Die Once Live Twice

by Lawrence Dorr

  In Germany, Doctor Paul Ehrlich had taken the first step. Ehrlich made the brilliant assumption that since dyes stained bacteria, perhaps a dye could be a chemotherapeutic drug toxic to bacteria. After long efforts, he found a dye that was not toxic to humans and killed spirochetes, a complex bacteria that caused syphilis.

  Jonathan was studying bacillus pyocyaneus, a bacterium whose toxin, pyocyanase, was being commercially produced and used as a topical antiseptic on infected wounds. Jonathan figured if it worked on skin wounds, why not inside the body? But he also knew that a chemical may be safe on a skin wound but poison to the inner organs. To study its toxicity, Jonathan was mixing pyocyanase with human tissue in test tubes. So far his results were not promising. Since Pasteur first developed the concept of vaccination by using an anthrax vaccine in sheep, he had begun with studying pyocyanase against anthrax, and it had been effective against that bacilli in the test tube. Whether it would be usable in people was another question. Pasteur’s vaccine was solely veterinary and there were no successes of a vaccine against anthrax in humans.

  The drudgery and frustration of laboratory work made Jonathan’s weekly clinic day a welcome relief. Working with patients was far more satisfying and immediate than staring through a microscope or inspecting test tubes for months or years. Besides, he was able to spend the day with Marion. On this Friday, while he and Marion ate a bowl of borscht and a meat pie that Audrey, the Russian-Jewish nurse, had made in Marion’s kitchen-office, Rabbi Radulovic came in carrying a young child, looking very serious. “Her mother brought her to the temple. They are here from Russia only a few days. What is wrong, Jonathan?”

  Jonathan knew it was an infection by the girl’s appearance, febrile and listless. “What’s the history, Rabbi? Where is the mother?”

  “She is at the temple. She wouldn’t leave. This is in God’s hands, she is sure, so she is begging him for salvation.”

  Jonathan examined the girl, who was coughing with a mild wheeze, and could find no bites, neither lice nor animal, and no evidence of trauma. She must be three or four years old. Probably has never had any vaccinations. Her fever could cause the listlessness. His mind sorted through all the possible infections. He always told his students that being a good doctor meant being a superb detective. A successful diagnosis was the process of putting clues together to solve the mystery.

  The rabbi said, “Her mother says she’s been sick for a few days, complaining of aches, and she had fever. Today she got worse. Her mother sent this blanket to cover her. The girl is attached to it ever since a man on the ship gave it to her when she was cold.”

  Jonathan looked at the woolen blanket that the rabbi was giving to Marion. Suddenly, he knew the answer and he rose to grab Marion’s arm. “Marion! Do not take that blanket. Rabbi,” Jonathan said urgently, “do not touch anything and come with me.”

  Jonathan donned rubber gloves and led the rabbi through the kitchen to the fireplace outdoors. “Drop the blanket in the fireplace. Now go take a bath with your robes on. Then remove them and scrub all your skin with soap.” Jonathan set the blanket on fire. He then went inside and gathered the rabbi’s robes and added them to the flaming blanket. The rabbi dressed in clothes from the clinic and wore rubber gloves. When he returned to Marion, who was watching the child lying on a cot, she commented, “My goodness, Rabbi. You look like us!” Marion and Audrey, the Russian-Jewish nurse, had also put on gloves.

  Jonathan was all business. “Marion, hand me the girl’s clothes and the bedding she was on. Do not let them touch your skin. Take the girl and scrub her clean. Don’t let her skin touch your skin.” Jonathan burned the girl’s clothes and the bedding while Marion took the girl to the shower.

  The nurses and Audrey were transfixed by the flurry of activity. They never had seen this reaction to a sick child. Were they all exposed to a disease that would kill them? “Doctor, what is it?” Audrey asked, fear in her voice.

  “Anthrax. She got anthrax from the wool blanket. You are all safe. You can’t catch it from her breath. It passes by direct contact through the skin. Touch her only with gloves and burn all her excrement, even urine.”

  He turned to the Rabbi. “Get the mother to bring all the family’s clothing here and burn it. The clothes can have spores living on them.” He dug into his pocket and pulled out some money. “Here’s twenty dollars. Buy the family new clothes and make them all bathe. By the way, what is her name?”

  “Anna.”

  “Audrey, use ice to keep Anna’s temperature low. I will be back in an hour. Rabbi, can your driver take me to my lab to get medicine?” The rabbi nodded. “I must treat her immediately or she will be dead. Every second counts.” Jonathan knew once respiratory symptoms appeared the chance to save a patient from anthrax was slipping away.

  Anthrax was unusual in New York City, even in the United States, but occurred in Europe and in Russia. It was caused by bacteria in the soil and infected people through animal hide products, because its spore would attach to the animal and survive when the animal died. It was most common among those who worked with wool products.

  At his lab Jonathan counted out ten test tubes with pyocynsase toxin incubating in them. He had decided to take a risk because anthrax was invariably lethal. He had nothing to lose. If he did nothing, Anna was dead. Her only chance was what was in these test tubes.

  Using a pipette he drew up the chemical from each tube. He had no idea how much volume he needed for an in vivo effect in Anna. When he had ten ccs of pyocyanase he transferred it to a sterile syringe, attached a sterile needle and slipped them into a sterile glove. “Hell, this is life or death,” he said aloud, as if arguing with someone in the room. “This is one chance. I will not just watch this girl die when there is any chance.”

  As he re-entered the clinic he felt his breathing and heart rate increase. Rabbi Rad had brought Anna’s mother from the temple. At first she had thought she could not watch her daughter suffering, but the rabbi convinced her to be with Anna and now she would not leave her. Jonathan did his best to sound encouraging, but his gut tightened. In ten minutes this girl could be dead from my injection. He knew that, at least, he would not give her another infection. His experience managing the production of sterile antitoxin in the horses served him well in producing injections that were not contaminated. But there could be an allergic reaction to the toxin in pyocyanase. Jonathan was shaking inside.

  Lucia, who had come to help, held the girl’s arm still with gloved hands while Jonathan unwrapped the glove from around the syringe and needle. Anna’s veins were collapsed because she was dehydrated, but he managed to find one distended vein in the crook of her arm. As Jonathan slid the needle into the vein, he felt a surge of encouragement because Anna’s blood was not black, a terminal sign of anthrax infection. Sitting on a chair at the bedside, leaning forward over Anna’s arm, he patiently advanced the plunger of the syringe. One minute, two minutes, five minutes, and it was done. He sat back, relieved she was still alive. He withdrew the syringe and needle from the vein. Lucia put pressure on the vein to allow it to clot.

  All they could do now was wait. Jonathan sat in a bedside chair staring at Anna as if he could do something if she turned for the worse. Lucia put wet rags in Anna’s mouth so she would suck in water. A half hour passed and Anna was still alive. “I am certain now the injection did not kill her,” he told Marion. Her eyes widened as she realized what Jonathan had been facing.

  Six hours passed with Anna still alive and her breathing no worse. It was now evening, but Jonathan and Marion were not going home. “I couldn’t eat,” Marion said to Jonathan. “I couldn’t sleep. My mind would be here every second. So why go home? I’m staying with you.” Rabbi Radulovic sat with Anna’s mother and prayed with her. At midnight Marion was keeping watch in the bedside chair and Jonathan had fallen asleep with his head on Marion’s desk in the back room. Lucia had gone home. Anna’s mother had not moved and still held Anna’s hand. The rabbi dozed next to her.
r />   Jonathan was jarred awake by Marion’s hands on his shoulders. “What time is it?” he asked.

  “Four a.m. Come with me,” Marion answered.

  For Jonathan, joy was the excitement he felt with Angelo’s vaccination or when Marion agreed to marry him—and now what he felt when he looked at Anna. She was mumbling in Russian to her mother, who was giving her water from a glass. Anna’s chest was quiet as she breathed. “She survived,” Jonathan said, restraining himself from shouting it as he held Marion’s shoulders and looked into her smiling eyes.

  Lucia and Audrey returned to the clinic at dawn and relieved them. With Audrey able to communicate with the mother and Anna, the rabbi went home, too. As they rode the cab back home, Marion snuggled next to Jonathan. “You are the next Pasteur.”

  “Not yet, my love. I knew this pyocyanase killed anthrax so it wasn’t blind luck, but it was luck all the same. If Anna had any other infection I wouldn’t have tried it. And I can’t do anything for other infections. At least not yet. What I need is a chemical from a microorganism I know is not toxic to people and that works against multiple bacteria. But this revealed a huge secret of Nature, Marion. I know for sure that bacterial antagonism works inside the human body.”

  Chapter Twenty-three

  REVOLUTION

  In the spring of 1914 Jonathan and Marion boarded a train for Iowa to visit her parents in Des Moines and Jonathan’s brother Jeffrey in Iowa City. They were ready for a vacation. Jonathan’s past three years in the laboratory had not been very productive. Though he was sure bacterial antagonism would be the source of the answer to antibiosis, he could not figure out how to design an experiment to prove it. Some toxins were unstable and he did not know how to stabilize the chemicals. He studied molds, but none gave a chemical that killed bacteria. Research with viruses was no more satisfying. It was just not possible to isolate them without bacterial overgrowth. The only vaccine against a virus was the one against smallpox, and it had not been discovered by isolating the virus. In fact, no one had seen a virus yet. Infantile paralysis was studied vigorously without any solution in sight.

  All these research failures left Marion with no new treatments for patients in her clinic. Aspirin was the only drug she had to treat patients and Jonathan was happy to write prescriptions for it whenever needed. Although not a cure, it was a wonder drug and everyone hoped that the nonprescription form would be available soon. She passed it out all the time for children’s fevers and muscle aches and pains. For anything else, public health principles and existing inoculations were her only source of treatment. Her intuition in 1907 that trust and compassion helped patients get better had been proven over and over again, and was all she had for heart disease, diabetes, and the occasional cancer. Fortunately, tuberculosis patients could be sent to Phil Spanezzi for surgery. Fractures would heal with traction and casts, except hip fractures. These patients Marion had to watch die.

  They disembarked at Iowa City’s small brick railroad station, whose narrow platform was one-fourth filled with Marion’s two enormous trunks. “We aren’t moving to Iowa,” Jonathan said with some exasperation.

  “Oh, shush. They still think I’m a famous actress in Des Moines, so I will need to look the part. You can wear what you want. In New York you’re an important doctor, but in Iowa I’m the star!’

  “Well, la-de-da!” Jonathan smiled. “I’ll go hire a carriage for the princess. Wait here, Your Highness.”

  The clip-clop of horses’ hooves was all that was the same as New York City. “I’ll bet you’ve never seen anything like this before,” Marion teased.

  “Well, there is one thing that seems familiar,” Jonathan said, looking at the bars that lined both sides of Clinton Street. “I wonder if these are the study halls for the students?” Jonathan cracked.

  “Well, aren’t you the pompous one. Did you think Iowans only drank homemade corn whiskey?”

  “The air smells more of blacksmith shops and horse dung than cornfields. My goodness, I must bite my tongue.” Jonathan pointed to a group of buildings located on a large rectangular grassy lawn. “What are those impressive buildings? Especially the one in the center with a gold dome.”

  “That’s called the Pentacrest and the buildings are the classrooms. The one with the dome was the first capitol building of Iowa, before the capital moved to the big city of Des Moines.”

  The carriage stopped at the Jefferson Hotel, where Jonathan had booked one of the two suites with a washroom and a toilet. As they entered the lobby, Jonathan whispered to Marion, “Do you think we have to worry about bedbugs? Do they change the sheets here?”

  “Jonathan, you’re a horse’s ass. Just because it’s not the Plaza.”

  “At least I’m in a great place to be a horse’s ass. I’m probably worth money to a farmer!”

  As Jonathan and Marion settled in, Jeffrey was on the train from Chicago lost in thought about his assignment to review the University of Iowa Medical School, oblivious to the clickety-clack of the train wheels rolling along tracks bounded by cornfields. He was not sure how he’d be received. The Medical Education Council of the American Medical Association, of which Jeffrey was the Executive Director, provided the AMA an opportunity to seize some control over medical schools, and thereby doctors. The Council had been set up because of the woeful condition of medical education in the United States. Doctors owned the medical schools and made a profit on each student they admitted, so anyone with tuition money could get in. In most medical schools students never examined a patient nor performed an operation.

  In the mid-1800s, schools had nine courses and to get a medical degree the student had only to pass five. Even when Jonathan attended Harvard in the early 1890s, the course of study was only two years. Thanks to William Welch, Johns Hopkins Medical School had changed all that. Medical students needed a college degree, attended for four years, learned laboratory medicine, and were taught clinical medicine with an emphasis on patient contact. Welch, Katherine’s great soul mate, pressured the AMA to force bad medical schools to close or to be restructured and placed Jeffrey in its hierarchy. The AMA adopted Welch’s program as the only acceptable model of education, and in 1909, in partnership with the Carnegie Foundation, it established a review of all 160 medical schools. Abraham Flexner, Simon’s brother, was hired to do these evaluations and he recommended closing all but thirty schools, but offered a chance for survival to fifty others. By 1914 there were only ninety-five medical schools in the United States.

  Jeffrey hoped for the best from the Iowa school. The clinical teaching there had been so inadequate that Flexner’s original report recommended Iowa become a two-year school offering only lectures and basic science. But the leaders in Iowa wanted a qualified medical school of full-time academicians and hired Arthur Steindler to be Chair of Orthopedics after his former school, Drake, had been closed by Flexner. With Steindler they brought in a new Chair of Surgery and of Internal Medicine. Flexner was impressed with these changes, and if Jeffrey’s report from this trip was favorable, Flexner would recommend Iowa for a Rockefeller grant to build a new university hospital.

  When Jeffrey arrived at the same small brick railroad station where his brother had disembarked a couple of hours earlier, Doctor Frederick Specht stood waiting for him. As Specht tipped his hat, Jeffrey noticed he was balding rather rapidly. The two shook hands warmly. Specht was an Associate Professor of Orthopedics and Jeffrey’s contact person for his review of the medical school. “Frederick, I have a surprise for you.”

  “You have certified our school?” Frederick straightened up to his full height of five-foot six-inches in anticipation.

  “No. Not yet. Not until after this trip. The surprise is that my brother Jonathan and his wife Marion are meeting me here. In fact, they should be at the Jefferson Hotel now.”

  “Mein gott! Your famous brother from the Rockefeller Institute?”

  “The very same.”

  “Oh, I must call Louise Steindler and tell her tw
o more for supper. My wife is already there.” In his excitement Frederick left Jeffrey standing with his bag and quickly stepped to the station master to use the telephone. After making the arrangements, he helped Jeffrey carry his bag to the tiny parking lot where there were three horse-drawn buggies and one new Model-T Ford, to which Frederick pointed with pride. “Doctor Steindler’s.” Climbing into the driver’s seat, he donned driving gloves and sat rigidly behind the wheel. Traveling faster than five miles per hour risked blowing a tire in the rutted roads, so as they drove through the three-block-long center of town, Jeffrey could memorize the name of every business along the road. In front of small shops, owners swept their doorsteps, scrubbed windows, and chatted with passersby. A barbershop, two Sidwell ice cream parlors, six bars, and a drug store were identical structures differentiated only by their business signs.

  Frederick turned right at what he called the “bookstore corner.” Students in their suits and hats were going in and out of the bookstore. As the Model-T passed Weber’s blacksmith shop the clanging of metal on metal drowned out conversation. Frederick pointed out the anatomy laboratory on the left and the university hospital in the middle of the block. After parking, they walked one block to a three-story building fifty feet long and twenty feet wide, with seven dormers on the top floor.

  “This is where my TB patients are hospitalized,” Frederick said proudly. “I am the TB expert in Iowa and I will not be short of patients. Farmers rule the state government and they don’t want the expense of certifying their cows or pasteurizing the milk.” Unpasteurized milk was known to be the source of tuberculosis that infected the skeleton, most commonly the hip and the spine.