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 recently 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 abdication of his father, Reza Pahlavi, founder of the Pahlavi dynasty. Unlike his father, who had a strong, despotic demeanor, 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 upgraded 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 international relations. Physically he was handsome, urbane, and outwardly a healthy and active individual, twice escaping 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 extravagant 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 University of California, Los Angeles, Los Angeles, CA. Correspondence address: Leon Morgenstern, MD, FACS, Cedars-Sinai Medical Center, 8700 Becker Blvd, Becker Building - Suite 216, Los Angeles, CA 90048.
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 associated with that sport. Back in Tehran, his physicians determined that the swelling was an enlarged spleen and summoned urgent consultation with the French hematologist Dr Jean Bernard, well known for his expertise in hematologic 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 cervical lymph node enlargement. Blood studies, including bone marrow, established the diagnosis of chronic lymphatic 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 observation 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 patient. 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, Switzerland. There they found that the spleen was enlarging and recommended that the dosage of chlorambucil be increased. They also advised that the Shah desist from physical activities such as skiing, a sport he was inveterately fond
© 2011 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/11/$36.00 doi:10.1016/j.jamcollsurg.2010.10.014
Vol. 212, No. 2, February 2011
The Shah’s Spleen: Its Impact on History
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 leukemia, but the Shah himself still thought he had Waldenstrom’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 extremism. 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 calamitous 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 assumptions. One was that the departure was for a temporary “vacation” and that he would be recalled by popular sentiment 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 examination and laboratory studies. The visit to Egypt was a short one and was followed by a visit to Marrakech, Morocco, where he enjoyed the hospitality of King Hassan II. There he was again visited by Dr Flandrin, faithfully keeping vigil on his peripatetic patient. This idyllic stay in Mo-
rocco ended somewhat abruptly and unpleasantly after several 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 President Jimmy Carter. The Shah was told, to his great consternation, 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 climate 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 perhaps most important of all, his worsening health. He had discovered an enlarged lymph node in his neck that occasioned 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 transformation of the leukemia from a chronic, less threatening stage to an acute form that required more aggressive treatment, including radiation and possibly surgery for the splenomegaly. The chemotherapy was changed from
The Shah’s Spleen: Its Impact on History
J Am Coll Surg
chlorambucil to the stronger drug combination of vincristine, procarbazine, nitrogen mustard, and prednisone. Because 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 diagnostic and therapeutic measures. That would have meant revealing 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 Washington 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 remaining 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 acceptable. 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 physician 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-
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 difficulties 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 medical 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, originally in favor of hospitalizing the Shah in Mexico, agreed that the facilities in the US would be better. He then withdrew 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 physician. 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 permission to see this accomplished. The news that the Shah was suffering from cancer, that he needed urgent treatment, and that Kean had recommended 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 President 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. President 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
The Shah’s Spleen: Its Impact on History
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 October 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 medical center. Therein lay the genesis of another problem. The biliary tract operation was arranged, without the knowledge 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 cholecystectomy 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 worrisome odyssey of the Shah in search of treatment was destined to continue. Histologic examination of the excised node confirmed the malignant transformation of the relatively indolent chronic lymphatic leukemia into a more malignant lymphoma. The terminology of the diagnosis at the time was histiocytic lymphosarcoma, now called large cell lymphoma. 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 gallstone within the common bile duct. For treatment of this complication, the Shah’s physicians summoned Dr H Joachim Burhenne, a noted radiologist from British Columbia, 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 radiologic 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 Hospital. Initially, the hospital authorities at Sloan Kettering,
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 administered 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 continued presence could only make matters worse. It immediately became obvious that the Shah was no longer comfortably 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 noticeably 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 declared 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 Mexico 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 Mexico was out. Once again the Shah was a man without a country and once again to the United States fell the onerous 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
The Shah’s Spleen: Its Impact on History
J Am Coll Surg
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, feeling 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 indicated. As a temporizing measure the dosage of chemotherapy 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 available. 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 Lackland to convince the Shah that Panama was a good solution. 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 concurred that this was acceptable. Although not enthusiastic about the choice, the Shah ultimately agreed. After a 14day stay at Lackland Air Force Base in Texas, the Shah and his party were flown to Howard Air Force Base in the Canal
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 ambassador and were under constant heavy guard by a force, interestingly 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 multinational scale that did more to confuse than clarify the issue. Panamanian physicians, supplied by General Torrijos, supervised 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 Panamanian hospital, The Paitilla Hospital in Panama City. Dr Kean disagreed, requesting instead that an American surgeon, 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 Panamanians 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 believed that it was denigrating to have the operation by a foreign surgeon when they were capable of doing it themselves. 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 opera.” 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 hospital. 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 reality 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
The Shah’s Spleen: Its Impact on History
who said what to whom varies from source to source, which is not surprising considering the huge cast of characters: doctors, politicians, diplomats, family members, and others.) There was another urgent reason for the Shah to leave Panama. The Panamanian dictator Torrijos was secretly negotiating to have the Shah arrested and extradited to Iran. With plans for the operation off and the prospect of extradition 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 summarize 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 everfaithful 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 physicians to provide whatever help was needed. It was a formidable 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 operating 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 abdomen 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.
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 television monitor in a room adjoining the operating room. After the splenectomy, Crown Prince Reza took “hundreds” 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 prognosis.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 appreciation by awarding Dr DeBakey the First Order of the Republic. In Iran the Ayatollah Khomeini derided the Egyptian 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 findings, 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 advice, chemotherapy was begun by the Shah’s Egyptian doctors even before the Shah’s discharge from the Maadi Hospital. 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 involvement of a dismaying multiplicity of doctors that was certainly not in the best interests of the patient. Princess
The Shah’s Spleen: Its Impact on History
J Am Coll Surg
Ashraf requested that the Shah be seen by Dr Morton Coleman, the New York oncologist who had been consulted 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 attributed the Shah’s symptoms to the chemotherapy and advised 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 loggerheads 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 appeared 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 remnants 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. Finally, President Sadat stepped in and confirmed Dr Flandrin’s role as the Shah’s primary physician. The etiology of the subphrenic abscess added yet another note of acrimony to a tale already brimming with it.
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 pancreas had been injured during removal of the spleen. Dr DeBakey denied this.The controversy spilled over into the Egyptian 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 recognized that pancreatic tissue was divided during this maneuver . . . and meticulously oversewn . . . it was not felt that drainage was necessary.” But the pancreas is an unpredictable adversary in surgery. 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 majestic 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 Republic of Iran also influenced the 1980 presidential election.8 The occupation of the United States Embassy and the taking 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
The Shah’s Spleen: Its Impact on History
presidential inauguration not only humiliated Carter, but also infused Reagan with a confidence of power that was to characterize his presidency. The Iranian government relished this retaliatory act against a president who thwarted their plans for the deposed Shah. In October 1981, President Anwar Sadat was assassinated 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 extremist 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 patient was not cared for in the best tradition of good medical practice. There were too many governments, too many politicians, too many diplomats, too many disputatious family members, and too many doctors involved in a complicated illness that demanded meticulous and delicate management. The Shah was denied this. It was not a proud moment in world history, medical history, or the history of surgery.
until the Shah’s death in 1980. Thereafter, Flandrin resumed a distinguished academic career as Professor of Hematology 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 HospitalCornell 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 professorship at Cornell, eventually retiring as Clinical Professor Emeritus. He died in 1994 at the age of 82.
Dr Michael DeBakey
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 Diseases 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
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
Dr Flandrin, a pupil and trainee of Dr Bernard, was already a well-known hematologist in his own right when Dr Bernard 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
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
The Shah’s Spleen: Its Impact on History
J Am Coll Surg
abscess in Cairo in June 1980. On his return to France his surgical career was principally at the Hopital Henri Mondor, 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: University 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.
4. Kean BH, Dahlby T. One Doctor’s Adventures Among the Famous 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 Magazine. 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.