The Laws of Medicine Read Free

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 patientsrecovering 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 oranimal 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