by LaGreca, Gen
Chapter 4
The New Frontier
To serve the public interest above all other concerns—this is the noble work of medicine. David Lang read the gold inscription over the entrance to the Manhattan offices of the Bureau of Medicine. His eyes dropped contemptuously to the name under the quotation—that of the secretary of medicine.
In the serpentine lobby of the old brick building, he passed a mural of Antoni van Leeuwenhoek peering through his magnifying lens in a moment of discovery. Leaning against the picture was the ladder of a maintenance man who was changing a lightbulb. In the center of the lobby stood a statue of Joseph Lister gazing into a test tube. Propped against its legs was a makeshift sign with directions to the information desk. A white marble tablet in the floor displayed the etching To the independent mind that is the wellspring of science. The mural, the statue, and the tablet were the remains of a bygone era when the building was home to a distinguished medical school. David recalled hearing of students being required to walk around the tablet, with the placement of one foot on the inlay being grounds for punishment. Despite the building’s history, countless shoe prints now scuffed the inscription, the letters rounded from wear. As was his practice, David walked around the tablet. Riding the elevator to the Department of Medical Research, the man who spent more time in the OR than at home felt that it was he who was now out of step in this building dedicated to medicine.
He arrived at a small, austere conference room whose gray walls and fluorescent lighting were as cold as the seven people sitting around its oval table. They comprised the committee that would determine the future of his research—and of his life, he thought uneasily.
Rising to greet him was the head of the committee, a petite, businesslike woman in her forties, Dr. Alice Cook, the director of medical research for the BOM. The shorthaired and long-waisted Dr. Cook, fashionably clad in a blue suit, introduced David to the other members. With sweeping hand gestures and a measured voice, she seemed to enjoy lingering in the moment of having control over the fate of another. In an effort to establish what she liked to call a partnership with the community, she included in her group laypeople as well as health care professionals. Thus, she presented David to a research scientist, a public-health administrator, a retired gynecologist, a minister, a manufacturer, and a homemaker.
When everyone was seated, Dr. Cook walked to the podium at the head of the table and read from David’s curriculum vitae: “Dr. David Lang is a practicing neurosurgeon and a professor at West Side University Medical School. He has published dozens of papers and lectured internationally. He seeks permission to complete a research project he started years ago.” She turned to him cordially. “Dr. Lang, please tell us about your project.”
The man who approached the podium looked too young to possess the lengthy vita before Dr. Cook, except for an air of quiet confidence in his bearing. The aesthetic lines of his face made him seem too pure to deal with blood and death, but a ruthlessness in his eyes suggested that he could absorb such shocks. The silk suit he wore appeared too elegant for the grisly work of a surgeon, yet its tailored lines implied a laser-sharp focus on business.
“Thank you, Dr. Cook. Good afternoon, ladies and gentlemen.” On a small table beside the podium, David rested a soft leather briefcase that he had brought. Eyeing the laypeople in the group, he decided to explain his work in simple terms. “My research centers around the thing that makes humans the supreme creatures of the world, characterized by remarkable feats and endless progress, from the cave to the skyscraper, from the wheel to the rocket, from the campfire to the power plant, from the stone tool to the computer. This thing makes humans superior to other animals because we alone can understand the world and harness the powers of nature to control our destiny. This thing is the most exquisitely complex object known, housing the massive power of two hundred billion cells engaged in countless electrochemical reactions, yet it is nothing more than a three-pound gelatinous mass that fits in the palm of your hand. It is, of course, the human brain.
“It might seem that the most powerful device in the world should be hard and indestructible, but the opposite is true. The human brain is soft and delicate. A blow could crush it; a germ could destroy it; a block in one of its arteries could choke it. Perhaps nothing needs and deserves protection more than the vulnerable human brain. A neurosurgeon is the man or woman who is the brain’s defender.”
Like the megalithic statues David had seen on an ancient island, the entities before him seemed to possess huge, lifeless heads atop short stumps for bodies. He tried to dismiss the vision that his future depended on reaching the unreachable.
“The billions of cells in the human brain comprise its intricate governing body, the central nervous system. This system holds the key to the brain’s power—and also to its weakness. This nerve tissue ultimately makes possible every thought, movement, and process of the body. But however remarkable it may be, centuries of research and millennia of suffering demonstrate one thing this tissue can’t do. It can’t regenerate.
“When skin rubs off, the body makes more. When you lose blood, the body replenishes it. If you break an arm, the bone grows back. But what if a stab wound to the head severs your optic nerve? The nerve’s function is lost forever. What if you suffer a stroke? To the extent that the cortex is damaged, you will never again be yourself. What if you fall off a horse and injure your spinal cord? Because the spinal cord is an extension of the brain and has the same nerve tissue, the broken fibers will not reattach, and the movement they controlled will be lost forever.
“At birth, the brain and spinal cord essentially contain their full measure of nerves, each fiber like a strand of gold in a bank that permits only withdrawals. This is what makes nerve tissue precious and the brain vulnerable. Damaged nerves cannot be replaced; their assets are lost forever.”
David could read nothing on the faces of his audience. The group neither took notes nor yawned but merely listened dutifully.
“The suffering caused by the refusal of the nerves to regenerate is gut-wrenching. Every neurosurgeon dreads finding an injured teenager in the ER, completely and permanently paralyzed from the neck down, unable even to breath on his own. The only thing the kid can do is stare at you and cry, except when sleep brings a temporary reprieve to him—and to you.
“So much misery is endured because nerve cells won’t grow. They once grew like crazy, at the rate of almost a million per minute during the entire prenatal period, when a few starter cells create the majestic human nervous system. After birth, however, this self-generating capacity of the nerves is lost.
“Some primitive species do regrow damaged parts. If you cut off the leg of a crab or the arm of a starfish, the animal makes another. These simple creatures seem more hardy than humans because their injured parts grow back.”
David felt the chill of unquestioning eyes politely following him as he paced slowly before the group. Why did he suspect that the committee’s conclusion was foregone and his performance merely a formality?
“If we could recapture the priceless capacity for nerve growth that we had before birth, we’d cross a new frontier. Victims of paralysis would discard their wheelchairs and skip across that frontier. But the problems are formidable. I’ve grappled with them for seven years. First, the nerves of the brain and spinal cord won’t grow; if you put two severed ends together, the nerves won’t extend to fill the gap the way broken bone tissue would. Then, scar tissue grows at the lesion site, causing a serious, further impediment.
“Considering how complex nerve tissue is, we can appreciate the difficulty of regeneration. Take the optic nerve, which carries impulses from the eye to the back of the brain, producing vision. This nerve consists of over a million fibers. It’s like an unbelievably complicated cable containing a million wires, each color-coded with unique shadings and hues. When the cable is cut, each of the million wires on one side of the break must find its own severed end on the other side in order for the
cable to work again. The nerves seem as baffled by this task as the researchers.
“But today I can tell you a secret . . .”
The secret crying in David’s mind lured him like the music of the mythological Sirens, whose haunting songs ensnared all listeners. He forgot the audience, the BOM, the many obstacles plaguing him. His voice rose excitedly.
“The secret is that everything I told you is false.”
He paused for water, the last word lingering in the air.
“These nerves will grow. They’ll overcome the scar. They’ll find their mates. And the horror of nerve injury will join the black plague as a forgotten nightmare of the past!”
The exalted vision of such a future radiated on the surgeon uttering the words.
“A lot remains to be done: more animal experiments, then human trials. However, my recent experiments show that we can regenerate the central nervous system and restore lost function.”
David’s pace quickened. He seemed unable to stand still.
“I discovered a protein in the nerve tissue of mammalian embryos that disappears after birth. It holds the secret of growth. When injured adult nerve is treated with this embryonic growth protein from lower animals, the tissue acquires a most extraordinary power to regenerate.
“Regarding the other hurdle, the barrier created by the scar, I isolated a substance that inhibits the scar from forming. Unfortunately, this substance also stops the new nerve from growing. However, the problem can be treated in two stages—that is, with two surgical procedures: one to regenerate the damaged nerve with the growth protein and the other, three months later, to remove the scar tissue produced and prevent any more from forming by treatment with the scar inhibitor. I have a presentation that demonstrates my study.”
He removed from his briefcase a laptop computer, connected it to equipment in the front of the room, and projected an image onto a screen behind him. Someone dimmed the lights as he started the presentation. The first scene showed him in surgical garb standing over an anesthetized cat on an operating table.
“Here you see a complete transection of the spinal cord.” His trim form was silhouetted in the darkened room as he narrated the scenes. The camera showed him cutting the cat’s spinal cord.
“The first surgery is to reattach the severed nerve ends . . . ” A camera on David’s operating microscope showed him suturing the nerve ends together.
“ . . . and to implant the growth protein at the lesion site.” He positioned a capsule filled with a liquid at the point of the injury. “The growth protein is administered through a timed-release capsule that will introduce a continuous stream of the substance over a three-month period. The nerve tissue should then be fully regrown, and the empty capsule remaining will biodegrade and be evacuated by the body.”
Next the screen showed the cat after the surgery. “As you see, the spinal cord transection left the cat’s hind legs paralyzed.” The poor creature struggled to move, powered only by its front quarters, dragging two hind legs like lead weights.
“During the three-month period after the first surgery, partial function will be restored as the nerve tissue grows back.” The next scene showed the cat still using its front quarters to drag its body around, but now the hind legs moved, too, although the motion was limited and insufficient to enable the cat to stand.
“There will come a time when the partial restoration of function peaks. After that, it retrogresses because the growing scar tissue becomes an impediment.” The cat on the screen showed less movement of its hind legs than before. “Without the second surgery, the interference from the scar tissue increases until the restored function is lost completely, leaving the victim no better off than before the first surgery.”
The scene changed to the OR, where David prepared to operate on the cat’s spine. “The timing of the second surgery is critical. It must be done after the nerve has grown and before all of the recovered function is lost to scar tissue. If the cat’s hind legs retrogressed to full paralysis again, the loss of function this time would be irreversible.”
Onscreen, David began the second surgery, with the camera showing a magnified image through the operating microscope. “You can see that the nerve ends have grown back together. There is no more break where the cord had been transected. However, you can also see why the repaired nerve tissue can’t function. It’s entangled by the scar. Now I’ll remove it.” Small, shiny tools delicately cut away the scar, bit by bit, avoiding the repaired nerve.
“This next shot, taken hours later, shows that the scar has been completely removed. The nerve tissue is now freed.” The audience saw clean, glistening nerve tissue at the surgical site.
“I will inject some of the scar inhibitor over the nerve,” he said, as a needle dispersed a liquid over the area, “and implant the rest in another biodegradable timed-release capsule. The scar loves to grow back and tangle with the nerve. However, the prolonged presence of the inhibitor from the capsule will keep scar from ever again appearing here, so this nerve tissue will remain unobstructed.
“After the second surgery, the cat can walk again. Here it is a month later.”
The screen showed David playing with his furry patient. It ran and jumped with the energy of a kitten. A lively spirit had returned to the little creature. It seemed thrilled by its own bold leaps, performed effortlessly—thanks to the full use of its hind legs.
David stopped the presentation, and someone raised the lights. The expression that the committee saw bore the glorious contentment that results when a three-pound gelatinous mass harnesses the power of nature to control its own destiny.
“Ladies and gentlemen, this is the new frontier. This is the research that I must complete. . . . Thank you.”
Dr. Cook raised an eyebrow, as if David’s final words had overstepped the line from a request to a demand. The surgeon ignored her glance as he slid his computer back into its case.
Like an accused awaiting a jury verdict, David was escorted to an outer area while the committee deliberated. Minutes later, Dr. Cook retrieved him. Her unsmiling face foretold the verdict. She stepped behind the podium, as if to maintain a barrier between her and the green eyes staring insolently from a seat at the table.
“Dr. Lang, after careful consideration, the committee finds that although your work is valuable, it regrettably falls outside the scope of our more pressing social needs. Many people now question the wisdom of spending large sums for the benefit of a small minority when the majority funding universal health care has other concerns. We must weigh the relative value to society of offering one ground-breaking surgery to the few individuals needing it against providing, for example, one thousand pairs of contact lenses to those needing better vision.”
She paused as if expecting a polite nod from David but received none.
“You know, of course, that your research has been attempted by countless others and always ended in failure, despite the initially promising outcome of a few isolated experiments. I’m afraid we have a responsibility to allocate public funds for projects benefiting more people and having greater chances of success.”
David scanned the faces of committee members, who nodded in agreement. Like a jury in the presence of a judge, the others let Dr. Cook do the talking.
“Unfortunately, our budget is limited, and for every project we approve, there are twenty we must decline,” Dr. Cook continued. “However, we want to thank you, Dr. Lang, for the opportunity to consider your research. Please feel free to submit other proposals to us. And we wish you success in your career.”
Dr. Cook smiled, but David did not return the courtesy.
“Frankly, Dr. Cook,” he said, his voice solemn, his eyes intense, “I don’t want the public to fund my research. I don’t want to have to fit in with what this committee thinks it needs or feels will succeed. I just want to be left alone to finish my work. I want to procure laboratory animals and conduct experiments at my own expense or with the aid of investors as a pri
vate venture. I’m prepared to do that. Now if my work doesn’t cost the public a dime, then this committee should not have the power to object.”
“But we do have that power, Dr. Lang. You know the law,” replied Dr. Cook. Her voice remained coolly polite, despite the flush that formed on her cheeks. “Animals are protected. Their use in research is limited to projects approved by the state. We can’t allow anyone who feels like it to butcher animals. That wouldn’t be humane.”
“Is it humane to squash seven years of research and stand in the way of progress?”
“It’s not progress, Dr. Lang, when researchers go off half-cocked and are unaccountable to society,” said Dr. Cook, her voice rising. “To conduct animal experiments without the proper authorization would be a serious infraction of the law.”
One person folded his glasses into a case; another reached for her purse. Dr. Cook gathered her papers. The meeting was over for all but David.
“Where does that leave me and the thousands of patients who would want my new procedure, Dr. Cook? Would these patients think it humane of you to spare the animals and prevent me from properly testing the treatment on them first?”
“You know perfectly well that I don’t mean you can experiment on humans instead. You first have to complete the animal trials.”
“But thanks to this committee, I can’t do the animal trials!”
“To perform your procedure and use your untested drugs on a human subject without first obtaining exhaustive animal studies and the proper regulatory approvals could expose you to serious consequences, Dr. Lang, including loss of your license”—Dr. Cook’s voice dropped—“and even charges of manslaughter. Consider yourself warned.”
David sprang from his chair and approached the podium to retrieve the briefcase he had left there. He walked unduly close to the petite woman, his tall form towering over her, his face hot with anger, his voice heavy with contempt. “Seven people sitting in a room don’t have the right to tell me how to do my work. Seven people don’t have the right to deny thousands of patients a treatment they’d want to have. Seven people can’t run medicine for the rest of us, Dr. Cook!”
