The Youngest Science

by Lewis Thomas

  The odds were shifted by several circumstances which we knew about and which changed the sense of urgency. Some types of pneumococcus were more virulent than others, needing quicker treatment. Patients known to be alcoholics were much more vulnerable to septicemia and overwhelming infection than normal people. Pregnant women were more susceptible and at greater risk of dying. Old people were the greatest risks of all.

  The treatment was designed to match what we knew of the disease mechanism: the intravenous administration of type-specific antibody directed against the polysaccharide of the particular pneumococcus. Commercial preparations of purified rabbit antibodies against most of the known strains of pneumococci were available in the Thorndike laboratories, and it was the intern’s first and most urgent task to identify the pneumococcus so that the proper serum could be used. This could be done with a specimen of sputum, in which the pneumococci were usually present in abundance. One simply added samples of various antipneumococcal sera to bits of sputum and stained them with methylene blue; if you had the right serum, the capsule around each of the paired organisms would become swollen and dark blue. If you were lucky, and had a good sample of sputum (saliva wouldn’t do, it had to be real, coughed-up sputum), and had the right diagnostic serum at hand, you could make the diagnosis within a few minutes and telephone Dr. Finland’s laboratory for the needed supply of therapeutic serum. If not lucky, you had to wait; the blood culture might grow out of the pneumococcus within the next two days and you could type it then, or you could inject the sputum sample into a white mouse, and if there were pneumococci there that you’d missed seeing, they would grow out in the peritoneal cavity of the mouse within a few hours, and you could learn the type that way. One way or another, the intern had to find out the type; there could be no going to bed until that job had been successfully done. The treatment depended on the precise answer, and no other answer would do; it was not enough to know that the diagnosis was lobar pneumonia, not enough to know that the organisms were pneumococci; you needed to know next whether it was a type I, or a type III, or a type whatever, or there would be no way at all of treating the disease, nothing at all to do beyond watching the illness run its natural course.

  But when the type was known, the treatment could turn out a technological tour de force, the only genuine cure within an intern’s grasp.

  Given knowledge of the type, and a supply of the right rabbit serum, the intern became a man of power. The serum was injected, very slowly, by vein. When it worked, it worked within an hour or two. Down came the temperature, and the patient, who might have been moribund a few hours earlier, would now be sleeping in good health.

  It didn’t always come out this way, but it was successful often enough to make it worth great effort. An intern was judged by his superiors on this kind of success more than by any other quality: if your lobar pneumonia cases were well handled, you were likely to have a future; if not, not.

  The second of the great emergencies, even more demanding of quick thinking and precise action, was diabetic coma. If it was recognized early enough and the right things done with speed, an intern could have the certainty of saving a life, but if he stalled around or miscalculated the need for insulin and intravenous fluids, the patient might die. The management of coma was one of the occasions for calling on all the help and advice available. The senior visiting physicians came across the ramp from the Thorndike on the run, medical students were summoned from their quarters, and the house staff, all levels of interns, gathered at the bedside to work out the details together.

  Acute heart failure was another. There were only three things to be done, three sorts of technology, not always effective and never in any sense curative, but when done properly they possessed near-magical properties for pulling an occasional patient back from dying. Bleeding was the first, the rapid withdrawal of a pint of blood from an arm vein; often enough this served by itself to take away the desperate gasping for breath by reducing the load of venous blood to be coped with by the heart. Digitalis was the second, given gradually and with gingerly caution, just enough of the crude leaf preparations then available to add strength to the heart muscle, not enough to cause toxicity—it was a skill long mastered by the older clinicians on the visiting staff, very difficult to learn from scratch, something like cooking. The third was oxygen, provided by a tank brought to the bedside, delivered by way of an oxygen tent if one was available, otherwise by a rubber tube fixed in the nose by adhesive tape.

  And then there was syphilis. This was never an emergency for therapy; whenever it reached one or another of its life-endangering phases—an aortic aneurysm about to burst, for example, or a brain disintegrating from paresis—it was already too late for anything really effective. The time for action, and for diagnostic acumen in recognizing the disease, was in its earliest stages. An intern’s heart sank at the thought of what then lay ahead: months, even years, of arsenicals, mercury, and bismuth, with risks of liver destruction from the treatment itself. In the old days, at the Boston City Hospital, you had to rule out this disease, called “the great imitator,” before proceeding on other diagnostic lines. It was the routine to look first for the Argyll-Robertson pupil; you did this by two swift maneuvers: first you aimed your pocket flashlight at the eye and observed it for constriction of the pupil, then you persuaded the patient to look at your finger moving closer to the eye and watched for the pupil to constrict in accommodation; if it failed the first test but responded to the second you had your diagnosis: neurosyphilis. I don’t suppose a busy internist sees an Argyll-Robertson pupil more than once a year these days. The disease has vanished, for the time anyway. There is still syphilis, of course, probably more than at any time in the history of society due to the new sexual freedom, but it is easily cut off in its primary or secondary stages, and very few patients move on to the remorseless and lethal third stage, which catches the brain. No credit, or not much credit anyway, to medicine as a profession. Indeed, this entirely commendable advance in public health is very likely the result of bad medicine, the indiscriminate use of penicillin for any minor ailment, a cough, a head cold. The spirochete of syphilis has been caught up in a national aerosol of penicillin, and can only rarely gasp its way through to the formation of a chancre. Paresis and tabes, which used to be the principal anxiety of any young intern, have departed. No longer is a clinical clerk in Boston required to search for Argyll-Robertson pupils or to ask the patient to stand with his feet together and shut his eyes (the swaying and falling indicated tabes), or, as I was taught, to command the patient to repeat “God save the Commonwealth of Massachusetts.” In 1937, if you were obviously deranged but could manage that sentence, you had schizophrenia; if you stumbled over it you had paresis.

  Boston had lots of alcoholics in the 1930s, and the City Hospital contained a special ward of around forty beds just for them. Any night there would be three or four patients sent up from the emergency room with delirium tremens, as bad a sight to look at as anything in an intern’s life experience: tremulous, hallucinating, wild-eyed, unhinged men. The risk was fever; some of these patients would suddenly run their body temperature up to 108 or over, and then die in an aftermath of deep shock. The treatment was paraldehyde, huge doses by mouth, sometimes even injected into the buttock muscles, enough to produce near-anaesthesia. Ice packs at hand in case of the fever, vitamin B, and liver extract, also in huge doses (although nobody was at all sure what good these did, if any). That was it for the DTs, and we saw a lot of deaths.

  The Peabody Building had its working center in the laboratory on the top floor. Here were the microscopes and other equipment for doing blood counts and sedimentation rates, the urines and stools lined up for the Junior’s inspection each morning, the incubators for culturing samples of blood, pleural fluid, and spinal fluid. For the more specialized chemical tests—blood sugar, cholesterol, several tests for abnormal serum proteins believed useful in diagnosing cirrhosis, the blood levels of nonprotein
nitrogen (up in kidney failure)—the blood specimens were carried by the intern to the hospital’s central diagnostic laboratory, which occupied a couple of small rooms in the basement of an adjacent building. The complicated bacteriological procedures, especially those needed for diagnosing meningitis, pneumonia, and septicemia, were performed by one or another of the Thorndike research laboratories.

  The Peabody laboratory was the meeting place for the interns and medical students. A huge record book lay on a table just inside the door, containing the name and preliminary diagnosis of every patient admitted to the wards below. Traffic in and out of the door was rapid and incessant, people bumping into each other, carrying racks of test tubes or arms filled with reference journals.

  The Peabody had one secretary in a tiny office just off the laboratory, who typed each day the detailed case summaries for all the patients who were being discharged, and especially long and meticulous summaries for the patients who had died. Each Friday afternoon the house staff and visiting physicians met with one of the hospital pathologists, and the day-to-day records of all patients who had died were combed through, looking for mistakes.

  The worst mistake of all—perhaps the worst mistake I’ve ever observed at first hand—occurred in the first month of my service as Junior. A young black musician was admitted with a history of severe chills and fever during the preceding week. It was pneumonia season and the Senior intern suspected lobar pneumonia but could find nothing on physical examination. I was responsible for trying to get a sputum sample from him at the time of taking blood for the routine blood counts. The patient was drowsy and apathetic, had no cough, could raise no sputum, and I went along with my tray to collect the other blood specimens listed for the ward, then later in the morning upstairs to the laboratory to do the tests. His hemoglobin was alarmingly low, and I telephoned the ward with the news that the new patient had acute anemia; then I looked at the blood smear. I’d never seen anything like it. Almost every red cell contained blue-staining bodies, looking exactly like the textbook pictures of malaria. The hematologists came running across the ramp to take a look, then down to the ward to collect their own samples of blood. Pretty soon everyone arrived, all the house staff, all the visiting physicians, all the students. Nobody in Boston had ever seen malaria, it seemed.

  Later in the day it made sense. The patient admitted to being a heroin addict, accustomed to parties where the needle and syringe were passed around; someone in the group, probably someone from far out of town, must have been the source.

  Meanwhile, the ward visits continued all afternoon. The patient became drowsier, then, early in the evening, deeply comatose, and died within the next hour. He had the most malignant form of malaria, with clumps of infected cells occluding the small blood vessels of his brain. Had he received less clinical interest and animated attention, and been given quinine immediately the diagnosis was made, early that morning, he would perhaps have lived. The opportunity to cure an illness, even save a life, came infrequently enough on the City Hospital wards. This one had come and gone. The house physician went to his room and brought back his copy of Osler’s Textbook of Medicine, opened to the chapter on malaria. The first sentence, which he read aloud to the assembled house staff, said, in effect: Any doctor who allows a case of malaria to die without quinine is guilty of malpractice.

  The Fourth Medical Division regarded itself as the top service at the Boston City Hospital, the elite in the sharpest and brightest of all the teaching hospitals in town. We were the iron men, we told ourselves. The lights in the laboratory on the top floor of the Peabody Building were never turned off at night; the house staff never slept. After a while, we managed to talk ourselves out of the deep guilt which we had earned and into the easier sense of having been humiliated. Cerebral malaria, we agreed with ourselves, often moves so fast that nothing, no dose of quinine, could have made a difference. But the memory lasted: those clusters of white-uniformed professionals moving back and forth from the bedside of that extremely interesting case, taking new blood samples, discussing and discussing, and doing, in the end, nothing. It was a bad day for Harvard.

  6

  LEECH LEECH, ET CETERA

  A few years ago, I blundered into the fringes of a marvelous field of scholarship, comparative philology. I wondered—I forget the occasion—why leech was the word for the doctor and at the same time for the worm used by the doctor for so many centuries. Which came first, leech the doctor or leech the worm?

  The lovely American Heritage Dictionary has a fifty-page appendix of Indo-European roots, based in large part on Pokorny’s Dictionary of Indo-European Languages. My wife searched New York’s bookstores and found a copy of Pokorny in a rare-book store for my birthday, and I have never since looked back.

  The evolution of language can be compared to the biological evolution of species, depending on how far you are willing to stretch analogies. The first and deepest question is open and unanswerable in both cases: how did life start up at its very beginning? What was the very first human speech like?

  Fossils exist for both, making it possible to track back to somewhere near the beginning. The earliest forms of life were the prokaryotes, organisms of the same shape and size as bacteria; chains of cocci and bacilli left unmistakable imprints within rocks dating back as far as 3.5 billion years. Similar microorganisms comprised the total life of the planet for the next 2.5 billion years, living free or, more often, gathered together as immense colonies in “algal mats,” which later on fossilized into the formidable geological structures known as stromatolites. It was only recently, perhaps a billion years ago, that the prokaryotic algae had pumped enough oxygen into the earth’s atmosphere so that nucleated cells could be formed. The mitochondria, which provide oxidative energy for all nucleated cells, and the chloroplasts of plant cells, which engage the sun’s energy for producing the planet’s food and oxygen, are the lineal descendants of bacteria and blue-green algae, and have lived as symbionts with the rest of us for a billion years.

  The fossils of human language are much more recent, of course, and can only be scrutinized by the indirect methods of comparative philology, but they are certainly there. The most familiar ones are the Indo-European roots, prokaryote equivalents, the ancestors of most of the Western and some of the Eastern languages: Sanskrit, Greek, Latin, all the Slavic and Germanic tongues, Hittite, Tocharian, Iranian, Indic, some others, all originating in a common speech more than 20,000 years ago at a very rough guess. The original words from which the languages evolved were probably, at the outset, expressions of simple, non-nucleated ideas, unambiguous etymons.

  The two leeches are an example of biological mimicry at work in language. The root for leech the doctor goes back to the start of language: leg was a word meaning “to collect, with derivatives meaning to speak” and carried somehow the implication of knowledge and wisdom. It became laece in Old English, lake in Middle Dutch, with the meaning of doctor. Along the way, in early Germanic, it yielded lekjaz, a word meaning “an enchanter, speaking magic words,” which would fit well with the duties of early physicians. The doctor was called the leech in English for many centuries, and a Danish doctor is still known as Laege, a Swedish one as Lakere.

  Leg gave spawn to other progeny, different from the doctor but with related meanings. Lecture, logic, and logos are examples to flatter medicine’s heart.

  Leech the worm is harder to trace. The OED has it in tenth-century records as lyce, later laece, and then the two leeches became, for all practical purposes, the same general idea. Leech the doctor made his living by the use of leech the worm; leech the worm was believed (wrongly, I think) to have had restorative, health-giving gifts and was therefore, in its way, a sort of doctor. The technical term “assimilation” is used for this fusion of words with two different meanings into a single word carrying both. The idea of collecting has perhaps sustained the fusion, persisting inside each usage: blood for the leech, fees (and blood
as well) for the doctor. Tax collectors were once called leeches, for the worm meaning, of course.

  The word doctor came from dek, meaning something proper and acceptable, useful. It became docere in Latin, to teach, also discere, to learn, hence disciple. In Greek it was understood to mean an acceptable kind of teaching, thus dogma and orthodox. Decorum and decency are cognate words.

  Medicine itself emerged from root med, which meant something like measuring out, or taking appropriate measures. Latin used med to make mederi, to look after, to heal. The English words moderate and modest are also descendants of med, carrying instructions for medicine long since forgotten; medical students ought to meditate (another cognate) from time to time about these etymological cousins.

  The physician came from a wonderful word, one of the master roots in the old language, bheu, meaning nature itself, being, existence. Phusis was made from this root in Greek, on its way to the English word physic, used for medicine in general, and physics, meaning the study of nature.