2013年10月4日 星期五

White One Sent , Henry Norman Bethune

Henry Norman Bethune was a doctor; adventurer; artist; poet; dandy; rebel; philosopher; social visionary ahead of his time; humanitarian; political agitator; teacher; guerrilla; revolutionary; inventor of tools and gadgets; medical innovator; founder and administrator of hospitals and public health services.

He is revered as a saint in China. IN 1972 he was declared "a Canadian of national historical significance" by the Canadian Federal Government, and "the world's best known surgeon" by his medical colleagues. His contributions to military medicine is indisputable. Yet to his contemporaries he was a brawling, egocentric, alcoholic philandering swashbuckler, took to bedding the wives of his colleagues.  Who was the real Henry Norman Bethune ?

This is his story.

Norman Bethune was born on March 3, 1890, into a prominent Scottish Canadian family in Gravenhurst, Ontario. His anchesters were French nonconformist Christians who emigrated from France to Scotland in the sixteenth century and to North America in the eighteenth century. His great great grandfather, the Reverend John Bethune (1751–1815), was the family patriarch and established the first Presbyterian Church in Montreal. Norman Bethune's great grandfather, Angus Bethune (1783–1858),was a fur trader for the Hudson's Bay Company in the Lake Huron district. Upon retirement in 1839 he successfully ran for Alderman of Toronto City Council.  From early boyhood, Norman wanted to be called Norman after his grandfather, also named Norman(1822–92), and to become a great surgeon like him. Norman Senior was educated as a doctor at King's College, University of Toronto, and at Guy's Hospital in England,  graduating in 1848 as a member of the Royal College of Physicians. Upon his return to Canada, he became one of the founders of the Upper Canada School of Medicine,which was incorporated into Trinity College, which is now the University of Toronto. Bethune's father, Malcolm Nicholson Bethune (1889-92), was adventurous as a young man and travelled around the world. In Honolulu he met an English Presbyterian missionary, Elizabeth Anne Goodwin. They married in 1887 and returned to Canada, where he became a zealous evangelist. As both his parents were deeply religious, Norman grew up with a "fear of being mediocre",instilled into him by his emotionally strict father and domineering mother. Bethune's siblings were his sister Janet, and brother Malcolm.
Even as a youngster, Bethune stood out for his wide-ranging curiosity, and was variously described by his peers as independent, restless, reckless, driven energetic, and stubborn. Since his father's occupation involved frequent moves, the boy attended a series of different schools. In 1908, at the age of 17, he completed his high-school in Owen Sound collegiate, Ontario. after a spell as a primary-school teacher in the village of Edgeley, north of Toronto, he enrolled in the University of Toronto in 1909, to study physiology and biochemistry. Even as a medical student he demonstrated the compassion and commitment to helping less fortunate people that later became the dominant feature of his unorthodox but highly creative medical career. In 1911 he deliberately interrupted his studies for one year to become a volunteer worker-teacher with Frontier college, a unique canadian adult education agency, to teach immigrant laborers at remotr lumber and mining camps throughout northern Ontario to read and write English.

When Canada entered the First World War in august 1914, Bethune, in a flourish of patriotism, joined the Canadian Army Medical Corps. He was the tenth person in the City of Toronto to enlist in the army. In February 1915 he was with the No.2 Field Ambulance as a stretcher bearer in France and witnessed some of the worst slaughter ever suffered by Canadian troops.In April the same year, during the second battle of Ypres in Belgium he was badly wounded by shrapnel in the left knee. He spent six months in hospital, first in France then in England, before being invalided home. After returning to Toronto, he pinched pennies and worked his way to a medical degree in December 1916. Dr Frederick Banting, one of the discoverers of insulin, was in his graduating class.
In April 1917 with the war still raging, Bethune went back to England and the war, first as a surgeon sub-lieutenant in the Royal Naval Canadian Volunteer Reserve, and then in the Royal Navy aboard the seaplane carrier Pegasus. After demobilization, Bethune planned to specialize in pediatrics, and took up a six-month internship at London's famous Hospital for Sick Children on Great Ormond Street, London in 1919. But after 4 years caught up in the war, he felt dislocated in an unhinged world, and was quickly seduced by the uninhibited bohemian life-style permeating post-war London. To support this life-style, he needed much more money than the hospital salary can provide, so during his off hours he made side trips to ware-houses in France and Spain, ferreting out objects d'art to sell to London art dealers.He spent lavishly on food, drink, clothes, nightclubs, books, paintings and friends. He grew an elegant mustache, took to sporting a cane, and cut quite a dazzling figure for the three years he luxuriated in high living.

Bethune returned to Canada in 1920, re-enlisted in the army and served for several months on the medical staff of the Canadian Air Force. after military service he returned to England to begin his second internship in west London Hospital, and in the next year, to train as a surgeon at the Royal Infirmary in Edinburg

While in Edinburgh Bethune met the strikingly beautiful Scottish woman, Frances Eleanor Campbell Penny, eleven years his junior. They were complete opposites : she was a subdued introvert; he was a brash extrovert. In spite of their differences and the resistance of her upper-class parebts, they married in 1923. The same year Bethune passed the difficult examination to qualify as a Fellow of the Royal college of Surgeons in Edinburgh. After the wedding the couple went on a one year " Grand Tour " through continental Europe, where Bethune demonstrated his spendthrift ways. One time they had run out of money in Vienna, so Bethune got a friend to wire him some emergency money. On the way home from collecting the money, he spent it all on a piece of fine China that he saw in an art shop, much to the displeasure of his wife. In one year Bethune managed to spend his wife's entire inheritance. But the trip was not a total loss, ever the diligent student, Bethune took time off to observe the work of leading surgeons in Paris, Vienna and Berlin.

After the honeymoon and with little money,the couple settled in Detroit , Michigan, where Bethune took up private practice and a part-time job as an instructor at the Detroit College of Medicine and Surgery. During the two years in Detroit Bethune gained first-hand, personal knowledge of poverty, as his practice put him in daily contact with the poor and their never-ending medical and financial problems. Later as his surgical fame grew, rich patients came and paid handsomely, sometimes for what he regarded as trivial services. Gradually Bethune came to realize the extent to which money was corrupting the medical system.

The Bethune marriage was tempestuous, and as time went by, Bethune and his wife drifted apart. A passionate, energetic man, but also impatient and  authoritarian, Frances found his irascibility, among other things, difficult to live with. At the time Bethune was also heavily absorbed in his work, and Frances often found herself alone at home. Tired of their quarreling, particularly over money matters, in 1925 she went to stay with friends in Nova Scotia. Then personal tragedy struck. In 1926 Bethune, a smoker, contracted moderately advanced tuberculosis due to overwork. After treatments in Detroit and at the Gravenhurst Sanatorium, he was sent in late 1926 to a sanatorium at Saranac Lake, by the Adirondack Mountains in upstate New York. In 1927, believing he was dying, he insisted Frances divorce him and return to her native Scotland.

In the 1920's the conventional treatment for TB was total bed rest, and the prognosis was generally poor. By October 1927 a year had passed and the TB got worse. By chance Bethune came upon a book: " The surgery of Pulmonary Tuberculosis", and learnt about a radical new surgery for tuberculosis called artificial pneumothorax. This involved artificially collapsing the diseased lung, thus allowing it to rest and heal itself. Intoxicated by renewed hope, Bethune burst into the middle of a staff meeting and demanded that artificial pneumothorax be performed on himself. The physicians at the Trudeau thought the procedure was too new and too risky, whereupon Bethune bared his chest and laughed aloud, "Gentlemen, I welcome the risk!"  Progress was spectacular after the operation. Bethune was sputum negative two months later,and was able to leave Trudeau in good health by December 1927 .Before going, he drafted a plan for a university programme to be conducted at the sanatorium, to prepare patients vocationally and psychologically for their return to normal life. Ten years later at Saranac Lake his dream became a reality.

Upon recuperation Bethune immediately wrote to his wife and proposed marriage again. At first she refused but eventually they were remarried in 1929. The marriage did not last, and they were divorced again for a final time in 1933. However, though they were unable to live together, they always stayed in contact and remained genuinelly fond of each other ..

During his stay at Saranac Lake, Bethune initiated the beginning of a huge volume of writing and art. His most important art of the period was a multi-paneled mural entitled the "TB's Progress", painted in a wild moment of despair on the walls of a sanatorium cottage called " The Lea". Drawn in color, the 5-ft-high and 60-ft-wide continuous panel was autobiographic , depicting allegorically the nine phases of his life, beginning with birth and ending with the ninth drawing where the Angel of Death cradling him in her arms. Bethune predicted the date of his own death to be 1932 - off by 7 years.Below each of the nine drawings was a poem that described the drawing.  
                                                     Under the final drawing he wrote :
                                             Sweet death, thou kindest angel of them all.
                                                   In thy soft arms, at last O let me fall;
                                           Bright stars are out, long gone the burning sun
                                         My little act is over and the tiresome play is done.
Bethune experienced wide swings in mood throughout his life, passing from a deep depression as expressed in his murals to a high euphoria . After surviving tuberculosis, he was convinced he should devote his life to crusade against tuberculosis and the social conditions that caused it. He wrote to the pioneer in lung surgery, Dr. Edward William Archibald, the Surgeon-in-Chief of the Royal Victoria Hospital in Montreal (the teaching hospital affiliated with McGuill University) for a training post in thoracic surgery . Archibald suggested that he spend a preliminary period with Dr David T. Smith, later Head of Bacteriology at Duke University, at a tuberculosis hospital in Ray Brook, New York. Doctor Smith said later that Norman learned more about bacteriology in 3 months than most graduate  students learned in 3 years. Bethune was with Archibald first as a trainee and then as a colleague from 1928 to 1932, where he dove into the field of thoracic surgery "with a zest that only a condemned man saved by a last-minute reprieve can feel."

Bethune caused much controversy within the medical community because of his "devil-may-care" lifestyle and his unorthodox approach to Medicine. He dressed flamboyantly, drank heavily and socialized with artists. He was too exuberant, too impetuous, too headstrong to fit in with the other staid medical doctors. In 1964 CBC journalist Marjorie McEnaney interviewed doctors and nurses who knew him at the Royal Victoria Hospital, who recalled his legendary impatience in the operating room : an operation taking most doctors two hours would be whipped through by him in fifteen minutes. Archibald who trained Bethune described his surgical technique as "quick but rough, not careful, far from neat, and just a little dangerous." He would shout torrents of abuse at any nurse unable to keep up with his fast and furious pace, and half way through an operation would fling an instrument to the floor because it was not performing well. Once the operation's finished he would storm off to his study and scribble away at diagrams until he had come up with a better design for the instrument. He had a marked genius for mechanical innovations and developed or modified more than a dozen new surgical tools which were soon being used by thoracic surgeons throughout Canada and other countries. His most famous instrument was the Bethune Rib Shears, inspired by a set of leather cutting shears he saw in a shoe repair shop. This table-mounted scapula retractor (the iron intern) was a forerunner of the automatic table retractor now widely used in abdominal and thoracic surgical procedures today.
Bethune clashed with many of his colleagues because of his impatience and outspoken criticism of ideas he didn't agree with, but in research he had infinite patience, and was forever testing and perfecting new ideas in the laboratory. He published 14 papers of lasting significance, describing his innovations in thoracic surgical techniques and suggested improvements. 

Young doctors generally liked Bethune. He was an enthusiastic and gifted teacher, informal, outgoing, dynamic,cheerful, and in the words of Wendell MacLeod, a medical intern at the Royal Vic from 1930 to 1932, he was a "breath of fresh air". He used the small group approach and picked specific patient to demonstrate different disease. He listened with genuine interest to what the students found on examination and what they thought. He enjoyed ridiculing conventional practice, and his energetic pursuit of new approaches was especially refreshing to young trainees who were tired of dry formal instruction. A case in point was the successful use of maggots to heal chronic empyema resistant to standard drainage procedures. Young doctors also appreciated his frank presentations at meetings of the American Association for Thoracic Surgery, though his manuscript on "Twenty-Five Errors I Have Made in Thoracic Surgery" was never published. Bethune had a warm and considerate bedside manner, and took a personal interest in the welfare of patients. A dashing figure, Bethune would sat on patients' beds and frankly discuss with them and their relatives the pros and cons of each treatment.

He was also popular with many of the nurses who found him attractive, and he had a reputation of being a womanizer. According to his biographer Roderick Stewart, both medical and non-medical "polite society" in Montreal regarded Bethune as shocking and rude. The nonconformist, provocative side of his character finally caught up with him, and in the fall of 1932 Archibald dismissed him. By this time Bethune had already gained certain surgical fame among the thoracic surgeons of Canada and the United States.
The eight years in Montreal, Bethune developed his creative talents. He wrote plays, poetry and short stories. He was then 45 years of age, twice divorced, restless, and seeking new challenges. He plunged headlong into Montreal's social whirlpool.As a successful surgeon Bethune was earning an extravagant salary, which he also spent extravagantly. His Beaver Hall apartment was filled with all that's luxurious, sensuous and artistic .He supported young Canadian artists, designed his own furniture, and befriended actors. He gave his friends free run of his apartment, and they repaid in kind. At one evening party, Bethune told his guests he needed a new wallpaper in the bathroom. They immediately smeared their mouths, hands and feet with lipstick and printed a figured wallpaper for him. A rebel against the pretentiousness of his profession, Bethune hung his diplomas, which other doctors displayed with pride in their offices, in that same bathroom. 

An accomplished artist, Bethune found release and relaxation in painting. He loved children,in June 1936, together with the artist Friedrich Wilhelm Brandtner, an exponent of a new theory on art training for children, he founded Children's Art Center - first of its kind in Canada - to give free workshops in oil and watercolor painting to underpriviedged children from five to fifteen years. The classes were held in Bethune's Montreal apartment three afternoons a week .Every Saturday Bethune took the children to the art galleries, and explained to them the art exhibits. The school created quite a stir in Montreal art circles, and there were public showings of the children's paintings. Some of Bethune's pieces, such as Night operating theatre (completed around 1934), were exhibited in Montreal.In his diary Bethune wrote down his definition of a true artist - " he makes uneasy the static, the set and the still. In a world afraid of change, he preaches revolution, the principle of life. He is an agitator, a disturber of the peace, quick, impatient, positive, restless and disquieting. He is the creative spirit working in the soul of man." 

Bethune had to wait a year before getting the post to head a new chest surgery department at  the Roman Catholic Sacre Coeur in Cartierville, north of Montreal, because the  Archbishop and the nuns at the hospital had reservations about his "une vie de boheme".  Now that he was his own master, he gave full rein to his talents and creativity. Both the hospital and Bethune flourished ; the new clinic soon became an important surgical TB treatment center in French Canada, and the years Bethune spent at its helm were among the most productive in his short surgical career. He performed 300 operations during the first year, many on advanced bilateral cases of tuberculosis; trained qualified surgeons, and introduced new techniques, such as person-to-person blood transfusion, while continuing to invent surgical instruments and publish scientific articles.In 1932 he was made a member of the American Association for Thoracic Surgery and three years later he was elected to its council.

From 1935 to 1936, Bethune's life abruptly changed from apolitical exuberance to political intensity. At an artists' gathering, he met then fell in love with a painter, Marian Scott. Marian was involved in left-wing politics, and her husband, Francis Reginald Scott, a poet and law professor at McGuill University, was an important member of the Co-operative Commonwealth Federation. Through his socialization with literary and artistic people, Marian Scott in particular, Bethune was introduced to new political ideas. 

Against a backdrop of Economic Depression, Bethune became increasingly disillusioned with surgical treatment and more concerned with the socioeconomic aspects of disease. He noticed for every case of TB he cured, ten new cases flared into the open, because TB fed on poverty. Five years after the Stock Market crash, poverty was the spreading disease. He wrote in the Journal  of the Canadian Medical Association in July 1932:" Tuberculosis was not just a disease but rather a problem arising from the socioeconomic system. The rich recovers and the poor man dies. Lack of time and money kills more cases of pulmonary tuberculosis than lack of resistance to that disease ." Bethune was greatly troubled by the unattended suffering among the poor and with the impulsiveness with which he threw himself into any new cause that drew him, he opened a free clinic for any man, woman or child sent to him by the Montral Unemployment Association. Thia was the context in which his acute social conscience and his growing interest in communism developed, thus politics was a preoccupation for only the last four years of his life.

In August 1935, Bethune traveled to the Soviet Union to attend the 15th International Physiological Congress. While he was there he visited Russian hospitals in Moscow and Leningrad (St Petersburg) and observed first hand the Soviet medical system. He was deeply impressed by it, and by the preventive methods used to fight tuberculosis there. Bethune began to believe in the necessity of free medical care for all members of society. On his return he reported to a distinguished medical-surgical society in Montreal that " Russia presents today the most exciting spectacle of the evolutionary emergent and heroic spirit of man" This brief visit also led him to learn more about communism. On his return to Canada in November 1935, he formally joined the Communist Party (then an illegal organization)in Montreal with goals to change the world for the better.

In the course of that fall, he organized a study group called the "Montreal Group for the Security of the People's Health" which consisted of about a hundred like-minded doctors, nurses, and social workers. Bethune recognized that good medical care depended on team effort, and under his direction, the group met regularly to examine the health-care systems of other countries with a view to induce radical reform of medical and health care services in Canada. After about six months of study and discussions, the group came up with a Four-Point Plan: Municipal Medicine ; Compulsory Health Insurance; Voluntary Health Insurance, and Free Medical Care for the unemployed. In the summer of 1936, at the time of a provincial election, the Plan was submitted to the government,the opposition party, and health-care workers. The general public and politicians reacted negatively, while some doctors exhibited frank hostility. The speech he gave to the Medico-Chirurgical Society of Montreal, titled " Taking the Private Profit Out of Medicine " struck the medical profession at the time as socialized medicine, and led to his expulsion from the Society. Bethune grew increasingly frustrated by the failure of the Medical Reform Plan and openly expressed contempt for his own profession. He felt Canada closing in on him and saw himself as a " big frog in a small pond ".

In mid-July 1936, the Spanish Civil War broke out.It started as a right-wing nationalist military uprising led by Francisco Franco, against the newly elected leftist Popular Front government. The Nationalists were backed by fascist Germany and Italy, while Russia was on the side of Popular Front. The civil war was looked upon as a battle between fascism and communism , and Spain became a popular cause among many of the leftist artists and writers in the rest of the world.  Bethune saw this war as an opportunity to fled from his on-going discontent. He realized by now he could never have a real romantic relationship with Marian Scott; then of course the thrill of a risky adventure and an international stage on which to fight a humanitarian  cause was resistible. He resigned from his position at the Hospital du Sacre- Coeur, made his will leaving everything to his ex-wife, and joined the Committee to Aid Spanish Democracy(CASD), an organization of Canadian Communist sympathizers. Twelve hundred Canadian supporters went to Spain under the banner of the Mackenzie-Papineau Battalion, of these Bethune was the most famous.

Bethune set off for Spain on 24 October 1936, taking medical supplies with him. He was strongly motivated to fight fascism, and wrote a friend :" It is in Spain that the real issues of our time are going to be decided. It is there that democracy will live or die." This was an irrevocable turning point in his life .

On 3 November Bethune arrived in Madrid, and teamed up with Henning Sorensen, a multilingual Danish-Canadian journalist. After meeting with medical elements Bethune found there were enough foreign surgeons already in Spain. Not one to submerge himself anonymously in a hospital surgical team, Bethune also recognized that the only way to raise the publicity profile of the Canadian Committee was for him to spearhead a specific medical service. After an inspection of hospitals in Madrid which revealed a severe lack of facilities for blood transfusion, he decided the best way he could help was by providing a blood-transfusion service. In late November,he went with Sorensen to London to buy the necessary  equipment. 

Back in Madrid, he set up the Servicio Canadiense de tranfusion de Sangre in mid December. Theteam was made up of three Canadians, an American woman, and a few Spanish doctors, to collect blood from donors. They made a public appeal in Madrid and in one month had 1,000 donors listed who were called upon every 3 weeks if necessary for a 500 ml donation. The donors received a cup of coffee and a coupon for extra food. By January 1937, Bethune's unit was supplying 60 hospitals in the Madrid region.  

A frequent cause of death on the battlefield is medical shock brought on by loss of blood, but the standard practice at that time was to transfuse wounded soldiers only after they had been brought from the front lines to hospitals in the rear, which was often too late. In a TV clip first shown on 30 Nov 1980, Sorensen recalled how Bethune uttered the words that revolutionized military medicine :"I have an idea, I think we should organize an ambulant blood transfusion service." 
Bethune elected to lead his team as close to the front line as he could and transfuse on the spot. His concept was simple but innovative : extrate blood from volunteer donors in various cities, store it in refrigerators ( with sodium citrate added to prevent clotting) which would preserve it for two or eben three weeks, and deliver it to where it's needed, when it's needed, via a specially outfitted vehivle. The mobile transfusion vehicle he constructed incorporated a small refrigerator run by kerosene or gasoline, a sterilizing unit, an incubator, and equipment for drawing and administering blood transfusion in the field .

This mobile unit also contained dressings for 500 wounds, and enough supplies and medicine  for 100 operations. " In all, our equipment consists of 1,375 seperate pieces," wrote Bethune in December. The Instituto Canadiense de transfusion de sangre ( Canadian Blood Transfusion Service) transfused its first patient on 3 January 1937. Five months later the transfusion Unit _ composed of a central station which delivered blood to one hundred sub-stations strung along a front of over 600 miles ( 1000km) , supplied every military sector in Spain and administered up to 100 transfusions per day to wounded soldiers. Where refrigeration was not available, the precious blood containers were kept in cold mountain streams close to firing line. This mobile blood-transfusion service had drastically reduced fatalities among the wounded, in some sectors as much as 75 %. 

Bethune's pioneering battlefront mobile medical unit is viewed by medical historians as an important innovation to military and medical history. It's considered to be a precursor to the later development of Mobile Army Surgical Hospital (MASH) units, the portable surgical hospitals first set up in 1945, and would prove seminal to the Allies in World War II. It was later widely used in the Korean War (1950-53).

Not content with dealing just with medical therapy, Bethune had an idea of setting up a convalescent club run by an International Nursing Corps of French, German and English nurses, who could then comfort each of the wounded multi-national Brigade in his own language. 

Bethune had a flair for publicity. He made frequent broadcasts to America and wrote articles and poetry on the horrors of war. "Spain,”he wrote later," is a scar on my heart.”One of his most well-known poems was published in the 1937 July issue of Canadian Forum magazine:
         And the same pallid moon tonight,
        Which rides so quietly, clear and high,
        The mirror of our pale and troubled gaze
        Raised to a cool Canadian sky.

        Above the shattered Spanish troops
        Last night rose low and wild and red,
        Reflecting back from her illumined shield
        The blood bespattered faces of the dead.

        To that pale disc we raise our clenched fists,
        And to those nameless dead our vows renew,
        “Comrades, who fought for freedom and the future world,
        Who died for us, we will remember you.”
Bethune was reckless in the field. When Franco shifted the battle to the south, Bethune ignored all warnings and headed straight for Almeria . Malaga had just been bombed . With his Canadian companion Hazen Sise, Bethune arranged a marathon rescue relay to help the thousand upon thousands of evacuees from Malaga to reach the relative safety of Almeria . For two days and two nights without sleep he stayed behind caring for the wounded as they limped or crawled by the wayside. The memory of the pitiful children haunted him for weeks, and resulted in his idea of building a chain of Children's Villages to care for war orphans. The Spanish Aid Committee in Toronto eventually raised money for the building of the first two Children's Villages. Bethune later wrote an article recalling the brutality he witnessed called "The Crime on the Road; Malaga to Almeira".

Though Bethune worked extremely hard and showed great compassion for his patients in Spain, he also continued his womanizing, hard-drinking ways. His brash, opinionated nature and quick temper frequently got him into trouble with many of the Spanish Communists, with the result four and a half months later, following a feud, the previously independent transfusion unit was taken over by the Spanish Republican Government. By April 1937, Bethune's closest colleagues, Sorensen, Hazen Sise, and Allan May,were all concerned that Bethune's escapades of vulgar partying, sex and diversion of funds was hurting Canada's image. However, the triggering event which led to his removal was typical Bethune -- involvement  with a female he promoted to administrative rank who had little work merit. By mid-May, Bethune was in Paris living well on CASD money and on June 2 he was under escort by a member of the Canadian Communist Party en route across the Atlantic back to Canada, ostensibly to embark on a cross-country speaking tour to raise funds for the Spanish  cause.

Bethune arrived back in Montreal on 6 June1937, after an absence of 8 months, to a hero's welcome. One thousand met him at Windsor Station in Montreal and that night 8,000 people, a capacity audience, heard him speak (without notes), on the bravery of the Spanish people. He was a good speaker and his talks stimulated a moral and financial response far beyond all expectations across Canada. With expert help, he produced a propaganda film about the transfusion service,"Heart of Spain", which was distributed in North America.

By Oct 1937, tired of the touring, Bethune requested to be sent back to Spain. But the CASD had received a Spanish police report that a Swedish female journalist Bethune was romantically involved with was suspected to be a fascist spy and Bethune was no longer welcome in Spain, so he was offered instead a medical mission in support of the Chinese Communists who were fighting Japanese invasion

With the support of the Communist Party of Canada and the New York-based China Aid Council, Bethune set sail for Hong Kong on 2 Jan 1938. He was accompanied by Jean Ewen, daughter of a prominent Canadian communist and a registered nurse. Ewen had worked in a Shantung Hospital for 2 years and was fluent in Chinese. They landed in Hong Kong on the 27th Jan. Bethune,an avid correspondent all his life, wrote from Hong Kong and explained why he had come:“I refuse to condone, by passivity, or default, the wars which greedy men make against others. Spain and China are part of the same battle. I am going to China because I feel that is where I can be most useful.”In China Bethune craved his most enduring legend.

The troupe flew from Hong Kong to Wuhan, the provisional capital of the Kuomintang (the Chinese Nationalist Party), and met Chou En Lai, later premier of China. After working briefly in several cities, Bethune decided to go to Yan'an, the then Chinese Communist capital in Shaanxi Province. Travelling by truck and by train, by mule cart and on foot, Bethune and Ewen made the epic 800 mile journey through enemy-held territory and eventually arrived at the headquarters of Mao Zedong's 8th Route Army 5 weeks later. En route they treated combat casualties and narrowly escaped capture by the Japanese. On the 22 March they were greeted by Zhu De, the commander-in-chief of the 8th Route Army.

On 31 March Bethune met with Mao Zedong, who was president of the Revolutionary Military Council, in his cave dwelling. Their discussion lasted the entire night. Mao, recognizing Bethune's potential value, immediately made him a member of the Communist Party of China, and gave him free rein to organize a front-line service for the wounded.
After a month or so in Yan'an, on May Day in 1938, Bethune,at his own request, together with Ewen, travelled northeast to the frontier isolated mountain ranges of Jin (Shanxi)-Cha (Chahar)-Ji (Hebei), where fighting was extremely fierce and there were only a few qualified doctors to care for the 13 million people (sick peasants as well as wounded soldiers)in the area. On 17 June 1938 Bethune arrived in Jingangku, a village on the Wutai Shan mountain, which was the headquarters of Commander-in-Chief Nie Rongzh. Nie promptly appointed Bethune the Medical Commander to all Chinese Communist Eighth Route Army medical forces. In total 1,000 battles were engaged during Bethune's tenure.

China was in desperate struggle against incredible odds.With at least 25,000 wounded always in the hospitals, there were only five qualified Chinese doctors, fifty Chinese untrained " doctors"- peasants who had picked up the merest rudiments of operating by observation-, and Bethune, the only foreign doctor. There were few surgical supplies or medicines, and the " hospitals" were mostly just peasant huts.

Bethune was disappointed to find his ambulant blood transfusion system couldn't work in China. There was little electricity for refrigeration and the road conditions were too poor.With his genius for originating and organising, Bethune quickly conceived the idea of a mobile medical unit which travel directly to the fighting front and treat the wounded on the spot. The operating team consisting of Bethune, two Chinese doctors, an interpreter he had trained as an anesthetist, a cook, and two orderlies. The mobile surgical unit consisted of a collapsible operating table designed by Bethune,a full set of surgical instruments, antiseptics, 25 wooden splints, sterile gauze, and medicine, all built to fit onto the backs of two mules. In case of sudden enemy advane, the whole hospital unit could be packed up and on the move within half an hour.

The mobile units were particularly well suited to the guerrilla campaign being waged against the Japanese. Bethune and his operating theatre was often within minutes of the shifting frontline of the guerrilla fighters. On horseback he led his mobile operating unit through the barren Wu Tai mountains of Shanxi province and across the Hebei plains, covering hundreds of miles at a stretch, over tortuous mountain paths and primitive country.

Bethune worked prodigiously and took very little rest. He was always close to the fighting and forced to work under extremely harsh conditions, often engaged in marathon surgical sessions as casulties mounted.In April 1939, during the battle of Qihui led by General He Long, he and his team performed 115 operations in a 69 hour period - without sleep.His mobile unit helped save at least 500 lives a day and continued operating under terrible conditions. While working in the makeshift mobile unit was strenuous, conditions in the base hospitals were even worse. These were built wherever there was space, in temples, huts or caves; they had poor lighting, only benches or planks for beds, often without blankets.The sanitary condition was horrendous.
Bethune did not distinguish between casualties, and treated wounded Japanese prisoners as well as Chinese soldiers. After one night of steady operating, he wrote " Wounds", a poignant critique of imperialist war. This is an extract from the article : 

Any more? Four Japanese prisoners. Bring them in. In this community of pain, there are no enemies. Cut away that blood-stained uniform. Stop that haemorrhage. Lay them beside the others. Why, they're alike as brothers! Are these soldiers professional man-killers ? No, these are amateurs-in-arms. Workman's hands. These are workers-in-uniform.

No more. Six o'clock in the morning. God, it's cold in this room. Open the door. Over the distant, dark-blue mountains, a pale, faint line of light  appears in the east. In an hour the sun will be up. To bed and sleep.

But sleep will not come. What is the cause of this cruelty, this stupidity?
A million workmen come from Japan to kill or mutilate a million Chinese workmen. Why should the Japanese worker attack his brother worker, who is forced merely to defend himself. Will the Japanese worker benefit by the death of the Chinese? No, how can he gain? Then, in God's name, who will gain? Who is responsible for sending these Japanese workmen on this murderous mission? Who will profit from it? How was it possible to persuade the Japanese workmen to attack the Chinese Workman – his brother in poverty; his companion in misery?

Is it possible that a few rich men, a small class of men, have persuaded a million men to attack, and attempt to destroy, another million men as poor as they? So that these rich may be richer still? Terrible thought! How did they persuade these poor men to come to China? By telling them the truth? No, they would never have cone if they had known the truth, Did they dare to tell these workmen that the rich only wanted cheaper raw materials, more markets and more profit? No, they told them that this brutal war was “The Destiny of the Race,” it was for the “Glory of the Emperor,”it was for the“Honor of the State,” it was for their “King and Country.”

False. False as hell!

The agents of a criminal war of aggression, such as this, must be looked for like the agents of other crimes, such as murder, among those who are likely to benefit from those crimes. Will the 80,000,000 workers of Japan, the poor farmers, the unemployed industrial workers – will they gain? In the entire history of the wars of aggression, from the conquest of Mexico by Spain, the capture of India by England, the rape of Ethiopia by Italy, have the workers of those “victorious” countries ever been known to benefit? No, these never benefit by such wars. Does the Japanese workman benefit by the natural resources of even his own country, by the gold, the silver, the iron, the coal, the oil? Long ago he ceased to possess that natural wealth. It belongs to the rich, the ruling class. The millions who work those mines live in poverty. So how is he likely to benefit by the armed robbery of the gold, silver, iron, coal and oil from China? Will not the rich owners of the one retain for their own profit the wealth of the other? Have they not always done so?

It would seem inescapable that the militarists and the capitalists of Japan are the only class likely to gain by this mass murder, this authorized madness, this sanctified butchery. That ruling class, the true state, stands accused.

Are wars of aggression, wars for the conquest of colonies, then, just big business? Yes, it would seem so, however much the perpetrators of such national crimes seek to hide their true purpose under banners of high-sounding abstractions and ideals. They make war to capture markets by murder; raw materials by rape. They find it cheaper to steal than to exchange; easier to butcher than to buy. This is the secret of war. This is the secret of all wars. Profit. Business. Profit. Blood money.

Behind all stands that terrible, implacable God of Business and Blood, whose name is Profit. Money, like an insatiable Moloch, demands its interest, its return, and will stop at nothing, not even the murder of millions, to satisfy its greed. Behind the army stand the militarists. Behind the militarists stand finance capital and the capitalist. Brothers in blood; companions in crime.

What do these enemies of the human race look like? Do they wear on their foreheads a sign so that they may be told, shunned and condemned as criminals? No. On the contrary. they are the respectable ones. They are honored. They call themselves, and are called, gentlemen. What a travesty on the name, Gentlemen! They are the pillars of the state, of the church, of society. They support private and public charity out of the excess of their wealth. they  endow institutions. In their private lives they are kind and considerate. they obey the law, their law, the law of property. But there is one sign by which these gentle gunmen can be told. Threaten a reduction on the profit of their money and the beast in them awakes with a snarl. They become ruthless as savages, brutal as madmen, remorseless as executioners. Such men as these must perish if the human race is to continue. There can be no permanent peace in the world while they live. Such an organization of human society as permits them to exist must be abolished.

These men make the wounds.

This passage is all the more relevant today as Japanese militarism is once again on the rise.

Bethune took it upon himself to work feverishly in an endeavour to make improvements to China's medical system. He worked with Chinese carpenters and blacksmiths and invented several instruments, including a wooden packing container that greatly facilitated the transport of drugs and supplies, which could also double as operating table. Because of its shape, he gave it the Chinese name lugou qiao (Marco Polo bridge).

One of the most pressing needs was to train individuals to provide basic first aid and sanitation services and to carry out simple surgical procedures.In January 1939 Bethune organized a week of intensive training in the village of Yangjiazhuang. In August and September, he supervised a five-week program and trained everyone from orderlies to nurses to surgeons. This led to the opening, on 15 September, of a permanent model hospital(also to be used to train doctors and nurses),in Sung-yen K'on.
Bethune designed and established over twenty teaching and nursing hospitals. With adequate translation he taught hands-on surgery, and trained a large number of medical cadres in basic medical techniques. He performed near miracles by taking illiterate peasant boys and uyoung workers and made doctors ( the Barefoot doctors ) and nurses out of them. Another major achievement was improvement in sanitary conditions.

Bethune wrote and illustrated elementary medicine and surgery textbooks and graphic manuals for wartime surgery, as there was none available.The same year he produced another first- a medical manual devoted entirely to guerrilla warfare, known in Chinese as "Youjizhan zhong shi yezhan yiyuan de zuzhi he jishu," and in English as "Organization and technology of division field hospitals in guerrilla war." 

Victum still of his own foul temper, Bethune at times of frustration would lapse into his infamous behaviour. Jean Ewen described his near psychopathic rage : " Dr Bethune was furious, I had never seen such a temper brfoe......He stomped and kicked everything in sight " Yet his demeanor altered when he was with the sick. " He was very tender with the wounded, and very concerned ," Sorensen , his Spanish interpreter, recalled," It seemd his whole personality changed when he went in among the wounded. He was a terribly complex man." An assistant in China, Chu, also remembered how he was with a 5 month old baby with severe malnutrition, all matchstick limbs and a huge belly. The baby cried incessantly out of hunger. Bethune excavated a can of milk, a spoon and a cup with his sack and told Chu to get some hot water. Together with the mother, Bethune spoonfed the baby a whole cup of milk. The next morning the mother thanked Bethune profusely, saying the baby had not slept so well for many nights. The doctor just stood there grinning from ear to ear .  
Another story told how 10 days of continuous heavy rain caused raging floods in the Hebei North End village, and Bethune was very upset as he watched houses, trees and crops being washed away. When the flood threatened the Military Medical School, he undressed, jumped into the river and joined the rescue of the precious equipment. Because there were no boats, flat basket trays were tied to ladders to hold the cargo , a row of 10 people held hands to seady the ladder while Bethune swam and pushed the ladder along from the side. They had to make a dozen trips to transfer all the material to dry ground, all the while Bethune told jokes about the swimming practices he did in the lakes back in Canada

The soldiers adored him. Word quickly passed from mouth to mouth in China of the amazing Canadian doctor who shared his clothes, his food, and even his blood with wounded soldiers and civilians. He won the admiration of the locals by accepting their customs, sleeping in their homes, and suffered the same hardships as they. His name sparked the courage of thousands of Chinese soldiers, he was their war cry :" Attack! Bethune is with us !"

Bethune's letters from China, however, betrayed the many trials and personal hardship he endured. Isolated, experiencing a foreign culture, eating sparsely, and clothed in the threadbare uniform of a common Chinese soldier, he sometimes expressed a longing for the comfort of home: " I dream of coffee, of rare roast beef, of apple pie and ice cream. Books- are  books still being written ? Is music still being played ? Do you dance, drink beer, look at pictures ? What do clean white sheets in a soft bed feel like ? Do women still love to be loved ?"

Since his arrival at the frontier, Bethune had lost a lot of weight. He was forever surpassing his own records of fortitude, exhausting even to contemplate. He seemingly survived only by sheer will.  Long hours, poor food and overwork had taken their toll, the once proud, virile body was thin and bent, the handsome face now deeply lined and scarred by suffering. In a letter written in August 1939, he states that his teeth and his eyes are in bad shape and that one ear has gone deaf. Near the end at the age of 49 he looked 75. The Chinese affectionately called him " The Old Man".

But given the choice, Bethune would still have preferred to toil under adversity in China rather than live in luxury back home. The radical doctor who was scorned and shunned by the elite of Canadian medical society found solace and a sort of redemption among the Chinese peasants. In a letter to a friend in August 1938, Bethune wrote: " It is true I am tired but I don't think I have been so happy for a long time. I am content. I am doing what I want to do.....I have no money nor the need of it- everything is given me. No wish. no desire is left unfulfilled. I am treated like a kingly comrade, with every kindness, every courtesy imaginable."
In each letter home Bethune pleaded for more supplies and money. Supplies were dwindling to a trickle: lacking even ether for urgent surgery. Bethune worked on, by now bitterly resigned to the fact that the aid he entreated would not come. In late 1939 Bethune planned to return to North America for a  fund-raising tour, but delayed his departure when the Mount Motien (摩天岭)broke out in his area in Laiyuan County.

Painstaking down to minute details with the care of his patients, he was appallingly reckless with his own. On 28 October, even as the Japanese were seen advancing on the temple where he and his staff were operating, Bethune refused to evacuate before he had operated on all the wounded. In the ensuing rush, while operating barehanded (there were no surgical gloves) on a soldier whose head wound was badly infected, Bethune accidentally nicked the middle finger of his left hand. Immediately he plunged his hand into iodine solution to disinfect the cut but continued operating. It wasn't the first time he had cut himself in an operation. He was sure this would heal. But the cut did not heal. Despite their best effort to drain the infection, it spread. His hand and then his arm became badly swollen. Amputation of his arm was suggested, but Bethune rejected the idea. He knew his death was imminent. Blood poisoning had set in; his whole body was infected. His Chinese comrades tried to carry him to get help on a litter, but there was no help available. In America and Europe there were drugs that might have saved him, but out here in that remote, war-torn corner of China there were none.
Exhausted by his poisoned system, Bethune wrote one final letter, describing first his condition :" Vomiting on stretcher all the day. High fever, over 40C. I think I have either septicemia from the gangrenous fever or typhus fever. Can't get to sleep. Mentally very bright. Phenacitin and Aspirin, Woven's powder, antipyrin, caffeine, all useless." He then set out his last will and requested that some money be provided by the Chinese Aid Council to his divorced wife. His responsibility to her, he maintained, "is undeniable.” He also listed the basic pharmaceuticals his group needed " Each year will need to buy 250 pounds of Quinine and 300 pounds of iron, specifically for Malaria patients and a significant number of anemia patients . Do not go to Baoding-Tianjin area to buy drugs, because the price is twice as expensive as Hong Kong and Shanghai.". The part addressed to General Nie read : "Dear Commander Nie, Today I feel really bad. Probably I have to say farewell to you forever ! Please send a letter to Tim Burke the General Secretary of Canadian Communist Party. Address is No.10, Wellington Street, Toronto, Canada. Please also make a copy for Committee on International Aid to China and Democratic Alliance of Canada, send them a Japanese and a Chinese machetes, and a report of my work here, tell them there is a film to be completed .....tell them, I am very happy here, I only hope is to be able to contribute moreThe two boxes of surgical instruments are for the Military Health Minister, ling can take the doctors and the public health schools .The two camp beds are for you and hanif, the two pairs of shoes from England are for you, the riding boots and breeches are for Jizhong, the district commander . To my servants and cook, a blanket each, the Japanese ( patient) the pair of Shao-ping shoes . Please give my Kodak Retina II camera to comrade Sha Fei. I cannot write any more ! Norman Bethune, 04:20pm, November 11th, 1939". 

The day - 13 November1939, 5.20am, in a tiny peasant hut in the village of Huang Shikou (Yellowstone County) in Hebei Province, Dr. Norman Bethune died. He was buried in an American flag, as no Red Ensign or Union Jack was at hand.
His team carried his body for 4 days along icy mountain paths to a place of relative safety, as all around battles raged in the countryside. Two memorial ceremonies were held in succession in his honour : on 1 December 1939 a memorial meeting was held in Yan'an, the troops of the 8th Red Army stood row upon row, filling the valley between the honeycombed hills while Martial Chu Teh, the commander-in-chief, spoke to them of the man who died for them. Later on 5 January 1940, in the frontier region where he had worked, 10,000 people shuffled by the frail gaunt corpse. Bethune's death was a major loss to the 8th Route Army. A tomb was built for him in the valley where he died. Nine years later General Neieh revisited his grave to wipe off the desecration done by the Japanese. In 1952 his remains were taken to the Mausoleum of Martyrs,and re-buried in the Revolutionary Martyrs' Cemetery in Shih-chia-chuang, Hebei Province. A statue, a pavilion and a museum mark the site. Every year on the anniversary of his death, a ceremony is held there. 
Just next to Bethune's grave is the grave of an Indian doctor, Dr.Dwarkanath Shantaram Kotnis, who died in China on 9 December 1942. He was one of five Indian physicians dispatched to China to provide medical assistance during the Second Sino-Japanese War in 1938. 
Another foreigner honoured in this Mausoleum is Reverend Eric Liddell of Scotland, the hero of the Academy Award–winning film, Chariots of Fire. Liddell died while incarcerated in a Japanese prisoner of war camp in Shandong Province.
Bethune's affection for, and devotion to his Chinese comrades were fully reciprocated.After Bethune's death, Mao Tse Tung told his countrymen: " We mourn much more than the passing of a man". On 21December Mao Zedong published an essay entitled  "In memory of Norman Bethune,"( 紀念白求恩), which documented the final months of the doctor's life in China.It became one of Mao's most famous essays. In it Mao urged all Chinese people to emulate Bethune's spirit of internationalism, his sense of responsibility, his selfless spirit and his devotion to others." Comrade Bethune and I met only once. Afterwards he wrote me many letters. But I was busy, and I wrote him only one letter and do not even know if he ever received it. I am deeply grieved over his death. Now we are all commemorating him, which shows how profoundly his spirit inspires everyone. We must all learn the spirit of absolute selflessness from him. With his spirit everyone can be very useful to the people. A man's ability may be great or small, but if he has this spirit, he is already noble-minded and pure, a man of moral integrity and above vulgar interest, a man who is of value to the people. Comrade Bethune's spirit, his utter devotion to others without any thought of self, was shown in his great sense of responsibility in his work and his great warm-heartedness towards all comrades and the people."
Among Chinese only the name Mao Tse-Tung was more familiar than Pai-Ch'iu-En (White One Sent) because Mao's essay was included in textbooks in China's elementary schools. which had become required reading for everyone during China's Cultural Revolution (1966 76). Quotations of even a small portion of that essay were enough to identify him. .His name also appears in Chairman Mao's Little Red Book as "the ideal communist." and his picture appeared on posters and postage stamps.  Bethune's name becomes almost synonymous with Canada in China and is of great significance in 2010 as the two countries mark the 40th anniversary of diplomatic relations. 
After being elevated to hero status by Mao, Bethune has been revered by the Chinese people ever since.Bethune is one of the few Westerners to whom China has dedicated statues and memorials, of which numerous have been erected around China.Several colleges and universities of medical sciences and hospitals are named after him in China,e.g.the Bethune Military Medical College , Bethune Specialized Medical College,and the 800-bed Norman Bethune International Peace Hospital (which includes a Bethune museum on the hospital grounds), all three are in Shijiazhuang,Hsi Ching (Yenan Province). Norman Bethune University of Medical Sciences, founded in Changchun, Jilin, was later merged into Jilin University as Norman Bethune College of Medicine.

Except for his work in Spain, Bethune was virtually unknown in his homeland and his death received little attention in Canada. After Bethune's death, Edward Archibald, Bethune's erstwhile mentor, wrote, "He was definitely abnormal, but not 'mental' and not a genius or a leader. ... He was an egocentric. His vision was keen but narrow. He wore blinders. He trod on many toes, quite often without knowing or caring if he did know. He had a superiority complex and he was entirely amoral. And yet, it is not quite fair to say all that, because I do give him credit for sincerity in his social views." Then he added: "Change and progress are best accomplished within the confines of organized medicine, the hallmark of the unsung hero. If that fails, extraordinary measures will be required and they will have to be truly heroic and delivered by the totally dedicated and the supremely talented to succeed." Many believe that Bethune attained this exalted pinnacle and thereby became a truly sung hero. Leo Eloesser, another thoracic surgeon, in a memorial to Bethune, may have put it best: "It was not in a well-disciplined hospital that one saw the sinewy figure of Bethune best. His intense love of freedom, his intolerance of the reins of authority, and his human interests transcended his medical ones."

Even before Bethune left for China, he might already have mentally prepared himself for not being able to come back. He wrote a farewell letter to " Elizebeth", a former lover " My road ahead is a strange and dangerous one. You cannot come with me. I don't want to attempt in my time left any serious emotional engagement......Remember me as I will you -- with quietness and respect." Bethune also wrote another friend he was in need of an altar on which to immolate himself and rise again like the fabled phoenix from the ashes. Henning Sorensen commented years later " When I look upon the life of Norman Bethune, it seems to me to be one long preparation for the final period - his life and work in China " In China, away from whisky and women, Bethune had found his mission in life.

During the 19 months in China,Bethune taught the Chinese skills and gave them hope, in turn their devotion restored his faith in himself and humanity. Larry Hannant, a biographer of Bethune stated," Bethune found a movement and a people that satisfied his ideal of communism, with a hatred of Japanese militarism, a love for the Communists' allies around the world who shared their struggle, and a lack of personal vanity and ambition." For the first time he believed he was working together with the people in a united effort. Shortly before his death he wrote to a friend that his time in China had been" the most significant, the most meaningful years of my life. Sometimes it has been lonely, but I have found my highest fulfillment here among my beloved comrades."  For in China, quite simply, he had been needed,and he need to be needed. Thousands of miles from home, in the bleak mountains of China,the wounded doctor finally healed himself through the act of healing others.

Bethune will always remain a figure of controversy.  Ted Allan, a Jewish Canadian writer who was with Bethune in the Spainish war, hit the mark when he said " There were times I had loved him because he had been truly magnificent. There were times I hated him because he hadn't measured up to my ideal hero ". Maybe the problem is not Bethune but our unrealistic expectation of a fallible human. At any rate, Bethune should be happy that nobody, not anyone in the whole wide world,  could ever accuse him of being "mediocre" !