The Youngest Science

by Lewis Thomas

  There were other masters of medicine, each as unique in his way as Blumgart, surrounded every day by interns and medical students on the wards of the other Boston hospitals.

  The Boston City Hospital, the city’s largest, committed to the care of indigent Bostonians, was divided into five separate clinical services, two staffed by Harvard Medical School (officially designated as the Second and Fourth services), two by Tufts, and one by Boston University. The most spectacular chiefs on the Harvard faculty were aggregated on the City Hospital wards, drawn there in the 1920s by the creation of the Thorndike Memorial Laboratories, a separate research institute on the hospital grounds, directly attached by a series of ramps and tunnels to the buildings containing the teaching wards. The Thorndike was founded by Dr. Francis Weld Peabody, still remembered in Boston as perhaps the best of Harvard physicians. Peabody was convinced that the study of human disease should not be conducted solely by bedside observations, as had been largely the case for the research done by physicians up to that time, nor by pure bench research in the university laboratories; he believed that the installation of a fully equipped research institute, containing laboratories for investigations of any promising line of inquiry, directly in communication with the hospital wards, offered the best opportunity for moving the field forward.

  Peabody was also responsible for the initial staffing of the Thorndike. By the time I arrived, in 1937, the array of talent was formidable: George Minot (who had already received his Nobel Prize for the discovery of liver extract as a cure for pernicious anemia), William Castle (who discovered the underlying deficiency in pernicious anemia), Chester Keefer, Soma Weiss, Maxwell Finland, John Dingle, Eugene Stead—each of them running a laboratory, teaching on the wards, and providing research training for young doctors who came for two- or three-year fellowship stints from teaching hospitals across the country. The Thorndike was a marvelous experiment, a model for what were to become the major departments of medicine in other medical schools, matched at the time only by the hospital of the Rockefeller Institute in New York.

  Max Finland built and then ran the infectious disease service. He and his associates had done most of the definitive work on antipneumococcal sera in the treatment of lobar pneumonia, testing each new preparation of rabbit antiserum as it arrived from the Lederle Laboratories. Later, Finland’s laboratories were to become a national center for the clinical evaluation of penicillin, streptomycin, chloromycetin, and all the other antibiotics which followed during the 1950s and 1960s. As early as 1937, medicine was changing into a technology based on genuine science. The signs of change were there, hard to see because of the overwhelming numbers of patients for whom we could do nothing but stand by, but unmistakably there all the same. Syphilis could be treated in its early stages, and eventually cured, by Paul Ehrlich’s arsphenamine; the treatment took a long time, many months, sometimes several years. If arsphenamine was started in the late stages of the disease, when the greatest damage was under way—in the central nervous system and the major arteries—the results were rarely satisfactory—but in the earliest stages, the chancre and then the rash of secondary syphilis, the spirochete could be killed off and the Wassermann reaction reversed. The treatment was difficult and hazardous, the side effects of the arsenical drugs were appalling, sometimes fatal (I cannot imagine such a therapy being introduced and accepted by any of today’s FDA or other regulatory agencies), but it did work in many cases, and it carried a powerful message for the future: it was possible to destroy an invading microorganism, intimately embedded within the cells and tissues, without destroying the cells themselves. Chemotherapy for infectious disease in general lay somewhere ahead, and we should have known this.

  Immunology was beginning to become an applied science. Thanks to the basic research launched twenty years earlier by Avery, Heidelberger, and Goebbel, it was known that pneumococci possessed specific carbohydrates in their capsules which gave rise to highly specific antibodies. By the mid-1930s, rabbit antipneumococcal sera were available for the treatment of the commonest forms of lobar pneumonia. The sera were difficult and expensive to prepare, and sometimes caused overwhelming anaphylactic reactions in patients already moribund from their infection, but they produced outright cures in many patients. Pernicious anemia, a uniformly fatal disease, was spectacularly reversed by liver extract (much later found to be due to the presence of vitamin B12 in the extracts). Diabetes mellitus could be treated—at least to the extent of reducing the elevated blood sugar and correcting the acidosis that otherwise led to diabetic coma and death—by the insulin preparation isolated by Banting and Best. Pellagra, a common cause of death among the impoverished rural populations in the South, had become curable with Goldberger’s discovery of the vitamin B complex and the subsequent identification of nicotinic acid. Diphtheria could be prevented by immunization against the toxin of diphtheria bacilli and, when it occurred, treated more or less effectively with diphtheria antitoxin.

  All these things were known at the time of my internship at the Boston City Hospital, but they seemed small advances indeed. The major diseases, which filled the wards to overflowing during the long winter months, were infections for which there was no treatment at all.

  The two great hazards to life were tuberculosis and tertiary syphilis. These were feared by everyone, in the same way that cancer is feared today. There was nothing to be done for tuberculosis except to wait it out, hoping that the body’s own defense mechanisms would eventually hold the tubercle bacillus in check. Some patients were helped by collapsing the affected lung (by injecting air into the pleural space, or by removing the ribs overlying the lung), and any number of fads were introduced for therapy—mountain resorts, fresh air, sunshine, nutritious diets—but for most patients tuberculosis simply ran its own long debilitating course despite all efforts. Tertiary syphilis was even worse. The wards of insane asylums were filled with psychotic patients permanently incapacitated by this disease—“general paresis of the insane”; some benefit was claimed for fever therapy; but there were few real cures. Rheumatic fever, the commonest cause of fatal heart disease in children, was shown by Coburn to be the result of infection by hemolytic streptococci; aspirin, the only treatment available, relieved the painful arthritis in this disease but had no effect on the heart lesions. For most of the infectious diseases on the wards of the Boston City Hospital in 1937, there was nothing to be done beyond bed rest and good nursing care.

  Then came the explosive news of sulfanilamide, and the start of the real revolution in medicine.

  I remember the astonishment when the first cases of pneumococcal and streptococcal septicemia were treated in Boston in 1937. The phenomenon was almost beyond belief. Here were moribund patients, who would surely have died without treatment, improving in their appearance within a matter of hours of being given the medicine and feeling entirely well within the next day or so.

  The professionals most deeply affected by these extraordinary events were, I think, the interns. The older physicians were equally surprised, but took the news in stride. For an intern, it was the opening of a whole new world. We had been raised to be ready for one kind of profession, and we sensed that the profession itself had changed at the moment of our entry. We knew that other molecular variations of sulfanilamide were on their way from industry, and we heard about the possibility of penicillin and other antibiotics; we became convinced, overnight, that nothing lay beyond reach for the future. Medicine was off and running.

  5

  1937 INTERNSHIP

  No job I’ve ever held since graduating from medical school was as rewarding as my internship. Rewarding may be the wrong word for it, for the salary was no money at all. A bedroom, board, and the laundering of one’s white uniform were provided by the hospital; the hours of work were all day every day, and on call for admissions and emergencies every other night, all night long. There was no such thing as a weekend. The hours were real working hours; when the night came,
especially in the winter months, the intern was even more on the run than during the daytime shift.

  I am remembering the internship through a haze of time, cluttered by all sorts of memories of other jobs, but I haven’t got it wrong nor am I romanticizing the experience. It was, simply, the best of times.

  The lack of money was no great problem. None of the interns on the two Harvard Medical services at the Boston City Hospital was married. It would have been unheard of, and very likely a married applicant for this internship would have been rejected by the selection committee just for being married. There was little need for pocket money because there was no time to spend pocket money. In any case the interns had one sure source of spare cash: they were the principal donors of blood transfusions, at $25 a pint; two or three donations a month kept us in affluence. More than this, Massachusetts law in 1937 stipulated that a blood donor was entitled to a pint of whiskey; at the Boston City Hospital the pint was Golden Wedding.

  The internship was divided into six periods of three months each. One rose through the hierarchy automatically, but the jumps from one rank to the next seemed quantum leaps. The newest man was the Junior, also known as the pup; his life was spent collecting specimens of blood, urine, feces, spinal fluid, sputum, sometimes pleural fluid, and doing the laboratory diagnostic work—all the work for his assigned wards of thirty patients each. The day never ended; it was one long twenty-four-hour run, trying to keep up with the orders coming down from the upper ranks. The second three months was the externship, with two major responsibilities: all morning in the outpatient department, mostly sitting at a desk listening to the complaints of elderly patients who liked to spend their mornings visiting the clinics of the City Hospital; very few of them were acutely ill, many of them were patients who had been discharged from the hospital a few weeks earlier and were back for checkups; some of the patients had chronic ailments—diabetes, arthritis, hypertension, mild heart failure. The other half of the extern’s day was spent back on the wards performing the therapeutic procedures, such as they were, the installations of intravenous drips of saline, transfusions, injections of insulin or liver extract, and the administration of antipneumococcal antiserum. The third three-month period was spent across the street in a huge annex called the South Department, where all the contagious diseases were cared for—several hundred patients, mostly children, with diphtheria, whooping cough, scarlet fever, chicken pox, measles, and poliomyelitis. The work here was the same as on the general wards, but more time-consuming because of the necessity of wearing sterile gowns, gloves, and masks, and changing these from one bedside to the next.

  The last nine months contained the reward for the first nine: the privilege of giving the orders instead of taking them. The Senior had the responsibility for admitting patients to the ward, taking their histories, doing the physical examinations, deciding what laboratory tests and therapeutic procedures were to be ordered.

  The next rank up, the Assistant House Physician, supervised the Senior and went off on consultation calls to the surgical, neurological, and psychiatric services during most of his days and nights on duty. The top of the hierarchy was the House Physician, equivalent in rank and prestige to a Chief Resident on today’s house staff—except that one became House automatically after fifteen months of duty, while the contemporary Chief Resident is selected from among competitors at the end of four or five years.

  All day long the visiting physicians, in long white coats, moved back and forth across the ramp connecting the wards of the Peabody Building (which housed the Fourth Division, one of the two Harvard Medical services) and their laboratories and offices in the Thorndike. They came at ten in the morning to make the formal rounds, walked the bedsides for two or three hours with the interns and medical students, and then came back at odd hours throughout the afternoon and often until late in the evening to see patients with serious problems in whom they were especially interested.

  The wards were long, high-ceilinged rectangles, with thirty beds around the periphery. In winter each ward filled and doubled its capacity by adding thirty cots, lined up in two rows down the middle of the room. Ward rounds at this season took a longer time than in summer, partly because of the greater number of very sick patients, but also because of the logistic problem of moving the entourage of physicians and nurses over and around the beds and bed tables jumbled into every available space.

  Each ward possessed a single private room off at one end, reserved, in theory anyway, for the dying. In practice, it was used for patients in delirium whose outcries in the night would have kept the other patients awake. Dying was done out on the wards, and it happened every day and every night. Each bed was surrounded by poles carrying white curtains on metal rings; these were pulled to surround the bed for the privacy of physical examinations and for the time of dying. When a patient was dead, the removal of the body from the ward was accomplished by a ceremony with which all the new patients quickly became familiar. The head nurse would start at one end and walk rapidly from bed to bed, pulling the front curtain across the foot of each. Wherever you were in that building you could hear the zing-zing of the curtain rings, twenty-nine of them, and then the stretcher with the body would be rolled out of its cubicle, along the ward, out to the elevator, and down to the morgue. The patients on the cots in the center of the ward were hidden by movable screens. Everyone on the ward knew what was going on. It was not an effort to protect the sensibilities of the living, it was done in respect for the privacy of the newly dead.

  The open ward was viewed as a necessity, so that all patients could be within sight of the ward nurse at all hours. The public wards of hospitals of the time were run on very low budgets, and it was only on the private services of the great voluntary hospitals of Boston that a patient could afford a private room and a private nurse. Yet few people on the open wards complained; they made friends with each other quickly, and those who were well enough to be up and around moved from neighboring bed to bed, companionably gossiping, helping in the feeding of patients too sick to manage for themselves.

  The greatest part of the work done on these wards was simply custodial. Patients came in with their illnesses, almost all of them severe; you did not go to the emergency room for admission to the Boston City Hospital unless you felt in danger for your life. Once you were admitted, transported on wheeled litters through the tunnels of the hospital, up the elevators, and onto the wards, it became a matter of waiting for the illness to finish itself one way or the other. If being in a hospital bed made a difference, it was mostly the difference produced by warmth, shelter, and food, and attentive, friendly care, and the matchless skill of the nurses in providing these things. Whether you survived or not depended on the natural history of the disease itself. Medicine made little or no difference.

  And yet, everyone, all the professionals, were frantically busy, trying to cope, doing one thing after another, all day and all night. Most of this effort was aimed at being certain that nothing was missed, that the diagnosis was a matter of certainty, and that the illness was not one of the few for which there was believed to be a genuine and effective treatment.

  There were only a few, and they became the great emergencies of the ward when they were recognized.

  The commonest one, and the illness requiring the hardest and most urgent work by the intern, was lobar pneumonia. The pneumonia season began in late autumn and lasted until early spring. In order to make sure that no ward and no single intern was overburdened by the work, there was a system called the “pneumonia count”; the cases were sent up from the emergency room in rotation among the Harvard, Tufts, and BU medical services; if an intern was suddenly confronted by four patients with lobar pneumonia late at night, he was in for it, but at least he knew that each of his colleagues on the other services had the same problem. The diagnosis was usually the simplest part; the patient complained of the sudden onset of chills and fever, cough, sometimes with blood-tinge
d sputum, and pain in one side of the chest; physical examination revealed dullness to percussion with one’s fingertips over the affected lung area and a characteristic change in the breath sounds heard with the stethoscope at the same spot. Given this amount of information you could begin making predictions. The prognosis for a young adult was the most surely predictable: an acute illness lasting ten to fourteen days, with a high fever each day, more chest pain and more cough, perhaps with alarming manifestations of exhaustion and debilitation near the end of this period, and then, suddenly and as triumphantly as the bright sunshine after a thunderstorm, one of the great phenomena of human disease—the crisis. On one day or another, after two weeks of his seeming to come closer and closer to death’s door, the patient’s temperature would drop precipitously within a few hours from 106 degrees to normal, and at the same time, with a good deal of sweating, the patient would announce that he felt better now and would like something to eat, and the illness would end, like that. All of this could be nicely explained; indeed, lobar pneumonia is the only disease I can remember that had an intellectually satisfying explanation at that time for what went on. The cause was the pneumococcus, a bacterium which was stained dark blue by the gram stain, always as two round, paired cocci. The capsule of this organism contained a polysaccharide, a carbohydrate that endowed it with its invasive properties and protected it against being engulfed and killed off by the host’s white blood cells. There were about forty different types of pneumococcus, each with its own special type of capsular polysaccharide. The game to be played involved, initially, the invasion of the alveolar spaces of the lung by the pneumococcus, the spreading of new generations of pneumococci through that part of the lung, until an entire lobe became solidified by the jammed populations of bacteria and still-ineffectual leukocytes within the alveoli, sometimes the spread of the organism into the patient’s bloodstream with septicemia, and then, on or around the tenth day, the mobilization of an effective defense by the patient’s own antibody, chemically designed to fit precisely with the molecular configuration of the polysaccharides of that strain of pneumococcus and no other. Once this happened, and the levels of circulating antibody in the blood were high enough to have combined with all of the polysaccharides, the pneumococcus was the loser. When it combined with the antibody it was immediately swept up by the leukocytes and killed, and the disease was over. This event was the crisis, the sudden drop of the temperature, the sweats, the return of appetite, the end of the game.