PROFILES

HYPER OR HYPO?

S. N. Behrman
The New Yorker
 April 8, 1939: 23-29

On his sixtieth birthday, a few years ago, the "pupils, friends, and colleagues" of Dr. Emanuel Libman undertook to pay him a tribute. There was a dinner party at the Waldorf with speeches, but the occasion elicited from Dr. Libman's friends a more enduring memorial than the pleasantrie, of after-dinner congratulations. Eminent doctors all over the world who had either been pupils of Dr. Libman or had been influenced by him or admired him were asked to contribute articles in their respective fields to be presented to Dr. Libman on his birthday and to be known as the "Libman Anniversary Volumes." The editorial committee, in its introduction to the books that resulted from this invitation, apologizes that "material limitations rendered it impossible to publish the contributions of all who desired to voice in this way their admiration and friendship." Nevertheless, enough got in to fill three closely and beautifully printed volumes. Scientists from England and America, from France and Germany, from Italy and Norway, from Japan and Sweden put their best foot forward: 147 savants cover 1,284 pages with alembicated thoughts on their specialties. The authors listed in the table of contents constitute a scientific Almanach de Gotha: Alexis Carrel and Albert Einstein, Lord Horder and William H. Welch, Harlow Brooks and Alfred E. Cohn, the Mayo brothers and Östen Holsti. Ryokichi Inada has written about "The Disturbances of the Circulatory System in Beriberi," Pierre Lecomte du Nouÿon "The Biological Problem," Jonas S. Friedenwald on "The Pathogenesis of Albuminuric Retinitis," Cesare Pezzi on "The Radioscopic Sign of the 'Hilum Dance,'" F. J. Poynton on "The Dawn of Heart Disease in Childhood," Professor Achard on "La Maladie des Cardiaques Noirs." The late Dr. William H. Welch, probably the greatest figure in contemporary American medicine, in his introduction to the anniversary volumes said that they reflect "in a most impressive manner the character and variety of the fields of medical science and art cultivated by Libman, his international reputation, and the wide extent of his professional and human contacts and influence."

The subject of the "Libman Anniversary Volumes" is a bachelor. Since 1889 he has lived in a narrow four-story brownstone house at 180 East Sixty-fourth Street. The Doctor is proud of the antiquity of his house; he will seize you by the arm, take you to the front windows on the fourth floor, and make you look back through the hall and his study to the windows facing on the garden. The line is not true. The house curves somewhere along its middle, and this architectural eccentricity Dr. Libman cherishes. With him live his sister and two nephews. The nephews are twins and so alike in appearance that you can hardly tell them apart. Both did well at Johns Hopkins and have lately been appointed to interneships at Mt. Sinai. Dr. Libman has very Spartan ideas about the bringing up of these young men. When other people are there, he will pass his nephews in the hall of his house, without greeting them, and none of his friends have met them. While they were at Johns Hopkins hardly anyone knew of their relationship to Dr. Libman, but although he never speaks of them, he is probably proud of the fact that they have come along entirely on their own. "Young people," he says, "should work in the dark." For their sakes, he does not want people to think that they have traded on his position.

The waiting rooms and consultation offices on the ground floor have the sobriety and the steel engravings of porticoed ruins and bearded dignitaries characteristic of most doctors' offices. You get perhaps the first hint of the Doctor's unorthodoxy when you discover that he has added to the gallery of distinguished medical men that line the walls of his inner sanctum the portraits of several distinguished patients. Hanging with Koch and Pasteur, with Welch and Janeway, are Sarah Bernhardt and Albert Einstein. The dramatic portrait of the Divine One, whom Dr. Libman attended in her last illness and whom he adored, has a florid and affectionate inscription in French; the one on Professor Einstein's reads in German: "To the noble-minded Dr. Libman with the secret-divining eyes."

Professor Ludwig Aschoff, generally considered the world's leading pathologist, who contributed "Uber den Enterokokkus Libman" (the streptococcus named after Libman, its discoverer) to the anniversary volumes, tells how much he was impressed by Libman's "infallible physician's eyes" when he first met him at Mt. Sinai. It is undeniable that Dr. Libman is one of those individuals who convey instantaneously a suggestion of genius, and it is probably chiefly due to his eyes. They are gray, clear, and penetrating. He is a small man, about the size of Toscanini or Napoleon, with both of whom he has elements in common: authority, great mobility, and colossal memory. His skin is dead white and his flatly brushed hair is silver. His gray mustache is neatly trimmed. His fingers are long, youthfully supple, and active. He fixes you with a falconlike, darting look—a mercurial ghost. The diagnostic sixth sense, the ability to sniff disease, the accurate, swift generalization are facets of a temperamental inability to do anything slowly, a highly charged and incessant volatility. Those who disbelieve the Libman legend derogate this quickness, as the temperamentally slow inevitably suspect the temperamentally fast, and the epithets "superficial," "guesswork," "flamboyant" have often been applied to Libman's lightning diagnostic method. But those in a position to know will tell you that Dr. Libman's knowledge in every field of medicine is encyclopedic and his memory phenomenal. He has read everything and remembers everything. He will see a patient whose father he treated thirty years before and tell the son details of the father's illness which the son had forgotten or never knew. He is the last of the old clinicians like Janeway and Delafield, who were consultants before the human body had been zoned and subdivided by the departmental specialists. He is equally at home with the bacteriologist, the clinician, and the pathologist. This universality in Libman's knowledge is stressed by his partisans. These, indignant at the imputation of superficiality, say that Libman is one of the few men who check the references printed at the end of each scientific paper to see whether they are accurately quoted. Such papers are sent to Dr. Libman by the hundred from all over the world. Dr. Carrel mice said, "In the same manner as Claude Bernard personified physiology, Libman is medicine itself."

Libman has a tremendous admiration for Dr. Carrel and sees him occasionally but, as he says, sparingly, because he considers Dr. Carrel's work too important to be interrupted and feels that his energy should be saved for his research rather than dissipated in social amenities. Once in a while Libman also visits Dr. Einstein in Princeton. Among Libman's limited list of friends are some who are also patients, such as the Eugene Meyers and the George Backers. They all call him Libby.

In Washington some years ago, Dr. Libman was invited to a dinner attended by President Harding. The story goes that the following morning Libman called up Eugene Meyer and said, "Who is Vice-President?" When Meyer expressed surprise over this sudden interest of the Doctor in miner officialdom, Libman explained, "Because whoever he is, within six months he will be President. The President has a disease of the coronary arteries." And so it came to pass.

Dr. Libman is supposed to have an uncanny instinct that tells him whether a patient will survive an illness. In examining a patient, he pays close attention to symptoms likely to escape the superficial observer: color and expression of the face, posture, odor, pigmentation, the breathing, the speech, clubbing of the fingers, tenderness over the sternum, and other manifestations. It is said that once on entering a hospital ward he sniffed and said, "I smell typhoid here." It turned out that a patient just brought in was in the early stages of that disease. Another time he "smelled" a case of gas-bacillus infection. His uncanny instinct for color and smell in disease leads him often to impromptu diagnoses when he is off duty. As when he peered at a mother-and-child painting by an old master in the drawing room of a millionaire friend and proclaimed, "Rickets?" On another occasion, so the tale runs, he came up close to a tall Van Dyke and declared that the bearded immortal hanging there undeniably suffered from subacute bacterial endocarditis, a disease which it remained for Osler and Libman to discover some centuries later. Often, at a movie, Dr. Libman will dim somewhat the irradiation from a glamour girl by telling you that she is working up to pernicious anemia. One day, while he was lunching with Belle Greene of the Morgan Library, the waiter became maddeningly inept, misplacing dishes and forgetting orders. Miss Greene was irritated. Dr. Libman mollified her. He explained to her that the waiter was suffering from an obscure disease that made him momentarily unable to coördinate—he would be all right by the dessert. He was.

Very early, Dr. Libman became known as a remarkable diagnostician. A paper of his on the dread disease subacute bacterial endocarditis has become a classic. Doctors will tell you that if he had done nothing else in his long career, this paper alone would assure him of immortality. The disease, observed and described by many, was first firmly established as an entity by him and is therefore also known as Libman's disease. Though many bacteria may be the cause, streptococcus viridans is the most common. It took tremendous patience to prove that this bacteria invade the endocardium, the lining of the heart, where they cause irreparable damage. To make a positive diagnosis of this disease is generally possible only when the bacteria are found in the blood stream, but it is said that Libman can do it without such evidence and that in many cases post-mortem findings proved him to be correct.

In later years, working almost entirely as a diagnostician, he has become absorbed by the distinction between patients who are under- and over-sensitive to pain. For this, he has devised the Libman test: he presses or pokes the patients (most often without warning) with the thumb just under the ear, in the mastoid region, and from the response he grades the patients as normals, or as hypo- or hyper-sensitives. In his paper "Observations on Individual Sensitiveness to Pain," he has some interesting things to say about the courage of Indians, for example, who are usually not very sensitive to pain. He had a study made of leading pugilists and found that 97 per cent were hypo-sensitive. "The pugilist," he wrote, "suffers from shock, usually not from pain."

The Eugene Meyer chauffeur, a middle-aged stalwart of Irish extraction, was astonished one day, while he was holding the door for Dr. Libman, when he was suddenly given the Libman test behind the ear. "If it wasn't that I knew he was a great friend of yours, Mrs. Meyer," he said later, "I'd have let him have it." The chauffeur, it seems, was hyper-sensitive.

To the patient who happens to be "hyper," the introduction to the Libman test may be disconcerting. Oscar Levant, who is no respecter of persons, wished to have Libman look him over and was introduced by one of the Doctor's patients. The composer entered the room, and before he could get across it to shake the Doctor's hand, Libman whispered to the intermediary who had arranged the meeting, "Enlarged gall bladder." The introductions over, Dr. Libman promptly poked the unprepared patient behind the ear. As the composer happens to be "hyper," he fell into a chair, speechless. When he got his breath, he looked up at Libman and said, "Professor, you and I are through!" This arrangement was entirely satisfactory to Dr. Libman, who is really interested only in difficult cases, and he permitted the conversation to drift to general topics. This did not finally satisfy the composer, who, recovering from his shock, pleaded with Dr. Libman to resume his examination. "Give me," he begged, "some of that famous sixth sense of yours." Dr. Libman preferred to go on chatting about this and that. The meeting ended pleasantly enough with the composer taking Dr. Libman off to Lindy's, a restaurant not hitherto patronized by the author of the classical paper on subacute bacterial endocarditis.

Libman tells endless stories of his medical practice. There was the woman to whom he was forced to say that her child had syphilis and who cried out ecstatically, "Thank God! I thought it was measles!" Another is about the East Side colleague who sent him a heart case. Dr. Libman examined this patient and saw that he was hopelessly ill. He dismissed him and instructed his wife to take him home at once and put him to bed. He would telephone the family physician later. The patient departed. Dr. Libman telephoned the man's physician at the end of the day. It was a time when the standard of medical education was much lower than it is now. "Your patient," said Dr. Libman, "has coronary thrombosis." "He has vot?" inquired the bewildered doctor. Libman repeated the name of the disease. "He has coronary vot?" Irritated at his confrere's illiteracy, Dr. Libman abandoned the formalities. "Anyhow, he is sick," snapped Dr. Libman. "No, he isn't," came the imperturbable reply. "He's very sick and he's going to die," insisted Dr. Libman. "He vouldn't. He did!" shouted the East Side man.

Then there was the rich though not overliterate patient who called for an appointment and was told that the fee would be ten dollars, He came in and was examined. As his ailment was negligible, the fee of ten dollars appeared staggering to him. Dr. Libman was firm. "Tell me, Doctor," demanded the patient, "are you really such-a-much that you charge ten dollars for nothing?" Dr. Libman admitted that he was. "Since how long are you such-a-much?" "About four months," said the Doctor. "Four months! That's not long enough for ten dollars. Please, Doctor, write yourself a check for seven dollars."

A patient visiting Dr. Libman for the first time is likely to find his method of examination bewildering and incoherent. To go through such an examination is quite worth the price of admission. After he has given you the Libman test, he will jump from one part of the body to another, tapping hard in one place, lightly elsewhere, pulling down eyelids, pressing under ears, running his thumbnail across the chest. His eyes shift everywhere, his movements are jerky, his speech rapid, his questions staccato and continuous, with no time out for answers. It is only when he reaches auscultation (listening through the stethoscope) that his tempo becomes slightly legato. Then, as like as not, the telephone rings. Someone wants Libman's advice about a student who has been sent to Europe with money from the Emanuel Libman Fellowship Fund, set up some years ago in his honor by patients and former pupils. "I cannot," you hear Libman say, "take the responsibility of sending that young man to Istanbul. However, I've been thinking about him. I have a feeling he should go to Vienna." (This was in the good old days.) He returns to the thumbnailed torso, acquiescent on the sofa, taps and pokes, asks a few more questions without waiting for the answers. The telephone rings again. This time Dr. Libman only listens. He returns, picks up a derby, and claps it on his silver-gray head. "Sorry. Have to go to Brooklyn. Very interesting case—suppuration behind the ear." And he is gone. You get up to put your shirt on, disturbed by the suspicion that without suppuration behind the ear you are an egregious bore.

On another day you may undergo further tests, and if by this time you are lucky enough to have in some degree won Dr. Libman's confidence, he will take you upstairs to the third floor of his house and invite you to hear a record. He is very proud of his records and his phonograph and his piano. He will put on a record, start it going, make a remark about its special soul-searing quality, be seized with impatience, stop the record, and put on another. It has yet to be chronicled of any of these impromptu Libman musicales that he has let a record play through to its end. He will put on in fairly rapid succession ten to fifteen records and give you a brief sample of their quality, or at a still more advanced stage of intimacy he will take you down to the second floor, sit at the piano, and tell you that he would like to give you a little selection of his own. He will then play a part of a short piece by Beethoven, stop abruptly, and promise sometime to let you hear a record by Hofmann of this same piece. You return to the examination room. The mail has come in. There is a long envelope, which he opens feverishly. He shakes out a letter and a check. "Just what I've been hoping for," he announces triumphantly, "a check for ten thousand dollars. Gift from a patient. Now I can give that medical library some books they need badly." He is at the telephone calling the hungry librarians.

Dr. Libman asks you to go with him to a consultation. You walk down Sixty-fourth Street. He is smoking a cigar in an amber holder. The holder drops and breaks in two. He is devastated, because the holder, it turns out, was given to him by a priest who came to him with a disease of the coronary arteries. Dr. Libman has long had the idea that there is a relation between this disease and gout. He has noticed that groups that get one get the other. The priest developed a gouty toe and Dr. Libman is enormously grateful to him for this coöperation.

As Dr. Libman is in a hurry to reach his patient, you hail a taxi. This he waves away impatiently. He walks on for several blocks and finally points to a taxi on a corner. "This is the one I want," he says, and gets in. You drive to the Drake Hotel, Dr. Libman talking incessantly about gout. At the Drake, he asks the taxi to wait outside and you to wait in the lobby. Forty minutes pass. Dr. Libman reappears, but the taxi-driver, for the moment, has disappeared. You ask Dr. Libman why he asked the driver to wait in the first place. "He is, as a matter of fact, not very efficient, but he has dizzy spells," Dr. Libman says. "I once took a trip with him and he waited for me an hour. I thought that was nice, so since then I always use him and ask him to wait. Would you like to see a wonderful collection of kidneys?"

Before you can express your delight at this prospect, the ailing taxi-driver has turned up and Dr. Libman has ordered the man to drive to the Academy of Medicine at Fifth Avenue and 103rd Street. It is after midnight. The attendants stiffen and almost salute as he appears. Dr. Libman passes rapidly down the marble corridors. You go into a great room, the walls covered with row upon row of glass cases containing kidneys. Dr. Libman's sharp eyes run down the rows of cases. He raps on one of them. Evidently this particular kidney has some special pathological distinction. He looks at you and you make a feint at sharing his appreciation. "Come, I'll introduce you to Dr. Martland. He's done wonderful work. This exhibition couldn't have been got together without him." He takes you into a room where three doctors are bending over specimens, carefully printing tags for them. Dr. Libman is greeted with the deferential joy that might meet the Duke of Windsor at a Long Island houseparty. Dr. Libman listens to complaints about the inordinate demands from various institutions for space in this exhibition. There is simply no room for all these kidneys and Dr. Martland will have to draw the line someplace, Libman advises. At one-thirty, he tells Dr. Martland to stop working and says goodbye to his colleagues, promising to appear at the opening of the exhibit on Monday. Fifth Avenue, after these humid chambers, is cool and refreshing. The dizzy taxi-driver holds open the door for him. "I've got to go back to the Drake," says Dr. Libman. "Got to see that patient. Nothing to be done for him, but it will make his wife feel good."

Dr. Libman was born in New York City in 1872. His father, Fajbush Libman, was a picture-framer of fairly comfortable means who lived to see his son's rise to prominence. Emanuel was educated in the public schools and got his A.B. degree from the College of the City of New York in 1891. Three years later, he got his doctor's degree from Columbia. Of all his teachers at the medical school, Dr. Delafield, who later became his friend, made the profoundest impression on him. After graduating from Columbia, Libman became an interne at Mt. Sinai. One of the attending physicians was Dr. Janeway, who also was an inspiration in his professional life. At this period Libman fell under the influence of the great Dr. Jacobi and became interested in the study of pediatrics. In 1896, he went abroad for a year of graduate study in Germany and Austria. The matrix of his scientific future took form during a period of three weeks that year, three weeks spent in Graz under Professor Escherich, an outstanding authority in pediatrics. It was here that Libman undertook a bit of experimental research—a study of streptococcus enteritis in infants, the results of which he published in 1897, when bacteriology was a very young science. It was during this period and this work that Libman's interest in blood cultures and the study of streptococci began.

The universality of Dr. Libman's knowledge, clinically, of pathology and bacteriology has its foundation in this preoccupation, which he has pursued for over forty years. An associate points out that Dr. Libman did a great deal of early work on haematology before it became a specialty and that he is still able to give opinions on obscure and baffling blood specimens. His studies of streptococci have resulted in the publication of several other papers which insure a medical immortality, particularly his work on sinus thrombosis, a serious complication of mastoid disease. When he returned to New York in August, 1897, Libman was appointed assistant pathologist at Mt. Sinai Hospital. His father had bought the house on East Sixty-fourth Street some years before, and the young doctor moved in with the family and opened an office on the parlor floor. He carried on a general practice at first, but he was already known to many doctors as a diagnostician and before long he was a successful consultant. Even as a young man he set arbitrary limits on the time he would spend in making money, reserving a good part of the day for his researches. It is probable that he has never earned more than $30,000 or $40,000 in a single year, which is said to be about a fourth of what an ambitious doctor with his reputation could make if he wanted to. Beyond the expense of keeping up the house, which he eventually took over from his father, he has little need for money and is in the habit of giving it away. With his own funds, he established the William Henry Welch lectures at Mt. Sinai and the Noguchi lectures at Johns Hopkins. A diagnostician in his position may, with no compunction at all, charge rich men heavily, but Dr. Libman usually sends bills for less than the rich man expects to he charged, which often moves the patient to contribute to one of the Doctor's various philanthropic schemes. He minimizes his philanthropy, which actually is a major preoccupation. "Most people do nothing," he says, "and so when one does something, most people think he is doing a great deal."

Dr. Libman became associate pathologist at Mt. Sinai not long after he went there as an assistant, and he held that position for twenty-five years. Physicians who worked as internes during that period speak of it as the Golden Age of the hospital. He was tireless in his efforts to make Mt. Sinai a world centre for the advancement and diffusion of medical knowledge. He went after rich men to establish fellowships and lectureships, to provide funds for some special line of investigation, or to aid promising young students. The list of men who have been helped and encouraged by him is long and distinguished. The Emanuel Libman Fellowship Fund exists for the purpose of supporting promising young men so they can do research in special fields, and it is Libman's chief hobby. With Dr. Carrel and other celebrated men, he also will help administer the Dazian Fund of over $1,500,000, provided for in the will of the late Henry Dazian, the theatrical costumer, who was a friend and patient of Libman's.

His desk is crowded with books sent to him by his protégés. "I don't write hooks," says Dr. Libman. "I don't have to. My protégés write them and send them to me—many copies." From the number of books dedicated to the master, you conclude that he has inspired an entire medical literature. People have been trying for years to get him to write a book. They say that if he did so, he might reorient medicine for a long time to come. But though he won't do a book, he does an enormous amount of writing. He has written ninety-one papers, of which it is said he has never had to retract one word. Libman doesn't believe in regular working hours for those who are not suited to it, but in spite of the seeming irregularity of his own life, he obeys some marvellously attuned inner coördination of his own. Actually, those close to him say, he never stops working.

Dr. Libman suffers acutely from sinus trouble and a large part of the time while he is examining a friend or talking or playing a record he keeps imbedded in one nostril a long pencil wrapped in medicated cotton. He shifts the pencil from nostril to nostril; the severe pain in his nose does not impede his movements or the rapidity of his speech. He has been operated on for sinus trouble a number of times and he has suffered intense pain for years, yet he has never permitted this to stop his work. Because the staphylococcus of sinus disease shows golden in the culture, it is called staphylococcus aureus, and Libman says that he will soon celebrate the golden anniversary of his union with this organism. Once he had shingles, an extremely painful ailment, and lay at home in a darkened room for over a month. He refused, he said, to bore people by asking them to come to see him, and pretended to be out of town. He does the same thing when he is working under special pressure; his servants say he is out of town. Sometimes he will answer the telephone himself and say, "Dr. Libman is out of town."

He loves good food. He thinks that certain restaurants are best for certain dishes and he will sometimes have soup or hors-d'oeuvre in one, go to another for the roast, and still another for the dessert and coffee. He is fond of boiled potatoes, and will go to a restaurant because it serves good boiled potatoes. Or he will have a run on black pepper and will go to places that use it in their cooking. He has an excellent cook, but he very seldom dines at home. He drinks wine and mild apéritifs, and smokes a good many cigars.

Since the advent of the Hitler regime, he has done an enormous amount of work for expatriated German physicians. He is tireless in his efforts to get exiled German doctors positions in universities and in private practice all over the world. When he succeeds in getting a place for one, his sense of triumph overflows. He takes equal pride in showing you a book by some disciple or in telling you that a specialist from Heidelberg whose chromosomes are not arranged in a pattern suitable to the Führer has just been placed in Chicago or in the university founded by Kemal Attatürk in Istanbul.

While he is playing a record, he will dart to his bookshelves, pick out a volume, and read you a quotation from a book on gout published in 1846. It is one of his ingratiating qualities that he assumes that you share his concern over the fact that nothing more advanced on gout has been written since 1846. You have an impulse, necessarily frustrated, to write something new about gout. "All the textbooks on internal medicine," he will say, "have to be rewritten." Fortunately, the telephone rings before you can set your mind to this problem.