House Calls (Lewis Thomas)

My father took me along on house calls whenever I was around the house, all through my childhood. He liked company, and I liked watching him and listening to him. This must have started when I was five years old, for I remember riding in the front seat from one house to another, and back and forth from the hospital, when my father and many of the people on the streets were wearing gauze masks; it was the 1918 influenza epidemic.

One of the frequent calls which I found fascinating was at a big house on Sanford Avenue; he never parked the car in front of this house, but usually left it, and me, a block away around the corner. Later, he explained that the patient was a prominent Christian Scientist, a pillar of that church. He could perfectly well have parked in front if there had been a clearer understanding all around of what he was up to, for it was, in its way, faith healing.

I took the greatest interest in his doctor’s bag, a miniature black suit- case, fitted inside to hold his stethoscope and various glass bottles and ampules, syringes and needles, and a small metal case for instruments. It smelled of Lysol and ether. All he had in the bag was a handful of things. Morphine was the most important, and the only really indispensable drug in the whole pharmacopoeia. Digitalis was next in value. Insulin had arrived by the time he had been practicing for twenty years, and he had it. Adrenalin was there, in small glass ampules, in case he ran into a case of anaphylactic shock; he never did. As he drove his rounds, he talked about the patients he was seeing.

I’m quite sure my father always hoped I would want to become a doctor, and that must have been part of the reason for taking me along on his visits. But the general drift of his conversation was intended to make clear to me, early on, the aspect of medicine that troubled him most all through his professional life; there were so many people needing help, and so little that he could do for any of them. It was necessary for him to be available, and to make all these calls at their homes, but I was not to have the idea that he could do anything much to change the course of their illnesses. It was important to my father that I understand this; it was a central feature of the profession, and a doctor should not only be prepared for it but be even more prepared to be honest with himself about it.

It was not always easy to be honest, he said. One of his first patients, who had come to see him in his new office when he was an unknown in town, was a man complaining of grossly bloody urine. My
father examined him at length, took a sample of the flawed urine, did a few other tests, and found himself without a diagnosis. To buy time enough to read up on the matter, he gave the patient a bottle of Blaud’s pills, a popular iron remedy for anemia at the time, and told him to come back to the office in four days. The patient returned on the appointed day jubilant, carrying a flask of crystal-clear urine, totally cured. In the following months my father discovered that his reputation had been made by this therapeutic triumph. The word was out, all over town, that that new doctor, Thomas, had gifts beyond his own knowledge- this last because my father’s outraged protests that his Blaud’s pills could have had nothing whatever to do with recovery from bloody urine. The man had probably passed a silent kidney stone and that was all there was to it, said my father. But he had already gained the reputation of a healer, and it grew through all the years of his practice, and there was nothing he could do about it. Even now, twenty-five years after his death, I meet people from time to time who lived once in Flushing, or whose parents lived there, and I hear the same anecdotes about his abilities: children with meningitis or rheumatic fever whose lives had been saved by him, patients with pneumonia who had recovered under his care, even people with incurable endocarditis, overwhelming typhoid fever, peritonitis, what-all.

But the same stories are told about any good, hardworking general practitioner of that day. Patients do get better, some of them anyway, from even the worst diseases; there are very few illnesses, like rabies, that kill all comers. Most of them tend to kill some patients and spare others, and if you are one of the lucky ones and have also had at hand a steady, knowledgeable doctor, you become convinced that the doctor saved you. My father’s early instructions to me, sitting in the front of his car on his rounds, were that I should be careful not to believe this of myself if I became a doctor.

Nevertheless, despite his skepticism, he carried his prescription pad everywhere and wrote voluminous prescriptions for all his patients. These were fantastic formulations, containing five or six different vegetable ingredients, each one requiring careful measuring and weighing by the druggist, who pounded the powder, dissolved it in alcohol, and bottled it with a label giving only the patient’s name, the date, and the instructions about dosage. The contents were a deep mystery, and intended to be a mystery. The prescriptions were always written in Latin, to heighten the mystery. The purpose of this kind of therapy was essentially reassurance. A skilled, experienced physician might have dozens of different formulations in his memory, ready for writing out in flawless detail at a moment’s notice, but all he could have predicted about them with any certainty were the variations in the degree of bitterness of taste, the color, the smell, and the likely effects of the concentrations of alcohol used as solvent. They were placebos, and they had been the principal mainstay of medicine, the sole technology, for so long a time- millennia- that they had the incantatory power of religious ritual. My father had little faith in the effectiveness of any of them, but he used them daily in his practice. They were expected by his patients; a doctor who did not provide such prescriptions would soon have no practice at all; they did no harm, so far as he could see; if nothing else, they gave the patient something to do while the illness, whatever, was working its way through its appointed course.

The United States Pharmacopoeia, an enormous book, big as the family Bible, stood on a bookshelf in my father’s office, along with scores of textbooks and monographs on medicine and surgery. The ingredients that went into the prescriptions, and the recipes for their compounding and administration, were contained in the Pharmacopoeia. There was no mistaking the earnestness of that volume; it was a thousand pages of true belief: this set of ingredients was useful in pulmonary tuberculosis, that one in “acute indigestion” (the term then used for what later turned out to be coronary thrombosis), another in neurasthenia (weak nerves; almost all patients had weak nerves, one time or another), and so on, down through the known catalogue of human ailments. There was a different prescription for every circumstance, often three or four. The most popular and widely used ones were the “tonics,” good for bucking up the spirits; these contained the headiest concentrations of alcohol. Opium had been the prime ingredient in the prescriptions of the nineteenth century, edited out when it was realized that great numbers of elderly people, especially “nervous” women, were sitting in their rocking chairs, addicted beyond recall.

The tradition still held when I was a medical student at Harvard. In the outpatient department of the Boston City Hospital, through which hundreds of patients filed each day for renewal of their medications, each doctor’s desk had a drawerful of prescriptions already printed out to save time, needing only the doctor’s signature. The most popular one, used for patients with chronic, obscure complaints, was Elixir of I, Q, and S, iron, quinine, and strychnine, each ingredient present in tiny amounts, dissolved in the equivalent of bourbon.

Medicine was subject to recurrent fads in therapy throughout my father’s career. Long before his time, homeopathy emerged and still had many devout practitioners during his early years; this complex theory, involving what was believed to be the therapeutic value of “like versus like,” and the administration of minuscule quantities of drugs that imitated the symptoms of the illness in question, took hold in the mid-nineteenth century in reaction against the powerfully toxic drugs then in common use- mercury, arsenic, bismuth, strychnine, aconite, and the like. Patients given the homeopathic drugs felt better and had a better chance of surviving, about the same as they would have had without treatment, and the theory swept the field for many decades.

A new theory, attributing all human disease to the absorption of toxins from the lower intestinal tract, achieved high fashion in the first decade of this century. “Autointoxication” became the fundamental disorder to be overcome by treatment, and the strongest measures were introduced to empty the large bowel and keep it empty. Cathartics, ingenious variations of the enema, and other devices for stimulating peristalsis took over medical therapy. My father, under persuasion by a detail man from one of the medical supply houses, purchased one of these in 1912, a round lead object the size of a bowling ball, encased in leather. This was to be loaned to the patient, who was instructed to lie flat in bed several times daily and roll it clockwise around the abdomen, following the course of the colon. My father tried it for a short while on a few patients, with discouraging results, and one day placed it atop a cigar box which he had equipped with wheels and a long string, and presented it to my eldest sister, who tugged it with pleasure around the corner to a neighbor’s house. That was the last he saw of the ball until twelve years later, when the local newspaper announced in banner headlines that a Revolutionary War cannon ball had been discovered in the excavated garden behind our neighbor’s yard. The ball was displayed for public view on the neighbor’s mantel, to the mystification of visiting historians, who were unable to figure out the trajectory from any of the known engagements of the British or American forces; several learned papers were written on the problem. My father claimed privately to his family, swearing us to secrecy, that he had, in an indirect sense anyway, made medical history.

So far as I know, he was never caught up again by medical theory. He did not believe in focal infections when this notion appeared in the 1920s, and must have lost a lucrative practice by not removing normal tonsils, appendixes, and gallbladders. When the time for psychosomatic disease arrived, he remained a skeptic. He indulged my mother by endorsing her administration of cod-liver oil to the whole family, excepting himself, and even allowed her to give us something for our nerves called Eskay’s Neurophosphates, which arrived as samples from one of the pharmaceutical houses. But he never convinced himself about the value of medicine.

His long disenchantment with medical therapy was gradually replaced by an interest in surgery, for which he found himself endowed with a special talent.
At last, when he was in his early fifties, he decided to give up general practice and concentrate exclusively on surgery. He was very good at it, and his innate skepticism made him uniquely successful as a surgical consultant. Years later, after his death, I was told by some of his younger colleagues that his opinion was especially valued, and widely sought throughout the country, because of his known reluctance to operate on a patient until he was entirely convinced that the operation was absolutely necessary. His income must have suffered because of this, but his reputation was solidly established.

Questions:

1. How did living through so many pivotal paradigms shifts within medicine affect his father’s final years of practice?

2. If his father was able experience medicine as it is today, how do you think he would feel? Do you think he would still be disenchanted by medical therapy?

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