Read The Laws of Medicine Online

Authors: Siddhartha Mukherjee

The Laws of Medicine (2 page)

BOOK: The Laws of Medicine
8.54Mb size Format: txt, pdf, ePub
ads

....

I spoke to no one, or, at least, I have no memory of speaking to anyone (I ran through a park by night, and through friends by day). “Illness reminds you that spontaneity, too, is a human right,” a patient once told me. Part of the horror of hospitals is that everything happens on time: medicines arrive on schedule; the sheets are changed on schedule; the doctors round at set times; even urine is collected in a graduated pouch on a timer. Those who tend the ill also experience some of this erasure of spontaneity. Looking back, I realize that I lived for a year, perhaps two, like a clockwork human, moving from one subroutine to the next. Days folded into identical days, all set to the same rhythm. By the end of my first month, even “flex” had turned into reflex.

The only way to break the deadly monotony was to read. In the medieval story, a prisoner is sent to jail with just one book, but discovers a cosmos of a thousand books in that single volume. In my recollection, I also read only one book that year—a slim paperback collection of essays titled
The Youngest Science
—but I read it as if it were a thousand books. It became one of the most profound influences on my life in medicine.

....

The Youngest Science
was subtitled
Notes of a Medicine-Watcher
and was about a medical residency in another age. Written by the physician, scientist, author, and occasional poet Lewis Thomas, it describes his tenure as a medical resident and intern in the 1930s. In 1937, having graduated from Harvard Medical School, Thomas began his internship at Boston City Hospital. It was a grueling initiation. “Rewarding might be the wrong word for it, for the salary was no money at all,” Thomas wrote. “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. . . . 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.”

Lewis Thomas entered medicine at one of the most pivotal transitional moments in its history. We tend to forget that much of “modern medicine” is, in fact, surprisingly modern: before the 1930s, you would be hard-pressed to identify a single medical intervention that had any more than a negligible impact on the course of any illness (surgery, in contrast, could have a transformative effect; think of an appendectomy for appendicitis, or an amputation for gangrene). Nearly every medical intervention could be categorized as one of three P's—placebo, palliation, and plumbing. Placebos were, of course, the most common of drugs—“medicines” that caused their effects by virtue of psychological or psychosomatic reactions in patients (elixirs for weakness and aging, or tonics for depression).
Palliative drugs, in contrast, were often genuinely effective; they included morphine, opium, alcohol, and various tinctures, poultices, and balms used to ameliorate symptoms such as itching and pain. The final category—I've loosely labeled it “plumbing”—included laxatives, purgatives, emetics, and enemas used to purge the stomach and intestines of their contents to relieve constipation and, occasionally, to disgorge poisons. These worked, although they were of limited use in most medical cases. (In an epic perversion, the tool and the therapy were often inverted. Purging was a common medical intervention in the nineteenth century not because it was particularly effective, but because it was one of the few things that doctors could actually achieve through medicines; if you had a hammer, as the saying goes, then everything looks like a nail.)

The paucity and ineffectiveness of therapeutic interventions had created what Thomas recognized as the reigning philosophy of medicine: “therapeutic nihilism.” Despite the negative connotations in its name, therapeutic nihilism was arguably one of the most positive developments of early twentieth-century medicine. Recognizing the absolute uselessness—and the frank perniciousness—of most nineteenth-century medical interventions, a new generation of doctors had decided to refrain from doing much at all. Instead, luminaries such as William Osler, at Johns Hopkins, had chosen to concentrate on defining, observing, categorizing, and naming diseases, hoping that this would allow future generations to identify bona fide therapeutic interventions. Osler, for instance, hospitalized patients in medical wards in Baltimore with no other purpose, it seemed, than to
watch the “natural history” of an illness unfold in real time. The all-too-human temptation to do something was purposefully stifled. (A doctor's job, Thomas once told an interviewer, “was to make a diagnosis, make a prognosis, give support and care—and not to meddle.”) Osler's students didn't meddle with useless medicines; instead, they measured volumes, breaths, weights, and heights; they listened to hearts and lungs, looked at pupils dilating and contracting, abdomens growing and shrinking, neural reflexes appearing and disappearing. It seemed as if the Hippocratic oath—
First, do no harm
—had been transmuted to
First, do nothing
.

And yet, doing nothing would have a deeply cleansing effect. By the 1930s, the careful bloodletting of the past had radically altered the discipline; by observing the evolution of diseases, and by constructing models of how diseases occurred and progressed, doctors had begun to lay the foundations of a new kind of medicine.

They had recognized the cardinal features of heart failure—the gradual overloading of the body with fluid and its extrusion into the lungs, the altered sounds of the stretched, overworked heart, or the lethal disruptions of rhythm that followed. Diabetes, they had learned, was a dysfunction of the metabolism of sugar—the body's inability to move sugar from blood into tissues; that in patients with diabetic acidosis, blood became gradually saturated with glucose, yet the tissues were starved of nutrition, like the Mariner who finds water everywhere, but cannot get a drop to drink. Or that streptococcal pneumonias often followed influenza infection; that patients
recovering from the flu might suddenly develop relapsing fevers and a hacking, blood-tinged cough; that through the earpiece of a stethoscope, a single lobe of the lung might be found to exhibit the characteristic dull rustling of consolidation—“like a man walking on autumn leaves,” as one professor of mine described it. Or that a patient with such a pneumonia might experience two very different trajectories: either the microbe would overwhelm his physiological defenses, resulting in sepsis, organ failure, and a swift death; or, about ten days into the infection, the body would mount an exquisite immunological defense against the organism, resulting in the sudden abatement of fever and the elimination of the bacterium from the blood. Pathophysiology—the physiology of pathology—was thus constructed, observation upon observation, and it would be the platform on which modern medicine could be built.

For Thomas, the astonishing feature of medicine in the 1940s was its ability to use this information to mount genuine therapeutic interventions against diseases based on rational precepts. Once heart failure had been reconceived in terms of pump dysfunction and volume overload (a failing pump cannot move the same volume of blood through the body, and the extra volume froths back into the lungs), then an effective, albeit crude, therapy for heart failure became self-evident: removing a few pints of blood from the veins to ease the straining heart. Similarly, once the miraculous recovery from streptococcal infection had been understood as the deployment of a host immunological response, then this, too, suggested a novel therapeutic approach: transferring serum from a convalescent human or
animal to a newly infected patient to supply the crucial defensive factors (later found to be antistreptococcal antibodies) to boost the host's immunological response. Here is Thomas describing the treatment for streptococcal pneumonia based on this principle: “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 be sleeping in good health.”

Thomas wrote, “For an intern it was an opening of a 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 became convinced, overnight, that nothing lay beyond the reach of the future. Medicine was off and running.” It was the birth of what Thomas called the “youngest science.”

....

By the time I read
The Youngest Science
, the scientific transformation of medicine had deepened even further. Take heart failure again. In 1937, Thomas wrote, the only reliable means to affect a failing heart, aside from propping up its function with extra oxygen, was to alter blood volume by inserting a needle into a vein and drawing out a hundred milliliters of fluid from the body. To a cardiologist working in the late 1990s, this would be akin to lancing an abscess using a skin cup: it might work, but it was a decidedly medieval approach. This cardiologist would now have at his disposal not one, or two, but no less than a dozen medicines to subtly modulate the volume, pressure, and rhythm of the failing heart, including diuretics, blood-pressure mediators, drugs that open channels for salt and water in kidneys, or medicines that maintain fine control on heart rhythms. Added to this were implantable defibrillators (colloquially called heart zappers) that delivered jolts of electricity to “reset” the heart should it enter a lethal rhythmic cycle. For the most intractable cases of heart failure—such as the young man whose heart muscles were destroyed, bit by bit, by the mysterious deposition of iron, like the Tin Man of Oz—even more innovative procedures exist, such as the transplantation of a whole foreign heart into the body, followed by a salvo of immunosuppressive medicines to ensure that the transplanted graft remains functional and intact in the body afterward.

....

But the more I read
The Youngest Science
that year, the more I returned to a fundamental question: Is medicine a science? If, by
science
, we are referring to the spectacular technological innovations of the past decades, then without doubt medicine qualifies. But technological innovations do not define a science; they merely prove that medicine is scient
ific
—i.e., therapeutic interventions are based on the rational precepts of pathophysiology.

Sciences have laws—statements of truth based on repeated experimental observations that describe some universal or generalizable attributes of nature. Physics is replete with such laws. Some are powerful and general, such as the law of gravitation, which describes the force of attraction between two bodies with mass anywhere in the universe. Others apply to specific conditions, such as Ohm's law, which only holds true for certain kinds of electrical circuits. In every case, however, a law distills a relationship between observable phenomena that remains true across multiple circumstances and multiple conditions. Laws are rules that nature must live by.

There are fewer laws in chemistry. Biology is the most lawless of the three basic sciences: there are few rules to begin with, and even fewer rules that are universal. Living creatures must, of course, obey the fundamental rules of physics and chemistry, but life often exists on the margins and in the interstices of these laws, bending them to their near-breaking limit. Even the elephant cannot violate the laws of thermodynamics—although its trunk, surely, must rank as one of the most peculiar means to move matter using energy.

But does the “youngest science” have laws? It seems like an odd preoccupation now, but I spent much of my medical residency seeking the laws of medicine. The criteria were simple: a “law” had to distill some universal guiding principle of medicine into a statement of truth. The law could not be borrowed from biology or chemistry; it had to be specific to the practice of medicine. In 1978, in a mordantly acerbic book called
The House of God
, the writer Samuel Shem had proposed “thirteen laws of medicine” (an example: “Law 12: if the radiology resident and the intern both see a lesion on an X-ray, then the lesion cannot be there”). But the laws that I was seeking were not attempts to skewer medical culture or highlight its perversities à la Shem; I was genuinely interested in rules, or principles, that applied to the practice of medicine at large.

Of course, these would not be laws like those of physics or chemistry. If medicine is a science at all, it is a much softer science. There is gravity in medicine, although it cannot be captured by Newton's equations. There is a half-life of grief, even if there is no instrument designed to measure it. The laws of medicine would not be described through equations, constants, or numbers. My search for the laws was not an attempt to codify or reduce the discipline into grand universals. Rather, I imagined them as guiding rules that a young doctor might teach himself as he navigates a profession that seems, at first glance, overwhelmingly unnavigable. The project began lightly—but it eventually produced some of the most serious thinking that I have ever done around the basic tenets of my discipline.

BOOK: The Laws of Medicine
8.54Mb size Format: txt, pdf, ePub
ads

Other books

Foundling Wizard (Book 1) by James Eggebeen
Spirit by Shauna Granger
Trust by Sherri Hayes
Unscripted by Jayne Denker
Head of the River by Pip Harry
Parade's End by Ford Madox Ford
Cut and Run by Carla Neggers