Francisco Gonzáles-Crussí - Full Transcript

Francisco Gonzales-CrussiRetired Professor of Pathology, Northwestern University Medical School; Head of Laboratories, Children's Memorial Hospital, Chicago, USA

Interview location: His Chicago apartment overlooking Lake Michigan
Interview date
: 14th November, 2007

Key Themes: Attributes of a Pathologist, Autopsy work, Children, History of Pathology, International Perspective, Life, death and the hereafter, Mentors / Influences, Motivation, Relationships with clinicians

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Francisco González-Crussi with his wife and fellow pathologistFG:  My name is originally Francisco González-Crussi, but it has been anglicised to Frank from many years of living in North America.

SA:  Tell me about your early life -- you were born in Mexico, weren't you?

FG:  Yes, I was born and raised in Mexico City in a family of rather small means. My mother was a widow and had two children to put through school and it was very difficult.  It was a ghetto-like type of neighbourhood.  But somehow I was fortunate and was able to pursue my studies.  Probably I'm atypical in that I grew up with a double line of preference -- on one side was literature (that's why I write) and on the other side medicine.

I came to a crossroads where I had to decide whether I wanted to go into the school of letters and philosophy, or the school of medicine.  But given my background, the restricted means of my family, the suffering of my mother that I could see daily, I thought that going for letters, especially in a third world environment, was probably too idealistic.  On the other hand medicine, biology, is a fascinating field, so the choice was clear.  I decided that I would do medicine.

SA:  But what sort of schooling did you have, and how easy was it to fulfill your ambition of studying medicine?

Mexico benefited tremendously from the diaspora of SpainFG:  As I said, it was not easy.  But the thing that was particularly stimulating was the presence of role models.  I knew a very inspiring teacher in biology when I was in high school.  And later on, in medical school... At that time Mexico benefited tremendously from the diaspora of Spain.  Spain was under the yoke of the Franco years; the Civil War had just taken place, and the cream of the intelligentsia of Spain emigrated. They naturally gravitated towards the Spanish-speaking areas of the world, and many came to Mexico.  It was a loss for Spain, but it was a great benefit to Mexico.

Old World; New World  

With the émigrés came a very inspiring professor of pathology who had trained actually in Germany.  Because at the time -- I'm talking about the first half of the 20th century, before World War Two -- the Mecca for pathology was Germany.  After World War Two it passed to North America; the United States became the leader in this specialty.  But this professor -- I still remember his name was [Isaac] Costero -- he was witty, he had a high sense of humour; his lectures were very heavily attended -- even those who were not officially his students just crowded into the room where he spoke.  And at the same time he was erudite: he knew all kinds of terms, he was a wise man, and he was one of the early influences.  I said:  "I would like to be like that man"!  He was truly a role model.

SA:  And at what stage did you have him as your teacher?

FG:  In Mexico medical school is six years, and one gets pathology in the third year.  But I had heard of him even before going, and I had attended some of his classes even before the third year.  So he was an early inspiration.

SA:  So was he the person who actually inspired you to do pathology rather than clinical medicine?

FG:  He was one, and I think a major force in that respect.  Then later there was... One of his students was a young person, and he had the fate of the good student which is to surpass the teacher, you know?  [Laughs]  He had a different orientation.  Dr Costero had all these baroque classifications of tumours with all kinds of complex terminology taken from the German pathologists that he knew very well.  His student had actually trained in the United States when the shift was already occurring, and he thought that much of that was burdensome and useless knowledge; that it was not so important to know all these cryptic words, these fancy terms; one had to have a more dynamic concept of pathology.  Not so much the classification according to all kinds of Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms. , but an enquiring mind as to how that morphology came about: which cells came first?  Why did they come first? 

He had an experimental turn of mind: that in order to understand the morphology you had to do planned experiments; to reproduce the lesions you were looking at, no?  And this again was like a revelation to me.  All of a sudden I saw that there were two worlds: one, the old world of the erudite, complex classifications, difficult terminology, all of which sounded very elegant, very impressive; and another which saw through this tangle of things into what was more essential, more rational.  

There was friction between the student and the teacher, the professor.  But I think that is the fate of all great teachers -- to see their pupils surpassing them!  By the way, this second teacher, who was then a young man (he is now in his late 80s), his name is Ruy Pérez-Tamayo, and he's one of the leading intellectuals of Mexico.  He also writes. Well, these were the two major forces in my life, the two people that I wanted to be like -- erudite, knowledgeable, like the first one; brilliant, enquiring, and even handsome like the second one… He had everything! [Laughs] They were very directing forces; that's why I came to pathology.

The love of a good mother

SA:  What about your mother?  You say your father had died, what age were you when he died?

FG:  I was about 10 when he died.  And my mother?  Well, I was very fortunate -- I knew from early on what maternal love really means.  I could do no wrong.  She did everything, she sacrificed herself for me, and I appreciated that.  On the other hand she did not quite understand what I was doing.  To her, after all this long sacrifice, I was supposed to see patients; become the family doctor of the neighbourhood or something!  And I didn't want to see patients; I wanted to be in the laboratory and to study thetheoretical aspects of pathology.  She didn't quite understand that... Her schooling was limited, she was from a poor environment. She was not an educated person.

As I say, fortunately she loved me so much that she went along with anything I did, but I could see that she was somewhat disappointed.  She expected me to be the doctor, and the doctor is the person who sees patients, who cures them!  And here am I, I don't even see a patient!  What kind of doctor am I?  [Laughs] That's what I think was her disappointment.

SA:  Were you bright at school?  Did you do well?

FG:  I cannot say that I was a uniformly good student.  I excelled in some things that I liked, and was rather mediocre in the things I didn't really like.

Broader horizons

SA:  But did you have a vision that you wanted to get out of poverty?  

FG:  Yes.  There was another incident which I think was very important, although it is not directly related to medicine.  The French have high prestige in Latin America, and they had a very wise policy of giving scholarships to young people to go and spend some time in France.  I was only 16 or 17, I was not yet in medical school, when I was very fortunate.  I participated in a competition which was actually a proficiency in French language at that time, and I won.  So here I am, winning that competition.  My mother could not even have dreamed of sending me to Europe to do studies!  But through the good graces of the French government I was sent, for a few months only, to Paris.

And so this again, this opened my world.  I said, "Well, you know, there is all this!"  And I developed then -- and up till now I preserve it -- a love for French literature. Not so much for France in general, but for French literature -- as I think you can see [laughs as he gestures towards a pile of French books on the table between us].

SA:  And also from your writings...

FG:  Yes, there is a lot of reference to French literature.

An experience I will never forgetSo that was another determining influence, although not directly related to medicine.  The mere fact of being 17, never having left my neighbourhood of Mexico City, not to talk of leaving the country! And all of a sudden finding myself in France -- it was an experience I will never forget.  It was something unique in my life.

SA:  Was it really profound?

FG:  Oh yes.  Everything was striking to me.  At that time (and I'm talking about half a century ago already), at that time there were still transatlantic cruisers.  You went to Europe by boat, you know?  I think it was the last gasp of those shipping companies, the Cunard Line and the Compagnie Generale Transatlantique.  My mother scrounged whatever she could and gave me something that would be about $40 today.  The ticket was paid by the school.  I had to go from Mexico City to New York -- I think it was something like four days nonstop -- and then take the boat to Le Havre, and then the train to Paris.  And as I said, me, never having been away from Mexico City, all of a sudden having to do this, it was an eye-opener!  It would be difficult for me to say in which way it influenced me but it certainly was a very profound influence.

SA:  And before that had you any sort of access to the outside world? Were you a reader, and were you aware of a world out there that you would like to join?

FG:  Only through literature, yes.  Another thing that was very fortunate for me was that, in the very poor neighbourhood where I was growing up, there was a family of Jewish people (something rather exceptional), who was next door to me and who had come fleeing from the devastation and persecution of  World War Two.  They came from Poland.  As is well known, Jewish families have this emphasis on academics, and I could see that the next door neighbours were readers.  My mother was working all the time so she couldn't take care of me, and I gravitated towards this family. I was almost like an adopted child for them.  I could see their interest in reading and so on, and that helped me very much, I think.  Because the other kids in the neighbourhood were not like that at all; they were overwhelmed by all the negative influences of poverty and destitution.  But this family, well they had the experience of transplantation, of having lived in some stetl in Poland, and they had to survive somehow, and they brought with them this tradition of "you respect the man who knows". 

So as a 12-year-old, talking about these things, reading... As I said, I was like an adopted child, so I read along with them.  That was in my early years.  Then in high school the teacher of biology, and then later in medicine the professors who were inspiring [mentors]… That is the way I see my career.

The influence of his own personality 

Then another aspect is my own personality.  You know, in everyone there are the outside influences and those that are inherent in the person.  I probably did not have the emotional strength to get into the world of medicine.  I was extremely shy.  My first experience…When I started the rotating internship [during medical training], I was terrified by the responsibility of caring for the patients.  Now in a properly structured teaching programme the professor should always be there to back the beginner, and one should not be left entirely alone with the responsibility.  But I'm talking... This was already in North America, when I was an intern in some clinic in the state of Colorado, and it so happened that sometimes the interns were left alone.  You had to call the attendant physician [equivalent to the consultant in the UK], and in the middle of the night they didn't always appear on time.  To me it was an unbearable emotional burden: "What if whatever I do has bad consequences?" 

I was anguished!  I remember I started losing hair, and I read the literature, "What is this?  Alopecia areata?" Like so many diseases where the cause is not really well known, they claim psychosomatic origin.  But anyway, I thought it was the pressure under which I was living.  

I was a little bit afraid of practising medicineSo I felt I was not fit to handle the responsibility of the care of patients.  But at the same time I loved medicine:  I thought it was extremely interesting, the pathophysiology, the evolution of a disease, the origin of a disease.  I wanted to study medicine, but at the same time I was a little bit afraid of practising medicine. So remembering the example of the professors that I most admired, I thought, "Naturally, pathology is my field!"


The pathology of poverty

SA:  So when you decided to go into pathology, was it here in the United States?

FG:  No, I started in Mexico.  As I said, the professors who inspired me were in the Mexican medical school, the National Autonomous University of Mexico as it is called.  I worked as an assistant, an attendant, to them in various hospitals in Mexico City -- mainly one hospital, which, by the way, doesn't exist anymore because in the 1986 earthquake it was completely demolished.  But my first experiences with the autopsies were with them, and I was sensitised to various types of pathology there.

It was the pathology of povertyIt was the pathology of poverty, where I was working.  It was a hospital for the indigent, and I remember seeing so many patients, or autopsies of patients, with hepatic amoebic abscess -- something that one does not see in North America, unless it be in immigrants.  And tuberculosis, which also had largely been eradicated from the industrialised countries -- it was very common in Mexico at that time.  So amoebic abscess, pulmonary tuberculosis and such things, I saw there, and I didn't see when I came here!

Of mentors and motivation

SA:  When you first started pathology in Mexico, how was it taught?  Was it mostly autopsy-led then?  Or were you also doing biopsies and diagnosis?

The resources of the institutions were more limited because of the povertyFG:  It was both.  By the time I was there I think already the mentors had mostly been trained in North America, so really the systems were very good.  The resources of the institutions were more limited because of the poverty of the third world.  But the systems were very good: the teachers knew what they were doing; they had the correct literature.  I remember reading very avidly the American journals of cancer and so on, because they encouraged us to do so.  

The shift occurred in about the 50s and 60s that many of the people who had trained in the US came back to teach in Mexico.  Before that it was mainly the European influence.  As I say, my Spanish professor had trained in Germany.  I remember he used to have a collection of volumes in his office, which perhaps people of the old guard still remember:  The Handbook of Pathology by Henke-Lubarsch.  It was one of these encyclopedic Teutonic works, and he used to say -- and he was probably correct -- that if it was not in Henke-Lubarsch, it didn't exist [laughs]!  But then later, as I said, the young people came with different ideas, with completely different concepts of how pathology should be studied.

SA:  Tell me of your first experiences in the lab -- before you went into pathology what were your experiences of death?  Had you known death quite intimately in your own life, or not?

FG:  No, I did not.  Well, I remember my father's death. But he didn't die at home -- when he felt he was dying he wanted to be taken to his home town, which was miles away from Mexico City.  I don't know, perhaps I was not reflective enough at my young age.  Deaths in the family were shaking experiences, but I didn't really think much about them.  At least they didn't influence me in my choice of career.

I remember an experience with a journalist who had already made up her mind before coming to interview me that I had to be somebody with a morbid turn of mind -- partly because of the books I had written, and partly, as she said, "Why did you choose to be a pathologist in the first place?"  She had this idea that the pathologist had to be someone like a revised version of Dr Jack Kevorkian [the Michigan pathologist who went to prison for assisting his patients to commit suicide], someone that is constantly obsessed by the idea of death.  But it was not like that at all. 

It is really the foundation, one of the sustaining pillars, of medicineI went into it for the reasons I said: because I think it is intrinsically very interesting and because it is really the foundation, one of the sustaining pillars, of medicine.  And secondly because of the personal role models that I had.  But an obsession with death?  No, I don't think I have it.  Not the kind that is described by Bertrand Russell in one of his essays.  He says that some fellow in Cambridge walked around with a hoe in his hand and when he saw a worm in the lawns, struck it and said:  "Ah, you haven't got me yet!"  [Laughs]  That is related by Bertrand Russell in one of his books.  That sort of obsessive preoccupation with death I certainly did not have, never have had.

The contemplation of death

SA:  That is why this project is being done -- because that has become a popular perception of pathologists in Britain, that you are "doctors of death".  As one person said, "That's so wrong, we are doctors of life."  And yet by the very nature of your job you are dealing with the fact of death, aren't you?

FG:  Well, you know, the contemplation of death, the spectacle of the cadaver being opened at dissection, is truly an important experience. In regards to this I once had someone ask me:  "You have passed your life doing autopsies... In all these years, what pearl of knowledge do you have?  What have all these experiences with the dead taught you?"  I didn't know what to say, because it was one of those loaded questions like, "Tell us what you know of the meaning of the next 10 seconds"! [Laughs]

I said, "Well, I think it has taught me the flimsiness, the tenuousness of life."  Because I recall cases of people dying from such banal causes -- a healthy 21-year-old who got asphyxiated with an olive in his throat.  I remember one of my earliest experiences, a four-year-old, angelic little girl, who collapsed in the physician's office after an injection of penicillin.  (At that time somehow they didn't know how to treat anaphylactic shock, or that physician didn't know.) And so many others like that.  So I told him, "Perhaps if I have learnt one thing, it is that our life is suspended by a thread."  And he said, "Well, in that case you really didn't learn anything, because that we knew already."  That's what he said!  

And then later reflecting on it, I thought, "He didn't really understand what I was saying". That life is finite and that we are all going to die, yes that we know.  But we know it from a purely intellectual standpoint.  It's one of those pieces of intellectual knowledge that do not determine your behavior. But when you actually look at it, look at the evisceration of a cadaver, it's like somebody grabbed you by the hair and dragged you to contemplate the spectacle of your own dissolution.  Because you can't help but say, "We are all made of that stuff… All that entanglement of cogs and wheels that I see, that's the same as I have here [he touches his own body], and now that is just a lump, an inactive mass of proteins in decomposition already.  That's going to happen to me too."  And so to actually see it, then you understand it in an affective way – it's in the realm of the emotions that you are now, the understanding that touches the heart.  The other was purely intellectual. 

SA:  A visceral understanding...

FG:  Yes, that's right.  I think it was Nietzsche who said that we think with the viscera -- meaning with the bones, with the intestines... The brain is just an apparatus of the concentration of thought.  But the other organs are also part of the thinking process.

SA:  That’s so true.  And would you say that is what you have learnt?  With your familiarity with death, do you think death is knowable, fathomable, or not?

FG:   I think that [my familiarity with dead bodies] gave me a closeness, a great sense of proximity to the fact of death which otherwise one always tries to keep at a distance, no? 

On the other hand, probably we as human beings are not made to have this sense of great proximity to death -- just as we are not made to actually perceive the daily functioning of life.  We never think of all those organs that die that I used to see every day.  We never feel the stomach unless we have indigestion.  We never think of our brain unless we have a headache.  If it is not diseased, the heart goes on with its rhythm, and we never realise the heart is there.  So we are not made to perceive the daily functioning of life.  And just as we are not made to perceive life, we are not made to perceive death.  When it happens, it happens. 

SA:  So how do you adjust then, to seeing it all the time?  As you say, when you open a cadaver, you realise "that's what I'm made of inside and I now know what my lungs look like, and my brain, etc".  What does that knowledge do to you?

We are not made to consider our own deathFG:  Well, as I said, first it perhaps gives me a greater sense of the fragility of life than I had before having the experience of a pathologist.  But having said that, I, like every human being, tend to forget about it! [Laughs] Because that is the way we are constituted -- we are not made to consider our own death.  

SA:  Yes, but it is the sort of thing you do ponder on in your essays, isn't it?  The meaning of things...

FG:  At the beginning I was a little... Because the books were successful, I thought, "There is a great interest of people in death, which is something nobody really knows.  And since everybody is interested and nobody knows, I can pose as an expert!" [We both laugh!]  But then I realised I was creating this bad impression that pathologists must be people who are death-oriented, and I didn't like that.  I wanted to show that there are so many other things, so I've written -- maybe to counteract the books about death -- I've written a book about birth, I've written a book on love... But I can see that when I'm invited to speak, that is the question they always come up with: "Being a pathologist, what about death?"  They always bring it back to this topic.

SA:  Well, they'll ask you, and they'll ask a priest, I should imagine!  And a philosopher.

FG:  Yes.


The different avenues for a pathologist

SA: Okay, so these other aspects of pathology that are not death-orientated, as you say, that are to do with understanding disease to help the living, what have you been involved in?  Where has your career taken you?

 FG:  Well my career is now over because I have now retired.  But I think in general the pathologist has several choices.  Number one, he can be more diagnostic-orientated, which in itself takes a whole life because the explosion of knowledge has been so great.  If one becomes proficient at diagnosing, adept at reading biopsies, it is very satisfying, and you know that you have done something for the patient.

A very rewarding avenue for a pathologistFor example, once some physician thought that his patient had a melanoma and he referred the case to me. I looked at the biopsies and decided it was not a melanoma. This was confirmed by other people, but I was the first to say that it wasn't a melanoma.  I didn't even know the patient; he was somewhere in California, but he sent me a plant and a card, he was so grateful!  So that's a very rewarding avenue for a pathologist, to become purely a diagnostician.

It used to be that all you could do was look at the biopsy.  You had a repertoire of images in your brain -- very large, if you were a good pathologist -- and you identified that this tumour was A, B, C or whatever.  And that was it.  Your opinion was held in high regard, but that was the criterion of validity -- how respected and famous you were! Now there are many other things that can be done besides the appearance of the lesion under the microscope.  There are tests of molecular biology, examination of genes, DNA stands for deoxyribonucleic acid.  This is the material inside the nucleus of the cells of living organisms that carries genetic information (see also RNA). , Flow cytometry  Analysis of biological material by detection of the light-absorbing or fluorescing properties of cells, or subcellular fractions such as chromosomes, passing through a laser beam., all kinds of things that contribute to a diagnostic opinion.  And they should all fit coherently -- all be part of the puzzle.  But at one time it was chiefly the Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms.

So that's one avenue for the pathologist -- to become a diagnostician, an expert diagnostician.  That was mainly what I did.

Then another thing is of course teaching, which I did, naturally.  You sit with the students and they look down the microscope. The thing is, when you look at something, even if it is right in front of your eyes, within your visual field, you don't see it unless you know what you are seeing.  The eyes are really guided by the brain, you know?  You must know what to look for otherwise you don't see it, and there are many examples of that.

The adrenal glands weren't discovered until, I can't remember, was it the seventeenth century or may be the eighteenth?  I mean, [Andreas] Vesalius had done careful dissections in the sixteenth, but they never saw the adrenal glands because they are buried in the fat. You have to tease the fat away to find the adrenal glands, which are of the same colour, yellow life fat, because they have a lot of fat.  So why did they take centuries after all the tremendous investigations of anatomy by Vesalius to discover organs which are now perfectly well known and very important to sustain life?  Well, because people didn't know how to look.

You only see that which you already knowI think some English author discussed in a book how it would be if you could put yourself in the shoes of the first anatomist -- when you lift up the breastplate and look at the organs.  They look like a mass, like a continuous mass.  You know now that if you cut this fibrous tissue there is going to be a heart -- now you know that, but the first people would not know even where to cut.  It was very difficult to discern one organ from the other.  The point of this is that you only see that which you already know, and which you are prepared to see.  And so the teaching of pathology was much like that.  You sit with a student and you teach him to see.  Then after that he's on his own, and he depends on his own ability.

The importance of a ‘good eye’

We're talking about diagnosis by microscopic examination, and that is largely dependent on sight, and there are individual differences there.  There are some people who, as they say, 'have the eye'.  And other people who may have tremendous abstract reasoning; they may have excellent memory and be excellent in many aspects, but don't have a 'visual intelligence' and so they don't become very adept at the microscopic interpretation because they seem to have like a physical difficulty.  

SA:  What about you yourself?   Because you are obviously intellectual, are you also good at seeing?

FG:  I like to think so... You know, there was a conference organised by some European pathologists in Spain and we went from town to town, all the way to Santiago de Compostela, like the old pilgrimages, no?  And this subject came out in one of the discussions there.  They said, "What do you need to become a good pathologist?"  (It was written up by Gianni Bussolati, an Italian pathologist, and published in Virchows Archives, Volume 448, 2006.)

The discussion was centred around what a pathologist needs to be a good pathologist.  He of course talked about this visual skill, and he presented some evidence... There is some technological gizmo -- an apparatus that consists of a helmet and some kind of lenses, and they are so made that you can tell exactly where the eyes are focused.  I can't describe it to you, I don't know how it works, but by means of this apparatus it is possible for someone to see on a monitor what that individual is focusing on. 
And so, using this apparatus, they put an expert pathologist and beginners to interpret a slide under the microscope.  They would try to see, where does the expert focus his eyes first?  Where does he focus his eyes second?  And so on.  There were discussions about this at the conference: is it something you can teach? That was the whole point of our discussion: can you teach a person how to see?  And I was the only dissenting voice there!  I said, to the surprise of everyone... and Bussolati put my comment in the article that he published -- he said: "We have a pathologist who writes 'hectic' books (that's how he put it!), who said that the other thing that you need is love."  

And I think that's true.  In other words, in addition to the skill in interpreting and all that, the first thing that you need is to like it.  Because some of those microscopic fields have an intrinsic beauty to them.  I'm sure that if you look at the abstract art that they display in the museums, and you look at a Papanicalaou  smear (a Pap smear) stained with all the dyes that they use, some of those images could be framed and put side by side.  You know, there is a certain beauty to it.  And some of it is just gorgeous… When you have fluourescent microscopy, against the dark like shining stars, the cells with the nuclei.  And especially if you use different colours to fluouresce, then you have a multicoloured image against the dark background shining -- it's all a beautiful thing. 

So I think the pathologist, in addition to having good reasoning faculty and good eyes, he needs to like it.  His eyes stop here and there and it's not a random thing -- they stop here and there because he likes what he is seeing.  He modified my comments a little bit but he was kind enough to publish them in Virchows Archives.  So there you are, that's another aspect of pathology that people don't usually mention.  I think you have to have a good visual ability in addition to a liking for the intrinsic beauty of microscopy itself. [Laughs]


The developing field of paediatric pathology

SA:  Okay, so your diagnostic work -- where did your career take you with that?

FG:  Well, then I specialised in paediatric pathology.  Because, well, I came here as an immigrant, on my own and so on, and that's where opportunities opened.  I think I would have been happy in any branch of pathology, because I like pathology in general.  And I had a good grounding in general.  But it so happened that the opportunities were open for me in the field of paediatric pathology, which, when I first came, was really a developing field. 

It still is, but when I came I remember there were not more than 100 people in the whole of the United States practicing that specialty.  They started founding a society which was not even called a society at the beginning, it was called a paediatric pathology club, because it was just a group of friends, really. There were maybe 25 people recognised as leaders in the field.  Now it's not a club any more, it's called a society, and it has hundreds of members.  Hundreds is still not the same as thousands, but it is still much better.

SA:  Why was it so slow to develop?

People thought that children were just adults in miniatureFG:  Because people thought that children were pretty much like adults.  They were just adults in miniature.  At least that was the implicit assumption.  People, when they studied, they knew that it was not the case, but they had this implicit assumption that, on the one hand, yes there is such thing as congenital anomalies -- stillbirths, babies with hearts all twisted, absence of intestines or whatever. But the attitude was "you can't do anything about them anyway, so you're not helping the medical profession, you're not helping the patient, you're not helping anyone by diagnosing those abstruse syndromes of congenital anomalies."  So there was a general lack of interest, I think for that reason.

SA:  And so babies born with such abnormalities or stillborn, were they not autopsied?

FG:  Many were autopsied, many were not.  Then in the 40s and 50s there was a leader in the United States, there was a woman who was a pioneer.  It was Edith Potter, and she was really like the founding mother of paediatric pathology, who was working in Chicago, in the Cook County Hospital.  She was skillful enough to obtain permission from the authorities of the city that any stillborn child there could be autopsied by her. You did not need to have the permission of the parents or anything, you could do the autopsy. 

And she did fantastic work.  She was brilliant and so hard working that she really made what became later like the bible of paediatric pathology: an inventory and a categorisation of the different forms of anomalies that can be present. Often times, even the parents -- especially in that hospital which was a hospital for the destitute -- they were not that interested.  The baby had been born premature or had been aborted or something, so they didn't want anything to do with that, which is why Edith Potter could do whatever she wanted -- very complete dissections, photographs etc.

SA:  So she put paediatric pathology on the map did she?

FG:  Yes she did...Edith Potter.

M: And did you even meet her?  Did you study under her?

FG:  No.  I saw her when she was already retired and all that, receiving the honours of the profession. 

A focus on childhood tumours

SA:  So you say that as an immigrant you got involved in that field...

FG:  Yes, but not just in the area of the stillborn, neonatology and all that, but the wider field of paediatrics, which extends all the way to teenagers as well.  And I was doing mostly surgical pathology, so I was looking at tumours.  And again, the tumours that children get are different from the tumours that adults get. 

I wrote a couple of now obsolete medical books.  One on tumours of the kidney in children, which are dominated by a special tumour called a Wilms tumour, or nephroblastoma.  I wrote a book on nephroblastoma and related renal tumours of childhood.  It was published by CRC Press. And then they assigned me to write another book, on teratomas which are fascinating tumours.  They are composed of all kinds of tissues exotic to the place where they arise.  For example, in the ovary you find thyroid tissue, hairs... hairs!  There shouldn't be hairs in the ovary, so the first people who ever saw a teratoma -- with bone and thyroid and hairs -- in pre-scientific times, thought that the woman had had carnal contact with the devil or something like that!

SA:  Where do they come from?  Where do they arise?

FG:  Well, that was the topic of my second book! [We laugh]

Different manifestations of teratomas

SA:  Where were you seeing it?

FG:  In the practice of pathology in the children's hospital.  It's a not uncommon tumour of children, and some of them are congenital.  There are specific locations -- they tend to grow in the middle of the body.  In other words you can see them in the neck, in the mediastinum; you can see them in the genital organs.  In fact, that's where they are most common: in the testicles of the male and the ovaries of the female.  With completely different implications for the patient. 

For example, in a baby, sometimes they can be born with a teratoma of the testicle, and they usually are of no concern.  They are removed by the surgeon and nothing happens, all the way to maybe three, four, five years of age.  But in an adult who happens to have a teratoma of the testicles, it is a bad business. 

Usually they have a malignant component and a rapid course of invasions and metastases and so on.  So age seems to be a very strong determinant of the prognosis of the teratomas of the testicles.  

They have, as I say, different locations.  In children -- newborns -- congenital teratomas are most common in the coccyx.  They are born with like a huge bag of... My book was like an atlas for the pathologist, a text atlas, sponsored by the Armed Forces of all people, the AFIP (Armed Forces Institute of Pathology).  It's now obsolete.  It was called    Extra-gonadal Teratomas, because the chief editor told me: "You can write a book about teratomas, but outside of the gonads, not of the genital apparatus."  He was taking away the most common and the most important part...

SA:  Why did he stop you writing about those?

FG:  Because he probably wanted to assign the teratomas of the genitals to another author, I guess!  Those were given by assignment to prominent pathologists.  So it was like a distinction.  I took it avidly; I was very happy to receive that honorific distinction -- that I am in charge of writing an atlas for the AFIP!  They are used the world over, so I was very happy to do it.  It had a big chapter on the teratomas of the coccyx because they are most common…A lot of clinical pictures and all that.  It's a horrible thing, some of the pictures are horrifying.

SA:  When did you first see a teratoma, do you remember?

FG:  It must have been in Mexico and it would have been a teratoma of the ovary which usually has a big mass of hair.  Some people call it a monodermal teratoma because they seem to have derivatives only of the ectoderm (the outer layer of cells in the early embryo).  But it's the wrong name, because you can have pieces of other tissues in it.  It's a big mass, and when you cut it you see hairs, and pieces of tissue that if you examine them microscopically you realise they are thyroid, skin, brain, hair...

SA:  Where does it start?

The potential to develop into all kinds of tissueFG:  Well, as I say, this is one of the things that is discussed. The classical theory is that it must come from germ cells.  In other words, early in the embryo you have cells that differentiate to become bone, to become brain, to become gut.  But there are some cells that remain primitive.  Why?  Because those are the ones that are going to give rise to the gonadal cells. These are the germ cells [from Latin germen, meaning seed].  And those very primitive cells, presumably they become trapped in the organism and they are the origin of the teratoma.  If they become tumoural they have the potential to develop into all kinds of tissue.  They are called 'totipotential', because they have the potential for everything. Traditionally, it was thought that these cells were the only totipotent cells, but recent developments have shown that stem cells of various origins also share this potential. 

The third avenue: research

SA:  But what makes them suddenly decide they're going to become hair cells or liver or whatever, in the wrong place?  Did you discover that?

FG:  No, no.  And I should add that when we were talking earlier about the various avenues of work for a pathologist, we decided there was teaching, and there was diagnostic service work, which took up most of my career.  But then there is the other main avenue, which is, of course, research.  Had I been a researcher, which I really was not, then I would maybe have planned experiments to see how a teratoma can develop.  There is, of course, experimental work of that nature.  But that's not what I did.

As I said, there are people with different potentials.  There are people who can be excellent researchers but they are not so good as diagnosticians.  My wife was mainly a researcher, and her line of research was a special disease of newborns that is now one of the major causes of death in nurseries -- it is where the whole intestine becomes dead, goes necrotic.  Like all researchers, you have to create a model in an animal that resembles a human disease.  And the actual creation of the model can be tricky, very difficult, and very time consuming just to figure out what animal can have a disease similar to a human, and under what conditions.  Then you can control the conditions. Anyway, like I say, I was not in the line of research.


SA:  Okay, so carry on telling me about how things developed with you specialising in paediatric pathology in the very early days of the discipline. Was it a thrilling field to be in?

FG:  Yes. When I really got into it I realised that it had been neglected for no good reason.  I think people thought, as I say, that some of the diseases are so far advanced by the time the child is born that there was no point in wasting time studying them.  Now with the upsurge in genetics and so on -- and not only genetics, there are now people who are even doing fetal surgery, right?  They operate on the baby and put it back in the mother's womb!   So now there is interest in all kinds of paediatric pathology.  Not to mention the fact that this business of congenital diseases, heritable diseases and so on, is only one aspect, though a very important aspect.  But there are all the other aspects -- of older children, who develop tumours for example, the Wilms tumour, neuroblastoma and all that, which are major causes of death in children.  

It used to be that at certain ages, the second most common cause of death was cancer.  Children, they have no reason to die, no?  The first cause was accidents, and the second cause was cancer -- these specific childhood forms of cancer that I've mentioned, the Wilms tumour and the neuroblastoma, which are the major things.  Other tumours, like teratoma, can become malignant too, but they are less prevalent.

SA:  And did you see quite a lot of that?

FG:  Yes.  Because I was in the Chicago Children's Memorial Hospital, not far from here, which is one of the major children's hospitals in this part of the world.  It was for a while the number one -- I don't know if it is now -- and we used to get referrals from all over.  And yes, we saw a lot of cases of cancer in children. And because, like I say, they are specialised areas, the pathologists in other hospitals don't have as much expertise, or they hadn't seen anything like that, and so they tend to refer them to the children's hospital -- which I think is the way it should be.

SA:  And so now has it been well accepted that children are not just mini-adults?

FG:  I think so.  There will be some diehards who say they see everything, and can do everything, adults and children.  But the right thing to do is to have people devote all their attention so that they can see the singularity of paediatric pathology.

At the surgeon’s right hand

SA:  So in your hospital here -- as you say, it was a centre of excellence of childhood cancers… Describe your day for me, how you fitted in with the clinicians and everyone else.

FG:  Well, at the end I was chief of service over there, but the normal day for the practice of a pathologist is that you look at the cases that are there for the day.  Then maybe you are called to the operating room...

SA:  So you worked with the surgeons?  Alongside them?

FG:  Yes. You see, there is one thing that I have seen happen, and perhaps like every old person, I am now out of sync with the technological advances; I belong to another era… In the past when I was working there, the surgeon called us and we had a personal rapport. We knew the surgeon because we had seen all his cases.  We had helped him.  (There was a very noted pathologist who wrote a book called Guiding the surgeon's hand -- he's a very famous pathologist, one of the best in the world).

So anyway, we were called into the operating room, and we had a close rapport with the surgeon. 

Sometimes he'd even say: "Look in here, look in here. What d'you think this is?" while the patient was being operated on.  "Where should I take the biopsy from?"  It was beautiful!  That worked very well in the old times.  An experienced pathologist working with an experienced surgeon and having a friendly and harmonious relationship with him is in the best interest of the patient, no?

Now, as I say, they have said there was too much waste of time.  Pathologists have other things to do.  And now I understand that we're not called into the operating room. There is a television camera, and the pathologist is maybe half a block away, in another part of the hospital, and you see it on the monitor and you talk to the surgeon by the microphone.  You look at it and you make your sections and you report it. It's impersonal.  I suppose if the camera is very good, and you see it in colour, it's probably alright.  But somehow I think that when you lose the personal contact you lose something else.  It’s not the same as talking face to face.

SA:  No, I can imagine.  And you did a lot of that, working alongside the surgeons in theatre?

FG:  Yes, it used to be common that, and then slowly it was lost.  And the place where you processed the piece of tissue that the surgeon gives you, in my time it was next to the operating room.  In other words, in order to go to it you had already put on your scrub suit, like you were a surgeon, and your mask and everything, to walk into your room, because it was within the premises of the operating area.

So the nurse went in, or you went into the operating room and received the piece of tissue from the hands of the surgeon, and you went into the next room where there was all the paraphernalia to do the processing: to freeze the piece of tissue, to cut it and to prepare the section for microscopy.  And the microscope was right there.  Sometimes the surgeon would come out to see what you were looking at down the microscope.  I suppose technology can now allow him to see what you are seeing on monitor. 

Maybe this is an exaggeration on my part, but he sometimes even contributed details that normally you wouldn't know.  I can't think of an example right now, but you saw things that you wouldn't see otherwise.

SA:  Okay, one thing you were saying was that as a young intern you were horrified by the responsibility of being alone with the patients and worrying that something might happen.  You are still in a hugely important position as the diagnostician, especially when you are doing it while somebody is under the knife.  How did you adapt to that?  Did you find that also panicked you?  Or was it different when you were one step removed from the actual patient?

FG:  That's a very interesting question.  I think that probably the same evolution would have happened eventually had I stayed in clinical medicine.  But in the pathology department the pressure is less because, for example, you have to make a diagnosis, but you are not alone.  There is a colleague who can look at the same thing as you are looking at, and give you his impression right there.  Sometimes there is a two-headed microscope and you can look at the same thing at the same time. And so I gained experience, and I became quite confident about what I was doing.  And I was respected.  Sometimes people did not accept the diagnosis of someone else until I looked at it, and so that gives you a sense of "I know what I am doing; obviously my opinion is held in high regard", no? 

Obviously there are cases where you look at an image and you think, "This could be A, but it could also be B.  What do I do?"  And you look to other colleagues to give you their impression.  And in pathology you usually have time to send a sample via the mail to some expert in another town.  With all that, the pressure is not as great as for the surgeon who has to make an instant decision right then and there and the wrong decision may have disastrous consequences.  In pathology, fortunately for the pathologist, there usually is more time.

The greatest pressure is when they are waiting for a diagnosis while the patient is still on the operating table.  They want your opinion right then and there.  But even so, you can consult with other colleagues.  And if you are uncertain, you can always say so: "No, I am unsure."  The patient may have to wait for another procedure.

What a surgeon does is not retrievable -- if you cut something that's itBut what a surgeon does is not retrievable -- if you cut something that's it.  You remove something, you can't put it back!  [Laughs]

The burdens of administration

SA:  So tell me, what percentage of your working time was devoted to diagnosis in living patients and what to autopsy?

FG:  Well I tell you, unfortunately at the end of my career -- and I say 'unfortunately', that's why, in a way, I was not unhappy to quit -- at the end the responsibility became more administrative.  Which is very bad.  I regretted that.  I felt disgruntled at the whole establishment over there.  Because I always wanted to be a pathologist.  Ever since I was young.  I loved pathology.  And I thought the better pathologist you are, the more responsibility you should be given as a pathologist, because that's the kind of thing you love to do.  But I once overheard the comment of an administrator: "He has no idea of what a modern chairman should be doing."  And what a modern chairman should be doing is attending a lot of meetings in the administration.  Many of my colleagues went and took MBAs, 'masters of business administration'.  I was offered...the hospital was willing to pay for a course in business administration at Harvard University, which another of my colleagues said was very good and I should take it.  But I felt at the time that that was not what I should be doing. 

It was better for me to quitSo my personal situation was, well, I could step down and just be a professor there, a pathologist, and let someone else take on the administration.  But in a small department it was very difficult to do that.  If I had done that, I would be casting a shadow over whoever came.  It would be very uncomfortable to have me there.  Once you're the boss it's very difficult not to be the boss!  So I decided it was better for me to quit.

So unfortunately, at the end of my career, administration took a large part of my time.  Before that it was like 60% of my time would be in service, 30% would be in teaching, and 10% would be in administration. 


“Less than 1%...”

The health scene has become a health industryAutopsies were part of the service.  And that, as you probably already know, has been decreasing gradually -- not so much in paediatric pathology, because in paediatric pathology there are so many things that are still unknown that even the physicians feel the need to request autopsies.  But in the adults, I understand there are hospitals where less than 1% of patients who die go through autopsy.

There are many reasons for that.  The main reason, I think, in North America, is the money.  Because the autopsy is an expensive procedure -- you have to pay for the time and the work of the specialist pathologist, which is expensive, for the technicians, and even the people who clean the morgue.  When you add it all up it comes to a few thousand dollars.  I don't know exactly.  And who's going to pay for that?  Not the survivors of the patient, because they see no benefit -- and especially when they are still grieving, it's hard to ask them to pay for something like that.  So the only way is for the hospital to absorb the cost, and today, especially in North America, the whole of the health scene has become a health industry -- they are competing for patients.  The situation is I think rather shameful in North America...It's become like a business.

SA:  What do you as a pathologist feel that has done to, as you say, one of the central pillars of medicine?  How badly affected is it by an industry which says, "Well, can we manage to do without that"?

FG:  The effect is negative, I'm convinced about that.  But when I say that one of the main causes of the decline in the autopsy is economics, there have been other causes.  You know, the fear of being sued by the patient...

SA:  Over what?

FG:  Well, should the autopsy find something that the physicians didn't see, here they are sued at the drop of a hat, and they don't want that.  

The arrogance of the physicians is another cause that has been much talked about -- they say, "In this day and age, we have nuclear resonance imaging, and CT scans, and we have such technological advances that we already know what the patient had.  So to do an autopsy to discover the cause of death is meaningless to us.  We already know everything that we need to know."  This has been proven incorrect by serious studies, some published in the New England Journal of Medicine, where in spite of all the wonderful advances in technology, there were a significant number of cases where things that they didn't know were uncovered by the autopsy.  Admittedly it is a much smaller percentage than it used to be.  Sometimes they uncover things that don't matter because they would not have changed the therapy.  But there is a small fraction of cases still today that, had they known that during the life of the patient, the treatment would have been different.  

The decline of the autopsy is negativeSo that's why I say the decline of the autopsy is negative.  Not only that, there are new diseases that can only be known by securing tissues and doing all the studies that an autopsy allows -- everything from microscopic investigation to examination of the tissues by other methods.  New diseases created by the physicians with the new therapies!  New prostheses and organ transplants that are giving rise to a new kind of pathology that didn't exist before.  I never saw transplant rejections before, because there were not so many transplants.  And all those things have a special pathology: how can it be known?  Not only by biopsies, you really have to examine the whole organ.

Anyway, as I was saying, the causes of the decline in autopsies include the fear of being sued; the cost that needs to be absorbed; the arrogance of the physicians who think they can learn nothing from an autopsy.  And I have to blame the pathologists too.  They have some role in the decline of the autopsy.  And that is because, in some institutions anyway, the autopsies are delegated to the least able.  Why?  Because the most brilliant ones, the people with the highest salaries and higher academic rank, are the researchers who are doing experiments and are bringing money to the institution from government and grants and all that.   And they are more prominent.  

So in some institutions there is a multi-tiered structure of pathologists.  Number one is the researcher, then of course the prominent service people, and the autopsies are way down.  So they are done in a neglectful way, by people who are not very experienced, and of course the report at the end is not very informative, because they looked at this, they didn't look at that. And there is a backlog of work, and so a clinician gets a report maybe months later when he has forgotten the case, and also with information which is not particularly useful because he didn't answer some of the crucial questions that he had.


An outsider in the system

SA: Okay, first of all, coming here as a young immigrant from the background you did, how easy did you find it to join the mainstream -- to move into a completely different social milieu?

FG:  It was a Calvary!  It was not easy at all.  First of all I came, so many years back, to a place... So much has changed now, but then the interns, especially the interns, were badly exploited, underpaid, overworked, and not really taught well.  But it was something you had to do because you knew it was leading to something you wanted.  So you had to subject yourself to all kinds of vexations.  
Later there was a movement among the interns in the United States.  They unionised, they wanted better salaries and so on.  But they used to say -- and that was even in Mexico when I was there as a student -- they used to say:  "Nobody is paid to learn!  You are here in a learning institution and you should be proud to be here!" And indeed there were [in Mexico] few places where you could learn, so for that reason you had to go there with no pay. 

Now in the United States when I first came it was a different culture, so therefore there was some pay, but it was very low!  I remember I got, I don't know, it was like $50 a month, plus the meals and a room to stay.  And they took $15 for the room, or something like that.  I never had any clothes.  I just used the jump suits of the operating room for the whole year.  And they said we were learning.  Yes, we were learning, but we were also working -- and working very hard.  And in an inhumane way, because I remember there was a 24-hour 'on call' every third day, or something like that -- so you were sleep- deprived, it was torture, you couldn't think so well when your head was foggy!  [Laughs at the memory]  That was very bad.  Much of that has changed because they realised that that was not to the benefit of the patients.

They assigned me, when I first came, chores that a nurse's aide would be doing -- washing patients and all that.  I had to do that for my internship.  But then I went into pathology.  And now sometimes when I reflect back on my past I say: "That was wrong.  I should have come recommended by a professor in Mexico, to a good learning institution, to secure a fine training and then to go back and practice in my country."  That was the idea.  But you know, "Man proposes, and God disposes"...and, they say, "The devil discomposes!"   [We both laugh]

SA:  So why did you not go home?

FG:  Well, at that time I was working in a hospital in the state of Michigan which was rather mediocre, and I wasn't learning very much. But the people there were very impressed with me because I was so anxiously wanting to learn -- I studied very hard -- that they recommended me to go to a university hospital in Florida.  And actually that was the only way that I could break into academic medicine, which is what I wanted to do in the first place. But I had years before of wandering around with a sense of frustration, and feeling "I should not have come here.  I could have learnt just as much in my own country.  This is a second-rate hospital.  What am I doing here?  I'm wasting my time!"

SA:  Did you feel discriminated against as an immigrant?

The hospitals that received the immigrants usually were not the bestFG:  Not so much, no…  Well, when I first started the hospitals that received the immigrants, the foreign medical graduates, usually were not the best.  The institutions where the standards were highest usually had mostly North Americans.  In fact that was one way you got an idea of the quality of the training programme -- if you saw that most of the resident staff were foreigners, then you knew that was not such a great place to be.  But I had to go there because I did not come with a recommendation as I thought I should have done.  Later I saw people that I knew from Mexico that did it the right way; they came from home to the Johns Hopkins, and went back to a job that was awaiting them.

But as I say, I grew up in such circumstances that I did not know my way around, my mother... No one could orientate me properly.  So when someone says: "You have to go to the United States," and when I saw that the best professors had been there and all that, I thought, "Okay, I go."  I did not know what I was getting into. Like I said, these were mediocre places.  But eventually, after years of work, I did get into a university hospital.  And then I did try to go back to Mexico.  But by then, as I say, it was the third world and there were not the right opportunities.  The best places were taken already by people who had done it the right way, been recommended by professors to the United States and then received back to good jobs.  They had no place for me.

I didn't know what to do.  And then someone said there was a job in Canada, would I go to Canada?  Well, I would go anywhere, anywhere.  "But it's in paediatric pathology." "That's fine."  So I went, and my first six years in pathology in North America were in Canada, in a university hospital, excellent place, very conducive to study.  A very little town, but a very good university.  It's called Queen's University, in Kingston, Ontario.

At first I thought I was coming to a rural area, but it was very good.  They had a lot of resources, andexcellent pathologists over there.  And then I came back to the United States…

Of susto and “magical potions”

SA:  Tell me, what did your mother do to support you? You said she was on her own and had to work to support you and your sister.

It was like the ancient apothecary shopsFG:  Well, my father had a small drugstore.  When I say 'drugstore', people think of something like Walgreens [a chemist chain in the US].  But it was like the ancient apothecary shops, a tiny little thing in a corner where we sold all kinds of traditional medicine and all that.  And when my father died she had to take over.  She wasn't prepared to be in charge of a drug store, so she had to avail herself of the services of somebody, a pharmacological chemist, who came every month to get the salary, and didn't do anything [laughs].  But that was our daily living.  We got the money to eat from my mother working in that little drugstore.

SA:  You say traditional medicines, what sort of things?

FG:  I wrote all that in a book which is semi-autobiographical.  It is mostly impressions of people I saw there, and this book is called There is a world elsewhere, and the title is taken from Shakespeare.  In Coriolanus, Coriolanus is banished, and he tells to the people, 'Okay, I am going.  But there is a world elsewhere."  I was in this country, and remembering my life in Mexico, I thought, "There is a world elsewhere".  So that is the title of this semi-autobiography, and I describe some of these things in there.

Yes, some of these things you wouldn't believe.  For example, in Latin America -- particularly in Mexico, but I think in the whole of Latin America -- there is a pathological condition which is called susto.  Susto means 'fright, startled', and to be startled is to be asustado. I was living in this impoverished neighbourhood where there were always all kinds of things to be startled about -- a brawl in the middle of street, the police chasing somebody, a fight between husband and wife and screams and all that, somebody hit by a car.  And people would come to the drugstore, agitated and trembling, and say, "We need something for susto."   So we would give them something.  It was just a placebo, but it worked, and I say, "Attention therapists!"  [Laughs heartily]

I was working there.  My father died when I was 10 years old, and my mother sometimes wanted me to be in the drugstore to help her.  Poor woman, she worked from morning till night -- the drugstore closed at 11 o' clock at night.  Of course I had to go to school, but the least I could do after finishing my homework was to come down behind the counter and help distribute the medicine, or whatever.  For susto it was magnesium carbonate, something like that, a little cherry syrup to make it tasty, and distilled water, and you stirred it and gave it to the people.  They took it right there.  

Now there could be after-effects of susto.  If a boy was not growing well, he was pale, not doing well in school, and you'd ask "What happened to him?"  And they'd say, "Well he got susto two years ago", or something like that.  So there you are -- a special form of pathology which is prevalent in the whole of Latin America.  There are other forms that are more or less equivalent in Asia and Africa...

SA:  But did you believe in it, growing up in that environment?

FG:  No.

SA:  And did your mother believe it?

FG:  I never asked her!  But it was just a job, just a job.  As I was mixing the cherry mixtures I didn't think about it.  I just thought about getting back to play or to do my homework, so I just did the preparation and gave it to people there.  There were other more colourful things even.  I guess I can give you a copy of the book.

SA:  Tell me some more...

FG:  Well, Mexico, as you probably know, is mostly an Indian country.  The population is 70% mixed, mestizo, some more Spanish and some more Indian, and some are 100% Indian -- you can see, they look like the statues of the Aztecs, some of them short, swarthy.  I look obviously more Spanish, but I am sure I have some mixture of Indian because I am from Mexico -- everyone in Mexico is mestizo.
So the Indians came from their towns -- I'm talking about 60 years ago already. Mexico was still a somewhat smaller city, now it's a huge metropolis.  People came from the surrounding areas.  And some of them had had, in their home towns, these magical potions.  They would come to our drug store and ask, "Do you have these love potions?"  And my father, who was a colourful guy, didn't want to say no, because, he said, " If I say no, they will go to the next guy who will sell them something."  So he sold them a powder for making a person fall in love with them.

I still remember that the name of this powder was licopodium. It must be a real name in the English language, I'm sure the word exists.  It was an extremely fine, very soft, silky powder.  He gave it usually to the Indian women, and he told them, "Don't give it by the oral route, that doesn't work.  What you have to do is take a little bit in your hand, and rub it softly into his hand.  Do it repeatedly while he is not looking, and it will work."

So there you are, another colourful anecdote -- we used to sell powders to make people fall in love. [Laughs]

“It’s a difficult thing to leave your home”

SA:  When did your mother give up this little shop?

It's always traumaticFG:  She was already elderly.  I have a sister who helped her along.  She must have been in her 60s when she quit.  By then I could send money from here and help them a little bit, and she could retire.  In the end I bought them a little house.  So, that's my personal situation.  I reflect upon it and, well, some of the things did not come out the way I expected, because ideally I would have wanted to go back and be there, you know? It's a difficult thing to leave your home, your country, your language, your traditions, your friends, no?  For a completely new place.  It's always traumatic.

SA:  When you went home, how easily did you fit back into your environment?

FG:  Well, very easily in terms of the people and the culture.  I know their ways, and when I left I was already a grown man.  All my formative years had been spent there.  But I did not fit in terms of securing a job.  Because the job situation was always bad.  It's the third world.  They offered me jobs which I didn't want to take.  They offered me work in emergency units, but I said, "I am not prepared for that.  I am a specialist in pathology."

At that time, electron microscopy was novel, and I became sort of an electron microscopist.  I wrote a lot of papers on the subject.  I would like to have done that in Mexico, but there were not that many electron microscopes in Mexico!  So I would have had to spend a year or so while I secured a proper job for myself, and what would I do during that time?

I had no place to stay.  My mother lived in a little apartment that she rented.  What would I do in the meantime?  How long would it be before I got a proper job?  Somebody said there's a job in Canada, doing what you like to do, and of course I was prepared to go there.  Then as time goes by it becomes more difficult to go back to your country.  Life becomes more complex.

SA:  The experience of growing up in that sort of environment, how much of that sticks with you, what influence has it had on you?

FG:  I think it's invaluable.  But that's not just for me; it's in general, for any immigrant.  It's an invaluable experience.  You see two aspects of life; two ways of looking at life; two universes, which are completely different.  Because south of the border is another world, a completely different world.  That's why I gave that title to my book. 

It gives you a broader perspectiveThe moment you cross the border everything is different – different odours, different people, different accents, different sense of humour, and the people react differently.  So the experience for an immigrant is always very valuable because it gives you a broader perspective.  You appreciate more from having seen both sides.

Death: the bigger picture

SA:  Two final questions.  First of all, what are the memories that most stand out in your mind of being a pathologist?

FG:  Well, major moments -- I think we have already talked about the first experience of confronting the autopsy, because of the profound human value, that can shock...

SA:  Well, tell me about that, because we haven't actually talked much about autopsy.  What is your relationship with the body?  Is it one of: this is a scientific enquiry, or this is a human person?  What is the relationship?

FG:  I never could divest myself of the human part of the [autopsy].Yes, when I am there for the purpose of writing a report and talking to my colleagues and all that, I have to confine myself to the purely medical aspects of the case.  But again, I could never, in the back of my mind, not think of the circumstances that surround that particular individual, that person.  That's probably one of the reasons that led me to write my essays.  In other words, to do the autopsy in the morning, and then to come home and reflect a bit and write my reflections of that case in the evening. 

I don't know how common this is among pathologists, but a colleague of mine, Dr Bolande, who's now passed away, he said, "Well, you do that because of your background and your sensitivity.  You like literature and you read."  Most people, especially in medicine… Medicine is so absorbing that there's no time to read.  And you have lots of medical journals to read, too, so when are you going to read Tolstoy?  

As my colleague said, "You do it because you have the humanistic learning.  Most pathologists", as he put it colourfully, "they might as well be working in the Kraft [meat processing] Company -- you know, cutting up the meat!"  [Laughs] They don't think beyond that.

The cause of death is such a broad thingBut as I say, in one of my essays I talked about that.  I said that the pathologist is supposed to find the cause of death.  But the cause of death is such a broad thing that what we actually look at is just a very small part of that enormous puzzle, which is the immediate, pathophysiological mechanism of death. Period.  But behind that there are all kinds of social circumstances, cultural circumstances.

The patient died because of cirrhosis of the liver.  Okay, he died of hepatic insufficiency.  But he got hepatic insufficiency because he was an alcoholic.  And he was an alcoholic because he was reared in such circumstances that led him to drink.  It becomes a labyrinth, you get lost in the meanders here and there.  So I said that in one of my essays -- that if you really were going to write a full report about the cause of death, it would be like the novels of the seventeenth century.  It would be like Cervantes' Don Quixote, where he starts with one narrative and he encounters a personage who tells another narrative, so you end up with a novel within the novel, no?  And then you forgot what the original story was.  So my autopsy report, if it were to be more faithful to reality, would be a big tome that no one would want to read!  [Laughs]

SA:  And does it really tease you that fact -- that you are not looking at the whole picture and that there is a story behind what you are seeing?

FG:  To me, yes.  I know that many people are not worried about that.  And I know, as I said, that you have to establish limits and know what you are doing: you are a pathologist and you are expected to render a service, a report.  And this report is supposed to tell them your understanding of the lesions that were present in the patient, and the possible cause of the mechanism of death.  That's what you are supposed to do, no?  So I do that only. 

I know the other aspect is very important, but that aspect is not part of the report, so where do I put it if I have the restlessness of putting it somewhere?  I put it in a book of essays.

SA:  One other thing: in one of your essays you talk about the various customs you had when doing autopsies to show respect to the body that I haven't encountered in any of my interviews so far.  You said something about covering the face -- was that something you developed?

FG:  No, that is something that is done in many places, and I think it is something done spontaneously by the people who are performing the autopsy. And I think that it's interesting that it should be so.  Because when someone is dead, in reality it is no longer a person.  As I say, sometimes it is a mass of protein, which has already started decomposing.  That's all it is: there are no projects, no emotions; it is insentient.  But the appearance, you know?  The appearance is of the person who was alive, and that is mainly because of the face.  So you prefer to cover the head before doing anything to the 'person' who you know is really not a person any longer.  

SA:  Did you always do that?

FG:  Yes.  

SA:  Would you have felt disturbed by having the face showing?

FG: Since I never did it I don't know, but I think I probably would have.  Because it would be restituting the condition of humaneness that had been lost through death.


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