splenectomy. The splenectomy had been
performed on March 28. The drainage was performed on
June 30. By any standards, that interval was too long.
Though the Shah’s condition improved temporarily, the
improvement was short lived.
Acrimony and difference of opinion continued among
the many doctors involved in the treatment of the Shah’s
illness. Coleman and Flandrin were at odds, the Egyptians
were unhappy with their subsidiary role in the case. In New
York, Dr Kean believed the chemotherapy should be halted
and was still considering a trip to Cairo. The Shah’s family
members Queen Farah and Princess Ashraf were also in
disagreement on who should manage the treatment. Fi-
nally, President Sadat stepped in and confirmed Dr
Flandrin’s role as the Shah’s primary physician.
The etiology of the subphrenic abscess added yet an-
other note of acrimony to a tale already brimming with it.
J Am Coll Surg
Flandrin faulted DeBakey for not having used a drain in
the splenic bed that might have prevented the abscess.
Some Egyptian doctors claimed that the tail of the pan-
creas had been injured during removal of the spleen. Dr
DeBakey denied this.The controversy spilled over into the Egyp-
tian and American press. Dr Gerald Lawrie, one of DeBakey’s
assistants at the Shah’s operation, offered the following
account: “The tail of the pancreas was deeply imbedded in
the hilum of the massively enlarged spleen . . . The splenic
vessels were controlled by clamping . . . It was well recog-
nized that pancreatic tissue was divided during this maneu-
ver . . . and meticulously oversewn . . . it was not felt that
drainage was necessary.”
But the pancreas is an unpredictable adversary in sur-
gery. In retrospect, it does seem likely that some pancreatic
leakage initiated the process that led to the subphrenic
abscess. The major judgmental error was the long interval
before drainage was performed.
Toward the end of July 1980 it was obvious that the Shah
was dying. On the morning of July 27, nearly a year and a
half after his departure from Iran, his odyssey and his life
ended. He died surrounded by his close family members.
He was given a State funeral and buried in a tomb befitting
his royal status in the el-Rifa mosque, a historic and majes-
tic structure located in a beautiful section of Cairo.
Did the Shah’s spleen really affect history? Perhaps it is
more accurate to say that his lymphoma had an impact on
history, and the spleen was a principal actor in the drama
that ensued, particularly in the latter part.7 Neither the
illness nor the spleen had any part in the Islamic revolution
that deposed the Shah, but the fundamentalist fury that
followed the revolution sentenced him to death and reviled
any country that countered that sentence. The admission
of the Shah to the United States for treatment of his illness
triggered the capture of the American Embassy in Tehran
and the taking of American hostages. Relations between
Iran and the United Stales have never recovered from that
hostile action, albeit for other actions as well. We are still
the “great Satan” to the Islamic theocracy, and The Islamic
Republic of Iran remains for us an irresponsible adversary
in the quest for a peaceful world.
During the latter part of the Shah’s ordeal, when his
need for splenectomy was paramount, The Islamic Repub-
lic of Iran also influenced the 1980 presidential election.8
The occupation of the United States Embassy and the tak-
ing of American hostages dominated the pre-election news.
The incumbent, President Jimmy Carter, might have held
his own against Ronald Reagan were it not for Carter’s
inability to solve the hostage crisis. The failure of the rescue
mission to free the hostages sealed Carter’s loss to Reagan.
The sardonic freeing of the hostages on the day of the
Vol. 212, No. 2, February 2011
presidential inauguration not only humiliated Carter, but
also infused Reagan with a confidence of power that was to
characterize his presidency. The Iranian government rel-
ished this retaliatory act against a president who thwarted
their plans for the deposed Shah.
In October 1981, President Anwar Sadat was assassi-
nated in Cairo, Egypt by the same extremist elements that
fomented the bloody riots after his welcome of the Shah the
year before. That event was not the sole factor in the ex-
tremist hatred of Sadat, but it was a component that built
up to the act of his killing.
Summarizing, in the 18 months that the Shah traversed
the world in search of refuge and medical treatment he
visited 7 countries and was under treatment by at least 8
teams of physicians. Henry Kissinger likened his odyssey to
the legend of the “Flying Dutchman,” the ghost ship that
sailed the oceans of the world endlessly seeking a port.
Neither the countries nor the many physicians involved,
with some exceptions, acquitted themselves well. The pa-
tient was not cared for in the best tradition of good medical
practice. There were too many governments, too many pol-
iticians, too many diplomats, too many disputatious family
members, and too many doctors involved in a complicated
illness that demanded meticulous and delicate manage-
ment. The Shah was denied this. It was not a proud mo-
ment in world history, medical history, or the history of
surgery.
BIOGRAPHICAL ADDENDUM: 2010
Dr Jean Bernard
Dr Bernard was 67 years old when he was summoned to see
the Shah of Iran. At the time, he was regarded as the dean of
hematology in France. He was a professor at the Pasteur
Institute, Director of the Research Institute for Blood Dis-
eases and Leukemia, and head of the University of Paris
immuno-hematology laboratory. He had eclectic interests
and activities. During World War II he was a resistance
fighter. In 1983 he was President of the French National
Council for Research Ethics in Medicine and Life Sciences.
He not only published prolifically in hematology but also
wrote 3 volumes of poetry and 20 books on medical ethics
and philosophy. He died at the age of 99 in 2006.
Dr Georges Flandrin
Dr Flandrin, a pupil and trainee of Dr Bernard, was already
a well-known hematologist in his own right when Dr Ber-
nard asked him to come with him on the trip to Tehran.
Flandrin was then 41 years old but looked remarkably
young for his age. At one point the Shah jokingly remarked
to him “Are you really a doctor or just a medical student?”
Flandrin tended to the Shah from the first visit in 1974
Morgenstern The Shah’s Spleen: Its Impact on History 267
until the Shah’s death in 1980. Thereafter, Flandrin re-
sumed a distinguished academic career as Professor of He-
matology at the famed Necker Hospital in Paris. He retired
as Professor Emeritus in 2006.
Dr Benjamin H Kean
Dr Kean was a practicing internist in New York City and
Professor of Tropical Medicine at the New York Hospital-
Cornell Medical Center when he was asked to consult on
the illness of the Shah, in Cuernavaca, Mexico, in 1974. Dr
Kean was then 67 years old. Of all the Shah’s physicians, he
was the most colorful and flamboyant. He had a reputation
as a gambler as well as a physician to the rich and famous in
New York. Because his role in the care of the Shah was
allegedly misrepresented in the august journal “Science,”
he sued for libel and won a settlement. After the death of
the Shah he returned to his New York practice and profes-
sorship at Cornell, eventually retiring as Clinical Professor
Emeritus. He died in 1994 at the age of 82.
Dr Michael DeBakey
If Flandrin was the most faithful of the Shah’s physicians
and Kean was the most flamboyant, then Michael DeBakey
was without doubt the most famous. When asked by Kean
to perform the splenectomy on the Shah, DeBakey was 66
years old. He was at the height of his illustrious career and
already legendary in American surgery for the introduction
of innovative techniques in cardiovascular surgery. In 2000
the Library of Congress cited him as a “Living Legend.” His
legendary status persisted to the very end of his life. When
he suffered an aortic dissection at the age of 97 his life was
saved by an operation that he himself had devised. Grateful
for the operation, which was successful (though performed
against his own expressed wishes), DeBakey lived for 2
more years. He died in 2008 at the age of 99, 2 months
short of another notable achievement, that of becoming a
centenarian.
Dr Morton Coleman
Morton Coleman was a senior oncologist at New York
Hospital when he was called to see the Shah there in 1979.
He was 40 years old. He was known for his aggressive
approach to the chemotherapy of lymphoma and persisted
in those recommendations for the Shah’s treatment almost
to the very end of the Shah’s life. As noted, that ending was
marked by bitter contention. At present, Dr Coleman is
Director of the Center for Lymphoma and Myeloma at the
New York Hospital-Weill Cornell Medical Center.
Dr Pierre-Louis Fagniez
Pierre-Louis Fagniez was 41 years old when he performed
the Shah’s last operation, the drainage of his subphrenic
268 Morgenstern The Shah’s Spleen: Its Impact on History
abscess in Cairo in June 1980. On his return to France his
surgical career was principally at the Hopital Henri Mon-
dor, a University of Paris Hospital in Cretail, a southeastern
suburb of Paris. He had a brief foray in French politics and
retired several years ago.
REFERENCES
1. Afkhami GR. The Life and Times of the Shah. California: Uni-
versity of Berkeley Press; 2009.
2. Shawcross W. The Shah’s Last Ride: the Fate of an Ally. New York:
Simon & Schuster; 1988.
3. Harris D. The Crisis. New York: Little Brown & Company; 2004.
J Am Coll Surg
4. Kean BH, Dahlby T. One Doctor’s Adventures Among the Fa-
mous and Infamous from the Jungles of Panama to a Park Avenue
Practice. New York: Ballantine; 1990.
5. Pahlavi MRS. Answer to History. New York: Irwin Publishing;
1980:1–34.
6. Demaret K. Interview with Dr Michael DeBakey. People Maga-
zine. Available at: http://www.people.com/people/archive/article/
0,,20076289.html. Accessed July 17, 2010.
7. Altman LK. The Shah’s health: a political gamble. New York
Times. Available at: http://www.nytimes.com/1981/05/17/
magazine/the-shah-s-health-a-political-gamble.html. Accessed July
17, 2010.
8. Parry R. How two elections changed America. Consortiumnews.
com. Available at: http://www.consortiumnews.com/2009/110409.
html. Accessed July 17, 2010.