The Youngest Science

by Lewis Thomas

  But medical students of those decades had other hard things to learn about. Prescriptions were an expected ritual, laid on as a kind of background music for the real work of the sixteen-hour day. First of all, the physician was expected to walk in and take over; he became responsible for the outcome whether he could affect it or not. Second, it was assumed that he would stand by, on call, until it was over. Third, and this was probably the most important of his duties, he would explain what had happened and what was likely to happen. All three duties required experience to be done well. The first two needed a mixture of intense curiosity about people in general and an inborn capacity for affection, hard to come by but indispensable for a good doctor. The third, the art of prediction, needed education, and was the sole contribution of the medical school; good medical schools produced doctors who could make an accurate diagnosis and knew enough of the details of the natural history of disease to be able to make a reliable prognosis. This was all there was to science in medicine, and the store of information which made diagnosis and prognosis possible for my father’s generation was something quite new in the early part of the twentieth century.

  The teaching hospitals of that time were organized in much the same way as now, although they existed on a much smaller scale than in today’s huge medical centers. The medical school was responsible for appointing all the physicians and surgeons who worked on the wards, and these people held academic titles on the medical school faculty. The professor and head of the Department of Medicine in P & S was also the chief of the internal medicine service in Roosevelt Hospital, the professor of surgery ran the surgical service, the pediatrics professor was in charge of all the children’s wards, and so forth. The medical students were assigned in rotation to each of the clinical services during the last two years of medical school. Interns were selected from applicants who were graduates of all of the country’s medical schools, and the competition for appointments in the teaching hospitals was as intense then as it is today. To be posted as intern on one of the teaching services at Roosevelt Hospital was regarded as a sure ticket for a successful career as a practitioner in the New York City area. The P & S faculty included some of the city’s leading physicians and surgeons, who made ward rounds each day with an entourage of students and interns, and taught their juniors everything they knew about medicine. Through this mechanism, the interns also had opportunities to observe, at first hand, some of the imperfections of medicine.

  When my father was an intern, one of the attending physicians on the P & S medical service of Roosevelt Hospital was an elderly, highly successful pomposity of New York medicine, typical of the generation trained long before the influence of Sir William Osler. This physician enjoyed the reputation of a diagnostician, with a particular skill in diagnosing typhoid fever, then the commonest disease on the wards of New York’s hospitals. He placed particular reliance on the appearance of the tongue, which was universal in the medicine of that day (now entirely inexplicable, long forgotten). He believed that he could detect significant differences by palpating that organ. The ward rounds conducted by this man were, essentially, tongue rounds; each patient would stick out his tongue while the eminence took it between thumb and forefinger, feeling its texture and irregularities, then moving from bed to bed, diagnosing typhoid in its earliest stages over and over again, and turning out a week or so later to have been right, to everyone’s amazement. He was a more productive carrier, using only his hands, than Typhoid Mary.

  Good doctors needed a close knowledge of what good nurses were able to do. In the medical textbooks used by my father, the sections dealing with the treatment of disease usually began with a paragraph about the importance of “good nursing care,” and what this really meant was that the services of “good nurses” had to be available. The nurses had their own profession, their own schools, and their own secrets. It was understood that nurses were there to do what the physician told them to but he usually knew so little about nursing that his instructions were often no more precise than to “look after” the patient. Nurses knew how to make sick people more comfortable, and more confident and hopeful as well; they also knew how to get things done in hospitals.

  My mother was trained in nursing at Roosevelt Hospital. She had been raised on a small, always impoverished farm in Connecticut near Beacon Falls. She never talked much to her children about her own childhood, but we gathered enough to know that it had been hard times. She was orphaned at the age of five or six, raised by grandparents and several unaffectionate aunts; the farm was a spartan place; the aunts took her to church and then to the local graveyard every Sunday to memorize the names and dates of all the family antecedents, Pecks and Brewsters who, the aunts claimed, were Mayflower progeny (which my mother doubted, since everyone in that part of Connecticut was raised in the same belief); she fled when she could, at the age of seventeen, and boarded a boat in Bridgeport for New York. She carried a letter from the family doctor in New Haven to a colleague at Roosevelt Hospital, recommending her as a strong-minded, intelligent girl who would make a good nurse.

  By the time my father had arrived at Roosevelt for his internship, she had finished nursing school and risen to head nurse on one of the wards. Later, she was elevated to the highest local distinction for a Roosevelt nurse, personal assistant to the chief surgeon, Dr. George Brewer. Brewer’s practice took him to various estates on Long Island, and my mother’s task was to go out a day in advance to prepare the household for his surgery, usually performed on a table in the kitchen. Wealthy people went through all their illnesses at home at the time; the hospital was seen as the place for dying.

  My mother’s skills were devoted almost exclusively to the family after she and my father were married. I can remember only a few occasions when my father served as the family doctor. When we developed serious illnesses he usually called one of his Flushing colleagues to make a house call to our house; it was considered vaguely unethical for a doctor to treat his own family. For most of our indispositions it was my mother’s responsibility to look after us.

  She took considerable pride in my father’s accomplishments, probably more pride than he was comfortable with, but her view of him must have provided a lifelong reassurance whenever he ran into bad times. Around the house, talking with the family, she was entirely explicit: our father, we were told, was not simply the best doctor in town, not just the best in Queens County, he was very likely the best anywhere. I remember a time somewhere in the late 1920s when he had begun concentrating on surgery and had a particularly difficult case to deal with—the minister of the local Baptist church who had developed a severe gallbladder infection. My father operated on him one night at Flushing Hospital, and he recovered slowly after a few weeks. When he returned to his pulpit, fit again, he delivered a rousing sermon which was printed the next day on the front page of the Evening Journal, under the headline: BAPTIST MINISTER GIVES THANKS TO GOD FOR RECOVERY. My mother was indignant, flapping the newspaper impatiently on her lap. “God indeed!” she said to all of us. “God had nothing to do with it. It was your father!”

  Once in a while, in emergencies, she pitched in to help my father in his office. The office door would open and we would hear him call, “Grace!” and we knew that something serious was happening downstairs, someone bleeding or fainting or needing more reassurance than he could provide. Some of his patients came back after office hours to see her, and as the years went by, she accumulated an informal, unpaid practice of her own.

  One night my father was called out for an emergency and came home with a baby. He had arrived at the household of one of the old Flushing families a few minutes after the young daughter, unmarried, had delivered, and found the grandmother trying to smother the newborn child with a pillow. Mother looked after the baby for a few days, tried her best to negotiate with its family to accept the event, and finally brought it to her friends the nuns at the Foundling Hospital in New York. Later, I learned that this had happened se
veral times in my father’s practice. My mother, who had been raised in Protestant fundamentalism, told me once that the Catholic nuns at the Foundling Hospital were, to her surprise, the best nurses she’d ever seen.

  A piano teacher, a middle-aged spinster, came to the office one morning hallucinating wildly and left in panic before my father came home for office hours. My mother took on the problem, visiting the lady’s apartment on the other side of town twice each day with trays of hot food. From her account, it was a typical case of acute, severe schizophrenia, which in other circumstances would have required immediate removal to Bellevue or the asylum on Blackwells Island, but my mother insisted on handling the matter in her own way. For several weeks the piano teacher refused to open her door; she and my mother would discuss her problems for a while, and then the tray would be left on the threshold, to be taken in after Mother had left. This went on for a couple of months, and then the lady recovered and resumed her successful career. All of this went on in secrecy; nobody in town knew anything more than that the music teacher was “ill” at home and my mother was “looking in” at her apartment.

  4

  1933 MEDICINE

  I was admitted to medical school under circumstances that would have been impossible today. There was not a lot of competition; not more than thirty of my four hundred classmates, most of these the sons of doctors, planned on medicine. There was no special curriculum; elementary physics and two courses in chemistry were the only fixed requirements; the term “premedical” had not yet been invented. My academic record at Princeton was middling fair; I had entered college at fifteen, having been a bright enough high-school student, but then I turned into a moult of dullness and laziness, average or below average in the courses requiring real work. It was not until my senior year, when I ventured a course in advanced biology under Professor Swingle, who had just discovered a hormone of the adrenal cortex, that I became a reasonably alert scholar, but by that time my grade averages had me solidly fixed in the dead center, the “gentlemen’s third,” of the class. Today, I would have been turned down by every place, except perhaps one of the proprietary medical schools in the Caribbean.

  I got into Harvard, the hardest, by luck and also, I suspect, by pull. Hans Zinsser, the professor of bacteriology, had interned with my father at Roosevelt and had admired my mother, and when I went to Boston to be interviewed in the winter of 1933, I was instructed by the dean’s secretary to go have a talk with Dr. Zinsser. It was the briefest of interviews, but satisfactory from my point of view. Zinsser looked at me carefully, as at a specimen, then informed me that my father and mother were good friends of his, and if I wanted to come to Harvard he would try to help, but because of them, not me; he was entirely good-natured, but clear on this point. It was favoritism, but not all that personal, I was to understand.

  My medical education was, in principle, much like that of my father. The details had changed a lot since his time, especially in the fields of medical science relating to disease mechanisms; physiology and biochemistry had become far more complex and also more illuminating; microbiology and immunology had already, by the early 1930s, transformed our understanding of the causation of the major infectious diseases. But the purpose of the curriculum was, if anything, even more conservative than thirty years earlier. It was to teach the recognition of disease entities, their classification, their signs, symptoms, and laboratory manifestations, and how to make an accurate diagnosis. The treatment of disease was the most minor part of the curriculum, almost left out altogether. There was, to be sure, a course in pharmacology in the second year, mostly concerned with the mode of action of a handful of everyday drugs: aspirin, morphine, various cathartics, bromides, barbiturates, digitalis, a few others. Vitamin B was coming into fashion as a treatment for delirium tremens, later given up. We were provided with a thin, pocket-size book called Useful Drugs, one hundred pages or so, and we carried this around in our white coats when we entered the teaching wards and clinics in the third year, but I cannot recall any of our instructors ever referring to this volume. Nor do I remember much talk about treating disease at any time in the four years of medical school except by the surgeons, and most of their discussions dealt with the management of injuries, the drainage or removal of infected organs and tissues, and, to a very limited extent, the excision of cancers.

  The medicine we were trained to practice was, essentially, Osler’s medicine. Our task for the future was to be diagnosis and explanation. Explanation was the real business of medicine. What the ill patient and his family wanted most was to know the name of the illness, and then, if possible, what had caused it, and finally, most important of all, how it was likely to turn out.

  The successes possible in diagnosis and prognosis were regarded as the triumph of medical science, and so they were. It had taken long decades of careful, painstaking observation of many patients; the publication of countless papers describing the detailed aspects of one clinical syndrome after another; more science, in the correlation of the clinical features of disease with the gross and microscopic abnormalities, contributed by several generations of pathologists. By the 1930s we thought we knew as much as could ever be known about the dominant clinical problems of the time: syphilis, tuberculosis, lobar pneumonia, typhoid, rheumatic fever, erysipelas, poliomyelitis. Most of the known varieties of cancer had been meticulously classified, and estimates of the duration of life could be made with some accuracy. The electrocardiogram had arrived, adding to the fair precision already possible in the diagnosis of heart disease. Neurology possessed methods for the localization of disease processes anywhere in the nervous system. When we had learned all that, we were ready for our M.D. degrees, and it was expected that we would find out about the actual day-to-day management of illness during our internship and residency years.

  During the third and fourth years of school we also began to learn something that worried us all, although it was not much talked about. On the wards of the great Boston teaching hospitals—the Peter Bent Brigham, the Massachusetts General, the Boston City Hospital, and Beth Israel—it gradually dawned on us that we didn’t know much that was really useful, that we could do nothing to change the course of the great majority of the diseases we were so busy analyzing, that medicine, for all its façade as a learned profession, was in real life a profoundly ignorant occupation.

  Some of this we were actually taught by our clinical professors, much more we learned from each other in late-night discussions. When I am asked, as happens occasionally, which member of the Harvard faculty had the greatest influence on my education in medicine, I no longer grope for a name on that distinguished roster. What I remember now, from this distance, is the influence of my classmates. We taught each other; we may even have set careers for each other without realizing at the time that so fundamental an educational process was even going on. I am not so troubled as I used to be by the need to reform the medical school curriculum. What worries me these days is that the curriculum, whatever its sequential arrangement, has become so crowded with lectures and seminars, with such masses of data to be learned, that the students may not be having enough time to instruct each other in what may lie ahead.

  The most important period for discovering what medicine would be like was a three-month ward clerkship in internal medicine that was a required part of the fourth year of medical school. I applied for the clerkship at the Beth Israel Hospital, partly because of the reputation of Professor Hermann Blumgart and partly because several of my best friends were also going there. Ward rounds with Dr. Blumgart were an intellectual pleasure, also good for the soul. I became considerably less anxious about the scale of medical ignorance as we followed him from bed to bed around the open circular wards of the B.I. I’ve seen his match only three or four times since then. He was a tall, thin, quick-moving man, with a look of high intelligence, austerity, and warmth all at the same time. He had the special gift of perceiving, almost instantaneously, while still approachin
g the bedside of a new patient, whether the problem was a serious one or not. He seemed to do this by something like intuition; at times when there were no particular reasons for alarm that could be sensed by others in the retinue, Blumgart would become extremely alert and attentive, requiring the resident to present every last detail of the history, and then moving closer to the bedside, asking his own questions of the patient, finally performing his physical examination. To watch a master of physical diagnosis in the execution of a complete physical examination is something of an aesthetic experience, rather like observing a great ballet dancer or a concert cellist. Blumgart did all this swiftly, then asked a few more questions, then drew us away to the corridor outside the ward for his discussion, and then his diagnosis, sometimes a death sentence. Then back to the bedside for a brief private talk with the patient, inaudible to the rest of us, obviously reassuring to the patient, and on to the next bed. So far as I know, from that three months of close contact with Blumgart for three hours every morning, he was never wrong, not once. But I can recall only three or four patients for whom the diagnosis resulted in the possibility of doing something to change the course of the illness, and each of these involved calling in the surgeons to do the something—removal of a thyroid nodule, a gallbladder, an adrenal tumor. For the majority, the disease had to be left to run its own course, for better or worse.