The View from the Vue (14 page)

“Not likely on the first two without fever and more signs of neurologic impairment,” Joel said. “And it’s a pretty chronic course for a brain abscess. But if she does have one, the tests we’re ordering for brain tumor will show it up.”

“How about a subdural hematoma?” asked Charlie. (That’s a blood clot beneath the skull, on the surface of the brain.)

“I doubt that too,” said Joel. “There’s no history whatever of a head injury. And she’s been sick pretty long for a subdural. Also, the routine skull films we got last night don’t show anything suggestive.”

“Okay,” Charlie said. “What are you going to do next?”

“She’s scheduled for an angiogram today,” Joel replied. “We got her on as a special case.”

Rosie went for her angiogram that afternoon. The radiologists injected a dye into the arteries leading to her brain, and then took X-rays. The blood vessels which nourish brain tumors show a characteristic arrangement. But Rosie’s angiogram was entirely normal.

This did not completely rule out a brain tumor, however, and Joel and I scheduled Rosie for her next test, a pneumoencephalogram. This involves the injection of air into the central fluid-filled cavity of the brain. Then, more X-rays are taken to determine whether there is any displacement of the normal contours of the air space. This test is more difficult and more dangerous than an angiogram, and by the time the sweating neuroradiologists had completed their work, more than two hours had passed, and Rosie had another negative test to her credit.

Mrs. Murchison clasped her hands together as I told her the news. “Oh, I’m awful glad, Doctor,” she said softly. “I don’t want anything to be growing in Rosie’s head. Do you think she’ll be okay now?”

“I really don’t know,” I answered. “We still thinks she has a growth, but maybe it’s located where the X-rays don’t show it up.” Translated, that meant right smack in the middle of her brain tissue, but I couldn’t quite say that. “We’ll go over her case again in the morning and see what else we might be able to do.”

Meanwhile, Rosie’s clinical course had been none too reassuring. She was becoming increasingly unresponsive and lethargic, and since she had been in the hospital, she had had two further convulsions. After the first one, we had started her on phenobarbital to try to forestall any further seizures, but obviously we had not had much success.

In the morning, as we reached Rosie’s bed, Charlie reexamined the child and then thumbed slowly through the chart, pausing to study the laboratory results. “Are you absolutely sure she has a brain tumor?” he asked.

“There’s nothing else she
could
have,” Joel answered. I nodded my head in agreement.

Charlie um-hummed and turned back to Rosie. He opened her mouth and pulled her lower lip away from the gum. “What’s this?” he asked sharply.

Joel and I peered into the crevasse. Running the length of the gum, right below the line of tooth insertions, was a black line. I had no idea what it was.

Joel whistled. “Jee-sus Christ!” he said. “Is that a lead line?”

“Looks like it to me,” said Charlie. “Better get to work.”

We got to work. Before the day was over, we had established that Rosie had elevated levels of lead in her blood and her urine, increased density at the ends of the bones of her legs, and peculiar blue dots in her red blood cells. Taken together, all these findings were diagnostic of chronic lead poisoning.

Lead poisoning, or plumbism, is a disease far more likely to be encountered at The Vue than at private institutions because of the way in which it’s usually contracted. It is an environmental disease. Until recent years, most paints were compounded with a lead base so that when the paint began to peel off a wall and found its way into a small child’s mouth the kid would slowly absorb the lead from its gut and suffer the disastrous consequences. Not only were the Bellevue pediatric clientele at greater risk because peeling walls in their tenement homes were less likely to be repaired, but in addition, some pediatricians have expressed the opinion that the poor diet to which the children were characteristically exposed made them more likely to want to eat the paint.

Rosie’s course was typical of lead poisoning. Unfortunately, the disease tends to mimic other conditions which occur more frequently and which are, therefore, better known. As in Rosie’s case, it can appear as an encephalitis with many of the signs of the various disorders we had in fact considered. Alternatively, the major symptom may be colic, in which case a number of abdominal diseases can be imitated. In either event, lead poisoning will be diagnosed only if the doctor keeps its possibility in mind.

If Joel and I hadn’t been wearing blinders, we might have paused when we noticed how low Rosie’s red blood cell count was. This too is typically found in plumbism. But we were convinced she had a brain tumor, so we simply ascribed the anemia to her poverty-level diet and to the lack of appetite characteristically seen in patients with brain tumors. Fortunately, Charlie Evers’ mind remained open; he made the connection and looked for the black lead staining on the gums that I had simply chalked up to poor hygiene. Similarly, the basophilic stippling, or blue dots, on Rosie’s smeared-out red blood cells hadn’t impressed us. When you’re absolutely certain the diagnosis is a brain tumor, it’s easier to write off any discordant data than to try to interpret them.

Lead poisoning is a dangerous disease. One quarter to one half of the patients who appear with encephalitic symptoms die, and many of the survivors are mentally retarded, paralyzed, or suffer recurrent seizures. The effect of the lead on the nerve cells of the brain is devastating. All one can do is treat and hope for the best.

The therapy is directed toward two goals: preventing any further absorption of lead into the body and accelerating excretion of the lead that has already been taken up.

Absorption is prevented by removing all sources of ingestible lead from the environment and by feeding large quantities of milk, which converts the lead into a non-absorbable form. Excretion is accomplished by giving the patient ethylenediaminetetraacetic acid (EDTA), a chemical which binds lead to itself and then carries it out in the urine. Toxic levels of lead in tissues and blood are further reduced by the administration of large quantities of calcium, phosphorus, and Vitamin D. These agents lower the solubility of lead in the bloodstream and augment its rate of deposition in bone, where it causes no harm.

All three of us on the ward house staff were considerably distressed over the missed diagnosis because in the two-day interval Rosie’s condition had worsened. She now lay quietly in her bed, unaware and unresponsive. This suggested that there was considerable swelling of the brain tissues, and that if she were to be saved, absolutely no further time could be lost. We decided to pass a tube into her stomach, pour milk through it, and at the same time, give her injections of calcium, phosphorus, and Vitamin D. Joel said he’d get right over and set up an intravenous infusion of EDTA.

“Isn’t there something you want to do first?” asked Charlie.

Joel looked puzzled. I was puzzled.

“If she does have any lead left in her intestines, the EDTA’ll make it more absorbable, and that would worsen her symptoms.” Charlie pounded his fist into his hand. “We’ve got to get a film of the abdomen and see whether there’s still any lead in her gut.”

“I know we’re giving her the milk, just to be on the safe side,” said Joel. “But she’s been out of her house for two days already. Do you really think she’s got any lead left inside? It seems like a wasted X-ray.”

“You were sure she had a brain tumor, too,” said Charlie dryly.

Joel wrote out the requisition for the X-ray. It turned out that it
was
negative for lead in the gut, but he didn’t complain.

For each of the next five days, either Joel or I gave Rosie an intravenous infusion of EDTA, and at least twice a day we reviewed her neurological status. By the fourth day, when I pinched the little girl, she made an effort to move away and let out a high-pitched groaning noise. On the day after that her eyes periodically flickered open.

It’s safe to give EDTA for only five days at a stretch, so during the next two days, Rosie received no chemical therapy. We all held our breath and watched her. Fortunately, she continued to improve. Our treatment must have mobilized a large quantity of lead from her blood and her tissues. On the seventh day, she shakily tried to sit up in bed. But in the same day, the lead concentration in her blood, which had been falling, showed a slight increase. This indicated that the metal remaining in her body was not being excreted fast enough, and so, beginning the next morning, we initiated a second course of EDTA therapy. The blood lead level fell immediately, and after the drug was again discontinued did not rise.

After Rosie had spent four weeks in The Vue, she was ready to go home. She had recovered neurologically, except for a slight residual weakness of her left arm. Her parents, who came each day to visit her, were sufficiently impressed to declare that Charlie, Joel, and I were, without question, genuine incarnations of Our Savior. At least, so the mother declared, and the father nodded in vigorous agreement.

Before we discharged Rosie, we took care to tell her parents that it was very important for us to see her regularly in the clinic so that we might monitor her continued progress. In addition, as tactfully as he could, Charlie warned Mr. and Mrs. Murchison that there are often long-term sequelae of lead encephalitis, including mental retardation due to damage to the brain cells. It was like talking to the wall. Mrs. Murchison replied that she “just knew” there wouldn’t be anything wrong. Mr. Murchison hugged his daughter and murmured over and over, “My little Rosie.” I realized that those were the first words I had ever heard him speak.

We sent out one of the social workers to make certain Rosie would get her necessary follow-up, and also to check the home situation. She returned in a grand snit.

“You just can’t imagine that place,” she said. “Two rooms, three kids, all kinds of crap all over the place, and strips of paint six inches long peeling off the wall. I showed the paint to the Murchisons and told them that was how Rosie got sick, and that she’d get sick again if they didn’t fix the place up.”

“So what’d they say?” I asked.

“Mrs. Murchison said they knew all that, because you guys had told them the same thing while Rosie was in the hospital,” said the social worker. “She said they’d been working on the landlord to scrape and paint, but he told them he wasn’t about to do that for the amount of rent they paid. He also said that he thought what they had was good enough for slobs like them. So Mr. Murchison led me over to one of the closets, opened it up, and showed me a couple of cans of paint, a brush, and a scraper. His wife said he was going to do the job this weekend.

Mr. Murchison did the job, the family received some dietary counseling, and that was the end of the lead poisoning in that household. Unfortunately, however, there were thousands of other people in New York living under similar conditions, so plumbism remained a recurring problem among the Bellevue pediatric population. Its importance has not declined with time, despite the fact that increasing numbers of tenements have been repainted with the newer leadless paints, in compliance with the 1959 New York City law. There has been no significant improvement because the original layers of paint remain under the new ones, as toxic as ever. Thus, even today, most of the poorly fed toddlers in the Bellevue catchment area still can’t gnaw the peelings off their walls without running the risk of developing lead poisoning.

Throughout its history, Bellevue Hospital has numbered very few famous persons among its patients. The fact of the matter is that a huge municipal hospital catering to the Lower East Side of New York, with its open wards, its peeling plaster, and its rats and roaches offers very little to attract the ailing celebrity crowd. However, fame and insolvency are not mutually exclusive traits, and so there have been occasional exceptions to the rule.

For example, in the winter of 1864 a thirty-eight-year-old alcoholic was brought to The Vue from his flophouse, where he had passed out. He was suffering from pneumonia, a lethal disease in those pre-penicillin days, especially when it attacked a malnourished derelict such as this one. The man lived for only three days. In his pocket, the attendants found thirty-eight cents and a scrap of paper on which were written the words, “Dear friends and gentle hearts.” Music students later concluded that this was to have been the first line of a song that the man had intended to write. He was composer Stephen Foster.

Exactly one hundred years later, as a Bellevue intern, I took care of a luminary of even greater renown. Let the former interns at Los Angeles’ Cedars-Sinai brag about the actresses for whom they were called to prescribe sleeping pills late at night when no one would dare to rouse a private physician. Let the erstwhile house officers at Columbia University’s Harkness Pavilion boast of the political dignitaries who once upon a time deigned to permit them to draw samples of blood. None of these doctors has anything on me.

Not one of them can make the claim I can: for ten days I served as personal physician to John the Baptist.

John came under my care on a bitterly cold January night. The radiators were hissing and were giving off little jets of steam. I was at the desk, near the front of the ward, reviewing the day’s lab slips while my wife transcribed them into the charts. Nearby, the ward clerk and the messenger were playing gin. I heard the elevator door clang down the long stone hallway. A minute later I looked up to see the Admitting Office messenger wheel in an old man in a wheelchair.

The new patient was about six feet tall, but he couldn’t have weighed more than a hundred and twenty pounds. He had long, gray hair and a beard, and both looked as though they hadn’t been combed in more than a year. His eyes were little and abnormally bright, and the way they were darting all around the room put me in mind of a sparrow on a telephone wire. He didn’t smell like a sparrow, though: his odor would have shamed a full-grown billy goat. In one hand he clutched a worn, dirty Bible, and in the other he held a straight, three-foot-long stick. All in all, he looked like a sick and dissipated John Brown.