Extract | The Laws Of Medicine: Field Notes From An Uncertain Science

Siddhartha Mukherjee’s latest book, The Laws Of Medicine: Field Notes From An Uncertain Science, asks whether medicine is a science in the way that physics is a science. Dr Mukherjee, an oncologist and author of The Emperor Of All Maladies: A Biography Of Cancer, draws on real-life cases in this book to cull some irrefutable laws of medicine. Edited excerpts:

In the winter of 2000, during the first year of my medical residency, I lived in a one-room apartment facing a park, a few steps from the train station at Harvard Square.

Lived is a euphemism. I was on call every third night at the hospital—awake the whole night, admitting patients to the medical wards, writing notes, performing procedures, or caring for the acutely ill in intensive care units. The next day—postcall—was usually spent in a dull haze on my futon, catching up on lost sleep. The third day we named flex, for “flexible.” Rounds were usually done by six in the evening—and the four or five hours of heady wakefulness that remained were among the most precious and private of all my possessions. I ran a three-mile circuit around the frozen Charles River as if my life depended on it, made coffee on a sputtering Keurig, and stared vacantly at the snowdrifts through my window, ruminating on the cases that I had seen that week. By the end of the first six months, I had witnessed more than a dozen deaths, including that of a young man, no older than I, who died of organ failure while awaiting a heart transplant.

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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.

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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 gruelling 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 labelled 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.

Reprinted with permission from Simon & Schuster UK.