Wednesday 29 June 2016

Medicine Watcher

Dau.I sent me two books for my bday two weeks ago: I've already told you TMI about Feynman and Leonard's testicles. The other [super wonderful] book was The Youngest Science: notes of a medicine watcher by Lewis Thomas. Thomas was, according to The Wik, "an American physician, poet, etymologist, essayist, administrator, educator, policy advisor, and researcher".   I don't think that evidence of multiple skills makes him a polymath, let alone a genius, in the way that Murray Gell-Mann or Jean-Baptiste Biot or JBS Haldane, could be so classified. administrator, educator, policy advisor, makes him look a bit ploddy; poet, etymologist, essayist, a bit butterfly. Don't dismiss him until you've read his 1974 collection of essays The Lives of the Cell: notes of a biology watcher which is a best-of from his commissioned column for the New England Journal of Medicine NEJM. That book came out just as I started college and the sequel The Medusa and the Snail (1979) was published just as I started graduate school. Both collections won prizes for inspiring youngsters to go into science. This was years before the world wide web, let alone blogs, so there were few enough avenues for putting down some thoughts on a range of topics and getting them published. The essay is a form I like very much: short enough to read at a sitting and long enough to develop some arguments that make you think.

The Youngest Science TYS is billed as Thomas's autobiography but it's really too sketchy to qualify for that. It's a series of themes and anecdotes which are co-terminous with the author's life but leave a lot of detail on the cutting room floor. Discarding the boring makes his life a bit more exciting. The key theme is how the practice of medicine has changed, changed utterly, since Thomas's GP father was struggling to make ends meet at the end of each month in the years before WWI. Young Thomas was never going down the GP route and went through a  succession of academic, clinical and administrative positions all over the USA. One of the most striking differences between the work of medicine in 1933, when Thomas first started clumping the wards at dead of night, and 1983, when TYS was published, is the range of diseases were not but are now treatable. In the 1930s there were effective therapies for
  1. lobar pneumonia [type-specific anti-pneumococcus antibodies; first type your pneumococcus from a sputum sample as quickly and reliably as possible]
  2. diabetic coma [a dribble of insulin and intravenous fluids]
  3. acute heart failure [bleeding (!) to reduce blood-pressure; digitalis as in tincture of foxglove Digitalis purpurea leaves to ooomph the heart muscle; oxygen] 
  4. syphilis [bismuth, arsenic compounds and mercury  . . . and a lot of time]
and that's about it.  The first three required speedy and accurate diagnosis if the treatment was to be successful.

All the rest of hospitals' work was 'simply custodial' patients would only be rolled into hospital if they were really sick but there was nothing really to do except "waiting for the illness to finish itself off one way or the other".  My father developed pneumonia after being taken for a bracing winter swim in the Irish Sea while at boarding school in 1929. The school called his mother, who sat by his bedside for ten days mopping his brow and talking to him until the fever broke and he started smiling again.  His immune system had finally triumphed over the invasive Pneumococci. His mother probably made a difference because of the untapped and poorly understood power of PNI psycho-nearo-immunology [bloboprev]. According the Thomas "If being in hospital made a difference, it was mostly the difference produced by warmth, shelter, food and attentive, friendly care and the matchless skill of the nurses providing these things". Certainly in those days, the nurses saved as many lives as the doctors. And nobody was in it for the money.

Now it seems that it is all about the money.  If you're a doctor prescribing a medicine which costs €160,000/yr, you'd be tempted to think "I'll have $ome of that"; you wouldn't be human or have a mortgage if that didn't cross your mind.  The Brother spent long years making quality TV commercials for a living.  The cost of 30 seconds of airtime in the evening was a king's ransom, just to play: so the companies tended to invest equally heavily in production values, and The Brother and his company (and the key-grip, the best boy, the continuity department and make-up) got a piece of the action.

In a life-time of science, I've had three good ideas and one of them turned out to be wrong and we got scooped on one of the others, so it was never published under my name.  It's been a bit like that for Dr Thomas and this book of essays written in retirement allows him to put down a marker on a couple of those unpublishable hunches: possibly to intrigue a youngster to take up the fading scent and keep up the hunt for a solution. One of these is the observation that a peculiar sort of arthritis in pigs is definitely triggered by mycoplasma bacteria [bloboprev] and that both mycoplasma infestation and the 'auto-immune' disease rheumatoid arthritis are both susceptible to treatment with gold salts. Nobody has ever been able to culture mycoplasmas, or indeed any potentially causative microbe, from RA inflamed joint tissue. But the list of bacteria that have never been grown on a Petri dish far far exceeds those that have.  I'm with, or at least behind, Thomas on this sort of idea. We will eventually find microbial infection - virus, bacteria or protozoan - acting as a trigger in all autoimmune diseases.

TYS is more than 30 years old, so parts of it are out of date and superseded, but as an inspiration for using science as a way of knowing & being open, curious, hard-working, stubborn and committed, it should be on the reading list for any favorite niece or nephew heading up to Med School.

I'll leave you with a final insight from Lewis Thomas “The future is too interesting and dangerous to be entrusted to any predictable, reliable agency.”  Which may remind you of JBS Haldane's: "I have no doubt that in reality the future will be vastly more surprising than anything I can imagine. Now my own suspicion is that the Universe is not only queerer than we suppose, but queerer than we can suppose."

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