Consumption (58 page)

The outcome was, fortunately, a happy one and the story ends, as Dr. Moody tells it, with Mrs. Moody telling her husband never to doubt his expertise again.

My friend Isabelle spoke once of him to me. After Moody left, in 1949, I was the next doctor to live in Kivalliq, though I did not arrive until 1969 and lived in Rankin Inlet rather than Chesterfield Inlet. I asked her about him, not suspecting the weight he carried in her memories. Isabelle, so light and talkative in every other circumstance, chose her words carefully and spoke as if she were giving a statement. “He was a dynamic man,” she said at last.

“Did you know him well?”

“I thought so at the time.”

“Did you like him?”

“Yes.”

“I only ask because in his book he seems a little full of himself.”

“He was.”

“So you weren’t that close.”

“Ultimately, no.”

“Why did he leave?”

“He followed his wife.”

“I don’t understand, she worked up here too?”

“Not in the sense you mean.”

“She didn’t like it here?”

“She became unhappy.”

Laughing. “Isabelle, you’re being so
cryptic!”

The prevailing conception of illness until only a few generations ago was that the sick were contaminated, whether by some toxin or contagion, or an excess of one humour or another. That understanding of illness contained within it the idea that these conditions could be improved by opening a vein and letting the sickness run out: bloodletting, the practice was called.

Once the toxins were gone, the patient immediately felt
different
, and often
better
. As anyone who has given blood can tell you, losing a pint or two makes you feel transported, transformed. Intuitively, it was satisfying to doctors that the procedure left the patient feeling drained—physically, emotionally, and into the sink.

The precise nature of the toxins drained off into the basin was a matter of some contention among the physicians who attended the patient, but it didn’t matter. Together with the putative toxins, something as distressing was much more incontrovertibly gone: fear. The patient was sick and now something has been done about that. Of course she felt better; at the essence of the experience of being sick lies fear.

It is understood now that bloodletting only hastened the death of the ill. (George Washington had 2.3 litres of blood drained from him in the two days
prior to his death; he had been suffering from a sore throat.) We know that bloodletting is unhelpful because a Parisian doctor named Pierre Louis did an experiment in 1836 that is now recognized as one of the first clinical trials. He treated people with pneumonia either through bloodletting or with purely supportive measures. The ill were randomly assigned to each group, and at the end of the experiment, Dr. Louis counted the bodies. They were stacked higher over by the bloodletting sink.

No sooner had the message about the dangers of draining blood out of patients been conveyed across the medical community—and that took the rest of the nineteenth century—than doctors developed a new passion for pouring it back into them. After cross-typing was invented and blood could be transfused safely, doctors quickly decided that very ill patients do better with as normal a level of hemoglobin as could be maintained. It made sense, and blood transfusions became a daily part of critical care medicine.

Then just a few years ago the results of a large study were published in
The New England Journal of Medicine
. Those results shook the community of intensive-care physicians worldwide. Except in the case of people with angina, routine transfusion of critically ill people with moderate or mildly low hemoglobin levels does not decrease their mortality rate—and in some subgroups, it actually
increases
the mortality rate. Nobody has a persuasive explanation for why this is, and few suspected that non-infectious blood could hurt anyone more than serious anemia does. But it is the case.

I have known her for twenty-five years, and in this time, I think she has not had confidantes. Certainly she would have known better than to divulge a secret to any of the nuns she worked with, or anyone who lives in Chesterfield Inlet: secrets run through these populations like infections. I think she longed to tell someone the story and for reasons that became clear, she thought she could talk to me about the matter without fear of censure.

When next his name came up we were ice fishing, lying prone on a river mouth and jigging our hooks through five feet of cobalt-blue sea ice. It was
warm, and Isabelle told me without prompting that it was good the doctor—by whom I knew her to mean Moody—had gone back to Toronto. “His wife and his child needed him there,” she said, looking down her ice hole.

“Do you think he was happy when he went back?”

“No.”

“Have you heard from him?”

“A few letters.”

“Do you write him back?”

“No.”

“Would he have been happy if he had stayed up here?”

“I don’t know.”

In the first weeks after a heart attack, those who experience frequent irregular heartbeats are much more likely to die suddenly than those who do not. It has been observed that a class of drugs called Ic anti-arrhythmics can suppress those premature beats. This was the rationale for treating people at risk for sudden death with Ic agents. These drugs had been in use for more than a decade for exactly that purpose when the Cardiac Arrhythmia Suppression Trial was finally conducted in 1989. The results shocked many in medicine. Not only did these drugs not save lives, they in fact resulted in one unnecessary death for every twenty-one patients treated with these drugs over a ten-month period.

Clinicians had been confident they were saving lives; no one suspected they were killing people. More Americans were killed by Ic anti-arrhythmics used in this manner than were killed in the Vietnam War.

Over supper, on another of my visits: she leaned back from the caribou and drained her wineglass. “Look at us, Keith, so old, and so full of secrets.” I watched her watch my reaction, and I wondered which of my secrets she was referring to.

“Don’t be so wary. I knew you to be what you are the moment you came up here.”

“Really?”

“I worked in soup kitchens in Halifax for the first ten years of my calling, and I did more than peel potatoes there.”

“I feel naked.”

She shrugged. “You know that I am fond of you. If I had wanted to, I could have told your secrets long ago.”

“Do you ever think that the responsible thing would have been to reveal them?”

“I have thought that sometimes.”

“Why haven’t you?”

“This is not a normal place. It does not draw normal people. And the alternative to those such as us is no one.”

“I suppose.”

“I’ve given the matter some thought.”

The point isn’t that some medical treatments don’t work as well as we think, or even that in treating patients, doctors sometimes hurt them—this has always been clear. The point is that the clinical experience of doctors and the impressions they form from day to day, non-systematic observation, are often not reliable data and are much less reliable than most doctors appreciate or readily acknowledge. Further, the vast bulk of medical therapies has not been evaluated by systematic study and is used simply because doctors believe that it works.

“Medicine is both an art and a science,” every medical student is told, over and over again, from the first day in the cadaver room and on. The “art” is represented to be that intuitive sense of a patient and her underlying diagnoses and how she might respond to certain treatments.

The body is so complex, and the ways it might go wrong so varied, that in the middle of the night, standing next to some fresh catastrophe, it is necessary
sometimes to generalize and to reduce very complicated problems to first principles. It is simply not possible to be rigorously intellectual and consult the available medical data about every single thing, all the time. It takes too long, and if all the intricacies of the medical data on every clinical problem were fully considered before acting, the operating rooms would grow dusty and people would die while the doctors’ chins are rubbed into a bright shine. Sometimes it is necessary to act on a feeling.