Osler’s Razor

Peter Medawar

  • The Youngest Science by Lewis Thomas
    Viking, 256 pp, $14.75, February 1983, ISBN 0 670 79533 X

Lewis Thomas is a physician, a scientist, a medical administrator, and a man of letters whose previous books, The Lives of a Cell (1974) and The Medusa and the Snail (1979), and occasional writing for the New England Journal of Medicine have brought him a large following. The Youngest Science will meet his fans’ highest expectations.

In American letters I can compare Thomas only with Oliver Wendell Holmes (the father of the one whom Americans think of first). But although both were medical professors and, in their time, deans, their affinity does not really go much deeper than the relaxed and genial style they share: only a young left-wing hothead, insisting always upon relevance and social engagement, would object to being compared with Holmes. As Lewis Thomas is none of these things, he will not mind it being said that his opening paragraph is very much in Holmes’s style: ‘I have always had a bad memory, as far back as I can remember. It isn’t so much that I forget things outright, I forget where I stored them. I need reminders, and when the reminders change, as most of them have changed from my childhood, there goes my memory as well.’

Lewis’s father practised medicine in an old clapboard house, the backyard of which abutted onto a cutting that gave way to the Long Island Railroad; and the dilapidated old church which his family attended ‘most Sundays’ today bears a sign saying that, so far from representing the Dutch Reformed Church, it is Korean Protestant – an apostasy which cannot but strike an Episcopalian as a non-sequitur. His mother’s family were Pecks and Brewsters, who, like everyone else in this part of Connecticut, were rated Mayflower progeny – something which his mother doubted. In the Thomas household there was never an end to worrying about money – ‘the family took it for granted that my father had to worry about his income at the end of every month’ – for few of Dr Thomas’s patients paid promptly and many not at all, though ‘some sent in small cheques, once every few months.’ Thus the domestic economy of the Thomas household could not have been farther removed from that of a great metropolitan hospital in the USA, with its elaborate security checks and something akin to a secret police to prevent patients slipping out without paying their dues. ‘The practice of medicine was accepted to be a chancy way to make a living, and nobody expected a doctor to get rich, least of all the doctors themselves ... my father’s colleagues lived from month to month on whatever cash their patients provided and did a lot of their work free, not that they wanted to or felt any conscious sense of charity, but because that was the way it was.’

These are considerations to keep in mind; and when, in countries lacking a national health service, people in need of medical attention accuse doctors of being mercenary, they would do well to remember that the profession has a substantial moral credit balance, for there is no thought or suggestion here that old Dr Thomas was alone or even unusual in his magnanimity. It was a sign of bad times in the Thomas household when his mother went foraging round the house for four-leaf clovers, murmuring: ‘The Lord will provide.’ This superstitious ritual had one purpose only: to get old Dr Thomas’s patients to pay their bills. He was not then ‘old’ – I call him so only to distinguish père from fils.

Lewis Thomas’s closest friend as a fourth-year medical student at Harvard was the Albert Coons who later became one of America’s most distinguished immunologists. It was then Coons’s lot to write the yearbook for the class of 1937. Lewis Thomas was on his editorial staff and prepared and circulated a questionnaire addressed to graduates from the years 1927, 1917 and 1907. It dealt with matters of internship and residency training; and also, delicately and with a promise of anonymity, asked the respondent for an estimate of his income for 1937. A space was left for any advice or general comments that might benefit the class of 1937. ‘The average income of the ten-year graduates was around $3,500; $7,500 for the 20-year people,’ Thomas reports. ‘One man, a urologist, reported an income of $50,000, but he was an anomaly; all the rest made, by the standards of 1937, respectable but very modest sums of money.’ The general drift of the advice given by the alumni was that medicine was the best of professions but not a good way to make money: if you could, you should marry a rich wife. In the meantime, work long hours, take very little time off, and don’t expect to be prosperous.

Like his fellow practitioners in Flushing, old Dr Thomas worked from home. His consulting-room and waiting-room were on the first floor; the dining-room was only one door away from the waiting-room, ‘so we grew up eating more quietly and quickly than most families.’ The household comprised a living-in maid on the third floor, a laundress who worked in the basement and a passionate Italian gardener; however, his mother always did the cooking, even when there was a maid, and when there wasn’t, she did all the cleaning and everything else in the house.

For those who believe that the riotous misbehaviour of young people is a modern innovation, the outcome of television, non-attendance at Sunday school and other contrivances of Satan, it is reassuring to know that ‘all the children in Flushing were juvenile delinquents, roaming the town in the evening, ringing door bells and hiding, scrawling on the sidewalks with coloured chalk and, at Halloween, breaking windows and throwing garbage cans into front yards.’ They shoplifted at Woolworth’s, twisted street signs to point in the wrong direction and at the age of ten were buying and smoking Piedmont cigarettes and breaking candy-vending machines. ‘We were expected to be bad, there was no appealing to our better selves because it was assumed that we had no better selves.’ An additional cause of grievance was that the children turned out rather well.

In watching his father, Lewis came to learn of the style of medicine that is farthest removed from the modern scientific medicine of which in later years Lewis was to be such an ardent advocate and skilful practitioner. Lewis is full of admiration for his father’s unremitting attention and kindliness towards his patients. One dramatic episode is described of the kind which all laymen and television producers take for granted as a matter of everyday occurrence in the life of a family doctor. Lewis’s father arrived at the household of an old Flushing family a few minutes after the unmarried daughter had delivered a baby which the grandmother was about to smother. His father reasoned with the family and arranged for the baby to be taken in by the Catholic nuns at the foundling hospital where the nursing was the best his mother had ever seen. There is, of course, an element of everybody’s father about old Dr Thomas, who could be heard to swear ‘not very demoniacally’ when called out of bed to attend sudden illnesses, births and deaths, or any one of a hundred other causes of being scared or in need of help. Lewis was often taken as a passenger when his father drove off on his rounds, and was fascinated by the contents of his father’s doctor’s suitcase, containing, apart from stethoscope etc, a variety of ampoules, syringes and needles. The only really indispensable drug was morphine; adrenalin was carried in case of an emergency which never in fact arose: anaphylactic shock. In due course insulin was added to the pharmacopoeia.

From the standpoint of today’s medicine a doctor of his father’s generation had very few if any specific remedies for human ills, but with the hindsight that Lewis’s sympathetic account of his father’s practice makes possible, we can easily see that alongside the good practitioner’s general medical wisdom, kindness and psychological support, the older physician had one other factor of immense importance working in his favour: his patients believed the doctor and believed that his ministrations would do them good. Indeed, they believed in medicine as well as in doctors. Nothing else in art and literature could make this point more clearly than the closing scene of Puccini’s La Bohème. Mimi is within a few hours of death from consumption. Extremities are cold, the pulse barely perceptible, the breathing light and shallow: but one of the household resolves to pawn his overcoat and another her trinkets to raise enough money to buy some ... medicine! A fat lot of good that would have done, speaks the voice of modern scientific medicine, expressing no opinion on the importance of solicitude, both for the patient and for her anxious friends. The days were yet to come of a doctor’s being quizzed by patients who had read the latest preposterously sanguine article in one or other digest magazine.

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