13
Monday, February 23, 3:36 P.M.
With the cloud cover Boston had enjoyed little daylight that day, and by 3:30 dusk settled over the city. It took a bit of imagination to comprehend that above the clouds shone the same six-thousand-degree fiery star which in summer turned the macadam on Boylston Street molten. The temperature had responded to the surrendering sun by precipitously falling to nineteen degrees. Another flurry of minute crystalline bodies wafted over the city. The outside lights along the hospital walkways had been on for almost a half-hour.
From within the illuminated library, it already appeared pitch black outside. The two-story window at the end of the room responded to the dropping temperature by starting an active convection current of cold air across its face. The weighted colder air fell to the floor at the foot of the window and then swept the length of the room under the tables toward the hissing radiators in the back. It was the cold current which first began “to nudge Susan from the depths of her intense concentration.
As with so many academic subjects, Susan began to perceive that the more she read about coma, the less she felt she knew. To her surprise, it was an enormous subject, spanning many disciplines of medical specialization. And perhaps the most frustrating of all was Susan’s realization that it was not known what determined consciousness, other than saying that the individual was not unconscious. The definition of one consisted of being the opposite of the other. Such a tautologous circle was a travesty of logic until Susan accepted the fact that medical science had not advanced enough to define consciousness precisely. In fact, being fully conscious and being totally unconscious (coma) seemed to represent opposite ends of a continuous spectrum which included partway states like confusion and stupor. Hence the inexact, unscientific terms were more an admission of ignorance than poorly conceived definitions.
Despite the semantics Susan was well aware of the stark difference between normal consciousness and coma. She had observed both states that very day in a patient… Berman. And despite the lack of precision in definition, there was no lack of information regarding coma. Under the heading of “acute coma,” Susan began to fill page after page in her notebook with her characteristically small handwriting.
Her particular interest was in causation. Since science had not decided on what particular aspect of brain function had to be disrupted, Susan had to be content with precipitating factors. Being interested in acute coma, or coma of sudden onset, also helped to narrow the field but still was impressive and growing. Susan looked back over the list of causes that she had noted so far:
Trauma = concussion, contusion, or any type of stroke
Hypoxia = low oxygen:
(1) mechanical
—strangulation
—blocked airway
—insufficient ventilation
(2) lung abnormality
—alveolar block
(3) vascular block
—blood cannot get to brain
(4) cellular block of oxygen use High Carbon Dioxide
Hyper (hypo) Glycemia = high (low) blood sugar
Acidosis = high acid in the blood
Uremia = kidney failure with high uric acid in the blood
Hyper (hypo) Kalemia = high (low) potassium
Hyper (hypo) Natremia = high (low) sodium
Hepatic Failure = increase of toxins which would normally be detoxified by the liver
Addison’s Disease = severe endocrine or glandular abnormality
Chemicals or Drugs…
Susan took an extra couple of pages for the chemicals and drugs associated with acute coma and listed them alphabetically, each with a separate line to make it possible to add information as she got it:
Alcohol Insulin
Amphetamines Iodine
Anesthetics Mercurial diuretics
Anticonvulsants Metaldehyde
Antihistamines Methyl bromide
Aromatic hydrocarbons Methyl chloride
Arsenic Naphazoline
Barbiturates Naphthaline
Bromides Opium derivatives
Cannabis Pentachlorophenol
Carbon disulfide Phenol
Carbon monoxide Salicylates
Carbon tetrachloride Sulfanilamide
Chloral hydrate Sulfides
Cyanide Tetrahydrozaline
Glutethimide Vitamin D
Herbicides Hypnotic agents
Hydrocarbons
Susan knew that the list was not complete but nonetheless it gave her something to go on, something to keep in mind during her subsequent investigations, and it could be enlarged at any time.
Turning next to the general internal medicine textbooks, Susan opened the ponderous Principles of Internal Medicine and read the appropriate sections dealing with coma. The articles in Cecil and Loeb were about the same. Both books provided a rather good overview, although no new concepts were added. Several references were cited which Susan duly copied down in an ever-expanding list of necessary reading.
It felt good to get up and stretch. Susan allowed a deep comforting yawn. She wiggled her toes to try to encourage the blood to go there. The cold draft along the floor had made her stir sooner than she might have otherwise. But once up she turned to the Index Medicus, the exhaustive listing of all articles published in all the medical journals.
Starting with the “most recent volumes and working backward, Susan searched for and extracted every article concerning acute coma and every article under the heading “Anesthetic complications: delayed return to consciousness.” By the time she had worked herself back to 1972, Susan had a list of thirty-seven prospective papers worth reading.
One title especially caught Susan’s attention: “Acute Coma at the Boston City Hospitaclass="underline" A Retrospective Statistical Study of Causes,” Journal of the American Association of Emergency Room Physicians, volume 21, August 1974, pp. 401-3. She found the bound volume containing the article and was soon immersed in it, taking notes as she read.
Bellows had to call her by name before she looked up at him. He had come into the library, located her, and had taken the seat directly across from her. But she did not look up from her reading. Bellows had tried clearing his throat with absolutely no effect. It was as if Susan were in a trance.
“Dr. Susan Wheeler, I believe,” said Bellows, leaning over the table, his shadow falling across the journal in front of her.
Susan finally responded and looked up. “Dr. Bellows, I presume.” Susan smiled.
“Dr. Bellows is right. God, what a relief. I thought for a moment you were in a coma.” Bellows shook his head up and down, as if he were agreeing with himself.
Neither one of them spoke for a few moments. Bellows had prepared a short speech during which he was going to correct any impression he might have given Susan that she was free to cut lectures. He had decided to tell her in plain language that she had to get her ass in gear. But once confronting her, sense of purpose failed, leaving him as directionless as a sailboat becalmed. Susan remained silent because her intuition had informed her that Bellows had something to say. The silence soon became mildly awkward.
Susan broke it.
“Mark, I’ve been doing a bit of interesting reading here. Look at these figures.”
She stood up and leaned across the table, holding out the journal so that Bellows could see the page. As she did so, her blouse fell away from her chest. Bellows found himself staring down at her splendid breasts, barely contained by a sheer flimsy bra, their skin of a smoothness Bellows imagined to be like velvet. He tried to concentrate on the page Susan was showing him, but his peripheral vision continued to record the insistent image of Susan’s lovely torso. Self-consciously Bellows scanned the library, certain that his preoccupation would be transparent to anyone in the room.