This happened when I was medical examiner in a rural county in Mississippi.
I was actually one of the first doctors to hold this position in the state. In 1865, physician-based health initiatives were part of the frenzy for science and technology that gripped the reunited nation. I was drafted into the Confederate army straight out of medical school, where I had been fascinated by the cutting-edge science of cellular pathology. Now I was excited about applying some real science to peacetime medical detective work.
I often thought about the Gettysburg Address, about America being founded on the proposition that all people are created equal. Science and its truths are the greatest equalizers. I wanted to bring my knowledge to promote health and justice for everyone, and especially the poor and disadvantaged.
Pedro and Maria Sanchez had come to our town from Lowell, Massachusetts as the engineers for the new textile plant. The factories that were springing up provided work for the returning Confederate soldiers and the former slaves who had chosen new opportunities. Pedro and Maria were an exotic, dark-featured young couple, deeply in love, and they had won the town's hearts. They always dressed in the traditional Spanish style, and taught the town's children phrases in their language. Pedro was amazing on his guitar, and when Maria started dancing with castanets or tambourine, scarf and ribbons flying, others would join in with her or at least tap feet. "Flamenco", they called it.
Today, Pedro and Maria sat in my surgery. I looked into their dark eyes. Both were teary.
"Mr. Sanchez. Mrs. Sanchez. I am sorry about your daughter."
Pedro looked back at me. He pushed his sombrero back over his brown forehead and thick, curly eyebrows. "Gracias. Thank you, Doctor. She was only five. She had always been sickly."
Maria lifted her veil and loosened the top of her dress. I gazed back at the stunning, dark-eyed beauty whose raven-black hair hung in ringlets. "Yes Doctor."
"I've completed the examination. Juanita's body is on its way to the mortuary now. I've also looked at some of the tissues using this instrument. It's the newest and most powerful microscope. Our little medical school on the Leaf River had several microscopes, and I started looking at blood and tissues there on my own. Since Rudolf Virchow's publication of 'Cellular Pathology' in 1858, we've all recognized that this is the key to understanding health and disease at a deeper level."
"Thank you", said Pedro. Maria nodded.
"I think I have the explanation. It's not in any textbook yet. I understand that Juanita was in her usual state of health until about thirty-six hours prior to her death. She had always had the yellowish color in her eyes, correct?"
"Since she was about six months old. Yes, Doctor", said Pedro.
"And she suddenly developed a fever, and a physician thought she probably had malaria."
"Neither Maria nor I have ever had malaria, though most of our friends have", volunteered Pedro.
"However, Juanita then developed a cough and shortness of breath, and despite all that the doctor tried, nothing worked. That was essentially what happened, correct?"
Pedro and Maria nodded.
"When I examined the lungs, they were solid, airless, and very inflamed. I touched a piece of lung to this piece of glass, colored it with hematoxylin and phloxine, the textile dyes, and looked under the microscope. Cells of the white series that ordinarily live only in the blood had invaded the lungs in great numbers, taking up the spaces meant for the air. They are called 'polymorphonuclear cells'. We don't know what they do, but often we find them in the lungs in deaths such as this one."
"We don't know why?" asked Maria.
"It's still mysterious. I also took a drop of Juanita's blood and looked under the microscope. Some of the polymorphonuclears contained tiny structures. They look like guitar picks in pairs, surrounded by a clear space. No one knows that they are. They might even be living things that cause disease."
"I see", said Maria. "Like the agents of infection that Dr. Oliver Wendell Holmes postulated in his article on puerperal sepsis?"
"Exactly, Ms. Sanchez. That was a great piece of work and 'The New England Journal of Medicine' became a premiere world medical journal thanks first of all to his publication."
I think that what I liked best about the times was how Reconstruction was bringing the nation's most scientifically literate people to the South. Our new president had asked at Gettysburg whether any nation conceived in liberty could long endure. The new factory directed by the Sanchez couple was a symbol for all of us. We were not just enduring -- America was thriving.
Pedro untied the bandana from his neck and dabbed his eyes. "But these structures -- living things, organisms if you like -- they must be all around us, and our bodies able to resist them. Why might Juanita have been vulnerable to this infection?"
"I think I know part of the reason. The other impressive finding inside the body was with Juanita's spleen. It was severely shrunken, almost gone. A tiny, mostly calcified scar."
"Madre de Dios," said Pedro. "I know that no one knows the true purpose or function of the spleen. But perhaps it is to protect us from these organisms. What could have happened to it?"
"Mr. Sanchez, I do have something to show you." I paused. "Here is Juanita's blood under the microscope. Oh, wait. Let me do this too."
I used what I learned in Year II pathology at Carey. I took a lancet out of the alcohol tray, drew my own blood, and pushed and dropper-stained a smear. "Take a look and compare."
The husband and wife took turns looking through the eyepiece and talked in Spanish. Finally, they turned to me. Maria said, "Hola, Doctor! Your red blood cells are round, like in scientific books. But many of Juanita's cells are shaped strangely."
"Some look like half-moons, or bananas, or knives", said Pedro. "That is 'muy' strange. Others look like bulls-eyes. And her cells seem less numerous, as if she was anemic. Perhaps that is why she became tired so easily. Could something have been destroying them and making her eyes yellow? 'Ictericia?'"
I explained what I'd learned from others. "This illness was known to the owners of the plantations. A child would be born of two healthy workers and seem well for the first year, then become jaundiced. They would always be weak, and would die young. They did best as house servants because field labor would kill them. They would suffer severe pains like arthritis at times, and they might develop leg ulcers that would not heal. Death was usually sudden." I paused. "I autopsied three such individuals in the past year alone. The blood shows these strange cells, and the spleen is gone. Just like poor Juanita's."
"Could the deformed red cells become entangled in the spleen and deprive it of circulation?" said Maria.
"That's what I suspect. I have showed this to my friends who have suggested the name 'sickle cell disease.'"
"It must be like jamming of a loom by bad thread. Does anyone know what causes it?" asked Maria.
"I have been told by friends of those who have died of it that these people's parents often seem unusually robust and resistant to the problems of Mississippi's climate. So I formed a hypothesis and have tested it, and found it confirmed so far. I wonder whether we might make a trial of this now. Maria, Pedro, would you be willing to have your blood examined?"
"Of course Doctor." Both nodded.
I took three more clean lancets out of the alcohol container. First I jabbed myself once again, and placed a blood drop on a clean slide. I took another dropper bottle and mixed a bit of chemical with the blood, then smeared and stained. When I lanced first Pedro and then Maria, I thought of our new President at his inauguration, and his hope that each drop of blood shed by the lash would not need to be atoned by blood shed on the field of battle. "This sodium metabisulfite is a good disinfectant in surgery, and has been tried as a fabric bleach too. It also seems to bring out the tendency to deform red blood cells in relatives of affected patients. Let's see." In moments, the three slides were ready.
I looked, and saw what I expected. Without saying anything, I showed the blood to the child's parents.
"Look, Maria, 'mi amor'. Our 'sangre' is different from the doctor's. We are carriers", said Pedro. Maria nodded. "Is there any way we could have known?"
"No way in the world, Mr. and Mrs. Sanchez. I am terribly sorry for your loss. I am going to publish my results so that others can know. This is a fairly common illness here in Mississippi. Dr. Virchow didn't discover it because it's evidently not recognized in Europe."
"A single dose gives strength, perhaps resistance to malaria, but two doses cause sickness and death", said Maria. "It is Charles Darwin's natural selection in action. Poor Juanita has paid the price for our good health."
I had read "The Origin of Species" when it was published in 1859. Again, it had troubled me but it explained a lot. I had not thought of this. But it made sense.
"Doctor, thank you. We will probably have more questions", said Pedro.
"We will want to follow your scientific work", said Maria.
I have stopped trying to understand people. I already admired the couple for their achievements, and what they were doing for the community. I simply looked at them for a minute, and then I could not help but ask.
"Maria, Pedro. It was an honor to be asked to find the cause of Juanita's death. Yet you are so composed, so thoughtful, so brave. You seem to already have accepted a loss that would devastate most parents. What is the source of this strength?"
Pedro paused and shook the front of his poncho for a moment. "We will tell you, 'Amigo.' Maria and I have an idea."
Pedro glanced upwards. "The universe is a very big place. We see only the tiniest portion. Even the planet Neptune remained unknown only two short decades ago. I read in school about how Immanuel Kant showed that the Milky Way is only one of many -- what did he call them? -- 'island universes'. Each would contain hundreds of thousands of stars. The cloud in Andromeda may be another such place, and perhaps these -- what are they? -- 'galaxies' is the word, no? -- are themselves as numerous in space as the stars are in our own Milky Way. And the other stars in all these places are not much different from our own sun. If stars form by accretion of particulate matter, then most should have planets, solar systems like ours, and among them other earths inhabited by living beings. I recently read a popular essay by none other than Edgar Allan Poe, the fiction writer, about how large the universe must be. It is unimaginable."
Pedro held out his hands to me. "That's the scientist and engineer in me. But my dark-skinned wife is a Spanish gypsy and I will let her explain the mystical."
Maria wiped her eyes, smiled, and shook her black curly hair. "The universe may even be infinite. That would ensure that what we are experiencing here is paralleled on many different earths, by people who are us or nearly us, but with each possible outcome realized somewhere. Every good thing that can happen, does happen somewhere out there. Even if a child sickens and dies on one world, we can be confident that same child lives and is healthy and happy on some other. "
Pedro nodded. "It does make sense in a way. She says she's certain of it."
Maria continued, "The same would go for everything else. If a battle goes badly in one world, in another the good people win. If an injustice happens anywhere, somewhere else the amends are surely made. And even for the greatest wrongs that we experience, somewhere else someone has the wisdom to prevent or make right."
"That's what Maria believes", said Pedro. "Parallel worlds. Again, I don't know. But it gives us strength. Gracias."
I wasn't sure how I felt about all this. The talk of vast distances made me think uncomfortably of my own limitations. Finally I said, "Thank you for that. This too is a new idea for me." I hesitated. "Maria, Pedro. There is something else that we could talk about, if it's all right."
"Sickle cell disease, and probably the carrier state, are only known so far in people of African descent."
The couple pulled closer to me and leaned forward. Pedro said softly, "You are a good man, our 'amigo'. I am Peter Smith, an octoroon, one-eighth African. My wife was born Mary Ryan, a quadroon, a quarter slave blood. We cherish both sides of our heritage. We have always lived in Boston's community of free persons of color."
I had suspected this since I'd met the couple. "Your secret's safe with me. It's simply wrong that 'one drop of blood' should ever have made any American a second-class citizen."
"We actually are both fluent in Spanish, and pretending has been so much fun that it's almost real", said Maria. "But tell me, Doctor. Do think that today's scientific literacy will dispel all the nonsense and wrong ideas that were used to justify slavery?"
"I expect that when the ordinary people of Mississippi meet in our factory, they will discover that they're really all alike. We won't even need scientists to tell us this."
"That's my hope as well", said Maria. "And I was thinking about something. After Robert E. Lee's victory at Gettysburg, he was able to appeal to both sides on behalf of peace, reason, and common sense. He spoke for every American who knew slavery was a dying, evil institution, and that our hope was sound economic policies for our changing world instead of short-sighted greed. If the Union had won the battle, and President Lincoln had delivered the Gettysburg Address instead of General Lee, people would never had accepted it even though he and Lee shared the same humanitarianism. And the war would not have ended as it did."
I shook hands with Pedro and kissed Maria on the cheek. I planned a formal study to put my ideas about "sickle cell anemia" on a really scientific basis. While the greatest benefits to humankind come from science, those who govern have a responsibility to make it possible. I thought of the words of President Robert E. Lee at his inauguration, that we would work for a better future "with malice toward none, with charity for all, with firmness in the right as God gives us to see the right".
If there are indeed parallel worlds where history plays out in different ways, I hope this is the final outcome everywhere.
Reference: Graham JK; Mosunjac M; Hanzlick RL; Mosunjac M.; Sickle cell lung disease and sudden death: a retrospective/prospective study of 21 autopsy cases and literature review. American Journal of Forensic Medicine & Pathology. 28(2):168-72, 2007 Jun.
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