The 1910s Medicine and Health: Topics in the News

THE "SPANISH" FLU EPIDEMIC CLAIMS MILLIONS OF LIVES

An influenza epidemic struck the East Coast of the United States in September 1918, lasting for several months. This contagious disease had origins in China but was called the "Spanish" flu because it had raged in Spain before spreading to other countries in Europe and the United States. Symptoms included sneezing, runny nose, chills, high fever, muscle and joint aches, and general weakness. So potentially deadly was this virus that it eventually would kill 21.6 million people around the world. This was 1 percent of the world's population. Although the majority of Americans who contracted this sickness recovered, more than five hundred thousand Americans died from the "Spanish" influenza during 1918 and 1919.

The speed by which the infections and fatalities occurred were so high that no medical experts could stop the flu from taking its course. Attempts were made to keep people from congregating in order to halt the spread of the disease. Schools were closed and meetings were canceled. Soldiers crowded into military camps were particularly susceptible to the flu. Many people wore masks over their noses and mouths to prevent picking up this contagious disease from friends and coworkers. Although it was not rare to have outbreaks of influenza in the United States, none before had affected one in every four people. During 1919, the epidemic subsided, but nobody knows how such a powerful and destructive virus disappeared so abruptly.

THE GROWING ACCEPTANCE OF GROUP PRACTICE IN MEDICINE

During the 1910s, the concept of structuring doctors into private group practice began in the Midwest. According to this plan, private clinics or medical centers were formed with doctors as owners and employees. They also included business managers and office and technical staff. Under this economically efficient system, several doctors could share the responsibility for purchasing expensive equipment. Without paying higher fees, patients had access to the expertise of several physicians in sophisticated facilities. The movement grew at a fairly steady rate from 1914 to the end of the decade.

One of the most prominent of these pioneering group practices was the Mayo Clinic, which opened a new building in Rochester, Minnesota, in 1914. Two brothers who were surgeons, William Mayo (1861–1939) and Charles

Prestigious Awards in Medicine and Pharmacology

Nobel Prize Winner in Physiology or Medicine

1912 Alexis Carrel (1873–1944) for transplantation and suturing (tying together) of blood vessels.

The Ebert Prize

The Ebert Prize is awarded for the best original paper published during the preceding year in the Journal of Pharmaceutical Sciences (the sciences of drugs such as toxins and therapeutics). It first was given in 1874.

The Remington Honor Medal

The Remington Honor Medal is given annually for the best work in American pharmacy during the year, or to an individual whose work over a period has advanced the pharmaceutical field. It first was awarded in 1919 to James Hartley Beal.

Mayo (1865–1939), brought together an expert staff of surgeons, diagnosticians (those who identify disease from symptoms), and medical researchers from across the United States and foreign countries. The following year, the brothers donated $1.5 million to endow the Mayo Foundation for Medical Education and Research at the University of Minnesota. The Mayos were a family of physicians. In 1889, their father, William Worrall Mayo (1819–1911), had founded St. Mary's Hospital in Rochester, Minnesota, as an emergency hospital to treat victims of a cyclone (a wind storm). From this seed would come one of the most significant group practices in the world.

The success of the Mayo Clinic sparked the development of private group practices in cities throughout the Midwest and Far West. Even so, the concept never became popular in the East because expansive hospitals with large staffs of affiliated physicians already had mushroomed in cities.

Although the concept of group practice had a huge following among doctors, many physicians preferred to remain in individual private practices. They argued that group practices were impersonal and their fees were undercutting the standard rates. As the decade closed, the spread of group practices started to slow. This slowdown was due to the sharp increase in sophisticated and costly medical technology following World War I (1914–18), which could be dealt with only within the structure of huge hospital centers.

AMERICAN REFORMERS SEEK BROAD HEALTH INSURANCE COVERAGE

As the decade unfolded, very few members of the working class were covered by health insurance policies. Laborers often purchased life insurance in order to ensure a proper funeral; however, the few who were insured against medical crises were covered not by their employer but by small brotherhoods or local chapters of unions. The first legislation related to health insurance dealt with workers' compensation, payments that would be made to workers who were injured while on the job. In 1911, the first workers' compensation law was enacted by the Wisconsin legislature. By 1915, about twenty states had passed similar legislation.

Still, there was little effort to insure people against the cost of paying for sickness and disabilities unrelated to their work. In 1907, the newly founded American Association of Labor Legislation (AALL) had called for social improvements for workers, including insurance against illness. In 1915, the AALL worked to introduce a bill into state legislatures calling for compulsory health insurance for workers who earned less than $1,200 per year, as well as for other employees who wanted to buy into a health insurance program. During 1916, a number of states did try to pass bills for health insurance and other social-oriented insurances. Among the detractors was Samuel Gompers (1850–1924), president of the American Federation of Labor (AFL), who did not support government intervention in matters that he believed could be handled by trade unions and employers.

During 1917, arguments raged among various groups who disagreed about the best approach to bringing health care to the American public. Many social reformers urged passage of compulsory health insurance laws, similar to laws that had passed previously first in Germany, and later in Great Britain. In January 1917, the Journal of the American Medical Association published editorials in favor of the compulsory health insurance program. Soon after, those reformers began citing the economic structure of group practices as the solution to obtaining affordable, widespread health care. That support placed that group of reformers at odds with individual physicians who were striving to retain the single doctor practice, and the resulting political fray led the American Medical Association (AMA) to change its stance and come out against compulsory health insurance policies. When the United States entered World War I in April 1917, the move towards government-supported health insurance further subsided. By then, any movement that was connected to Germany was considered unpatriotic. Furthermore, a Red Scare arose in the United States at the end of the decade. This fear of the rise of communism (a system of government by which the state controls the economy and a single party holds power) overtook many Americans and government health insurance programs were considered too "red," or communist, in their collective approach to protecting society for acceptance by the United States.

THE EFFECTS OF WORLD WAR I ON THE MEDICAL PROFESSION

In 1916, President Woodrow Wilson (1856–1924) began to prepare the nation to meet the medical needs that would result if the country had to enter the war in Europe. In so doing, he appointed a Council of National Defense (CND) with a medical division. Three surgeons general of the Army, Navy, and the U.S. Public Health Service served on the CND's executive committee, along with several of the country's most prominent physicians. It was their task to plan a strategy to handle the many medical situations that war breeds.

At the start of the recruitment process, doctors performed thousands of health examinations on young Americans who were about to join the military. To their surprise, they learned that many were in poor health. They lacked the stamina to pass physical tests required of soldiers, such as doing push-ups and running. Having never been checked before, the recruits were found to suffer from poor hygiene (the science of cleanliness to maintain health) and poor nutrition. Recruits from rural areas in particular were suffering from undiagnosed cases of venereal disease (illness that spreads from sexual intercourse with an infected person), which could have been treated to lessen the long-term damage of the disease. As a result of finding so many Americans lacking in health care, states instituted programs that called for physical examinations in public schools as early as kindergarten. Schools also began to emphasize the importance of physical education classes to improve strength and endurance levels among American youngsters.

Even the healthy recruits faced the dangers of communicable diseases (contagious sicknesses that could be passed from one person to another through close contact). As tens of thousands of soldiers were crowded into the country's thirty-two military training camps, healthy recruits became ill due to outbreaks of measles, mumps, cerebro-spinal (meningococcal) meningitis (a bacterial disease involving inflammation of three membranes wrapping the brain and spinal cord), and typhoid fever (a bacterial disease marked by fever and inflamed intestines). The highest death rates in camps were caused by pneumonia and the "Spanish" influenza epidemic.

When one considers the causes of wartime fatalities, it is routine to picture armed soldiers being killed by bullets and grenades. However, during World War I, 21,053 American soldiers died of pneumonia resulting from cases of the flu in late 1918. During the winter of 1917 and 1918, pneumonia, contracted as the result of having other communicable diseases, caused 3,110 deaths. Measles had been thought of as a minor childhood disease, and it would have been less significant an illness had it not been for the fact that it weakened men's immune systems. It reduced their resistance to other

bacterial infections. For every 1,000 men who contracted measles, 44 got pneumonia, leading to an average of 14 fatalities.

Combat wounds caused 53,400 deaths. Due to improvements in surgical techniques, as many as 204,000 wounded soldiers survived the war. Additionally, X rays (electromagnetic radiation of wavelengths) helped doctors identify problems, tetanus antitoxin injections helped to clear infections, and blood transfusions replaced lost blood to help soldiers heal. The use of motorized ambulance vehicles that could be driven right up to the trenches to pick up the wounded also contributed to the survival of many soldiers.

How Cancer Was Treated

In 1913, cancer was among the top six causes of death in the United States. In certain regions of the country, it was surpassed only by pneumonia and tuberculosis. At the time, weight loss and general weakness were considered the symptoms of cancer, and pain was believed to be a sign of the disease in its late stages. Early detection and surgery were the only known means of treating the affliction.

According to an article written by Samuel Hopkins Adams (1871–1958) in the May 1913 issue of the Ladies' Home Journal, specialists were urging the public to be educated about cancer, and to self-examine in order to locate tumors. The leading cancer was stomach cancer, which was operable in 1913, although only one third of those who had surgery survived. Forms of skin cancer also were operable. For women, breast and uterine cancer were common enemies. If cancerous tumors were located in the early stages, they could be removed through surgery, with varying survival rates.

In his 1913 article, Adams mentioned three "facts" about cancer, all of which were considered true at the time: "First, cancer usually develops from previous and continued irritation. Second, if the cause of that irritation [can] be removed in time the cancer will be averted. Third, if the development of cancer [can] be determined in the early stages the patient can probably be cured by operation, but not by any other method." These "facts" sound quaint to readers in the twenty-first century, since cancer knowledge is far more sophisticated and there are many options for treating cancers, including radiation, chemotherapy, and improved surgical techniques.

One of the least understood injuries of World War I was shell shock, a condition of modern warfare caused by the vacuum created by bursting shells. When air rushes into this vacuum, it upsets the function of the brain. Symptoms include dizziness, temper tantrums, headaches, fatigue, and the inability to concentrate. Eventually, those suffering from shell shock experienced mental breakdowns. At the time, it was suggested that the cure for the illness was complete rest and relaxation far away from battle, and shell-shock victims spent months and even years in mental asylums. Many others suffering from shell shock were mistakenly labeled cowards and malingerers who wished only to avoid combat. Many sufferers were dispatched back into battle. Some committed suicide. Others deserted. Still more disobeyed orders and were shot on the spot or courtmartialed. The British Army estimated that as many as 80,000 soldiers suffered from shell shock during the war.

Treatments developed to cure war injuries became standard medical practices in postwar civilian health care. The use of chlorine and the "Carrel-Dakin" approach to flushing wounds with Dakin fluid (a noncaustic hypochloride) proved to be a significant medical advance for treating infected wounds. Also, the spread of communicable diseases during the war led medical researchers to discover treatments for some illnesses, such as typhoid fever, lock-jaw (an early form of tetanus, which is an acute infectious disease involving spasms of voluntary muscles in the jaw), pneumonia, and meningitis.

THE GOVERNMENT CONFRONTS MATTERS OF PUBLIC HEALTH

During the Progressive Era of the first two decades of the century, American social reformers strived to implement new advances in medical science and technology to improve the general state of the public's health. First in 1902, and again in 1912, Congress passed legislation to expand the nation's first bacteriological laboratory at the Staten Island (New York) Marine Hospital. The 1912 legislation called for medical research, improved methods of public health administration, federal funding for state and local health departments, and interstate control of sanitation and communicable diseases.

By 1914, every state except New Mexico and Wyoming had set up public health laboratories in conjunction with state boards of health. The staffs of these laboratories coordinated efforts with physicians and public health officers to distribute vaccines and other medicines, and helped to diagnose outbreaks of communicable diseases. Until late in the decade, most public health work was done on a grassroots level. In 1918, the Chamberlain-Kahn Act, providing for the study and control of venereal disease, became the first significant instance of a federal appropriation for public health.

Early training in public health was offered in 1913 in a joint program from Harvard Medical School and the Massachusetts Institute of Technology (MIT). In 1918, the first separate Institute of Hygiene and Public Health was established at Johns Hopkins University. The degree was geared to doctors intending to work in the public health sector. It called for knowledge of sanitation, immunization, vital statistics, and various contagious diseases.

In 1914, the USPHS made a study in the South of an outbreak of pellagra (a disease marked by skin and stomach disorders and symptoms related to the central nervous system, including dementia, in severe cases). Believing it to be an infectious disease, the service assigned microbe (germ) researcher Joseph Goldberger (1874–1929) to investigate. Goldberger chose inmates of the Rankin State Prison Farm in Mississippi as a test group. After a testing period, he came to the conclusion that the disease was caused by a dietary deficiency, not the spread of microorganisms. Eventually, by further testing, Goldberger learned that pellagra could be stopped by adding niacin and protein to the diet.

USPHS research zoologist (scientist dealing with the study of animal life) Charles Wardell Stiles (1867–1941) investigated an infestation of hookworm in the southern states. Hookworm stems from the presence of a worm within the intestinal tract. These worms hatch from the larvae of eggs in soil tainted by feces. Then the worms penetrate the skin of persons walking barefoot. Since many rural southerners were impoverished and wore no shoes, the worms found many unwitting hosts. Once in the intestines, the worms feed from the person's blood supply, causing anemia and sometimes death. If the host is a child, the result can be impairment to mental and physical development. With the sponsorship of the Rockefeller Sanitary Commission, Stiles studied five hundred thousand children in eleven southern states and found that 39 percent of the youngsters suffered from hookworm disease. Working with local and state health organizations, the USPHS administered a widespread clean up program in rural southern regions to prevent the disease from spreading further, and also treated the sick with thymol capsules.

Another area of public health that called for attention was the infant and mother mortality rate. Thousands of babies died every year due to poor prenatal care, and mothers died while giving birth due to unhealthy birthing practices. By 1915, 538 baby clinics were running in the United States. These clinics offered medical care and education for pregnant mothers. Mothers learned about proper hygiene, good life habits, and healthy diets.

PATENT MEDICINES BECOME A MORE HONEST BUSINESS

Shortly after the century began, the packaged or nonprescription patent medicine market was estimated to be a $75 million to $100 million-per-year business. This industry had spun out of control, with dangerous consequences. Unsuspecting customers, particularly women, were purchasing pills, powders, and syrups to cure all ailments, from coughs, aches, "female problems," and infant discomforts to cancer. Since labels often listed no ingredients or false ingredients, the customer was ignorant of taking such components as alcohol and codeine, or even addictive narcotics such as morphine, heroin, and opium. Many of these medicines were debilitating when used over long periods, and some became killers when overdoses were administered.

The Origins of Sanitary Pads for Women

During World War I, German American chemist Ernst Mahler (1887–1967) invented an absorbent wood-cellulose substitute for cotton called "Cellucotton" to be used for bandaging at field hospitals near the trenches. Soon Red Cross nurses began using this bandaging in wads for menstrual pads. In 1921, the Kimberly-Clark Corporation, with whom Mahler was associated, began marketing the first widely sold disposable sanitary napkins made of Cellucotton. They were named "Kotex," short for cotton-like texture.

Advertised as "inexpensive, comfortable, hygienic and safe," Kotex cost five cents per napkin, or a dozen for sixty cents. Since the subject of menstruation was taboo, Kotex came in unmarked wrappers and could be purchased discreetly by dropping coins in a box, instead of having to deal with a store clerk.

The Pure Food and Drug Act of 1906 was enacted by Congress to clean up abuses in the patent medicine industry. This legislation helped to clarify ingredients and also made sure that patent medicines were produced in hygienic environments. Still, over-the-counter medicines continued to boast many fraudulent claims, and "quack" cures were prevalent. In 1912, the Sherley Amendment made fraudulent claims illegal. However, by placing the burden of proof on the government rather than the medicine manufacturers, the legislation was ineffective. Eventually, the American Medical Association (AMA) campaigned against false advertising of patent medicines in newspapers, leading to more honest advertisements. For example, for many years the Pinkham Company had marketed its vegetable compound to treat such "female complaints" as bloating, irregular menstruation, and a prolapsed uterus (fallen or slipped womb), and kidney complaints in both sexes. However, by 1915 the AMA had convinced Pinkham to sell its products with more general claims.

The AMA criticized drug companies for charging high prices for inexpensively produced patent medicines. For instance, the Bayer Company, the original producer of aspirin, was making questionable claims that their "Aspirin-Bayer" was expensive to produce. In 1917, the AMA was so incensed over Bayer's stance that they waged a campaign to prevent the company from renewing its proprietary patent on aspirin. As a result, Bayer's patent was not renewed, meaning the company lost its control of the market. After 1917, aspirin could be manufactured and sold by any company that wanted to enter the marketplace.

While it was fighting false claims of patent medicines and quack treatments, the AMA also was encouraging the public to entrust its medical needs to licensed physicians. The campaign was beneficial in preventing the uninformed public from buying useless or dangerous products. At the same time, the AMA was working to empower the trained medical profession to set the standards for treatments and cures by replacing many patent medicines with prescription medicines.

ADVANCED TECHNIQUES IN SURGERY AND THE USE OF X RAYS

Harvey Williams Cushing (1869–1939) was one of the outstanding neurosurgeons (brain and spinal cord surgeons) of the period. In 1907, he developed a process of using small silver clamps to stop excessive blood loss during brain surgery, resulting in a much higher operation success rate. By the start of the 1910s, he had achieved an astounding 90 percent reduction rate in brain surgery deaths. During World War I, Cushing's procedure saved the lives of many wounded combat soldiers. He also adapted his innovative surgical techniques for use in removing metal shell fragments from the brain with the help of a large magnet. The magnet's pull identified the location of the metal and helped to force the metal from the brain.

Wounds resulting from the violent battles of trench warfare sometimes left soldiers with terrible facial and limb disfigurement. To treat these victims, British and French surgeons came up with new techniques in reconstructive surgery. New York surgeon F. H. Albee (1876–1945) introduced a procedure to graft bone from healthy parts of the body onto damaged parts in order to make repairs. Using new techniques, doctors could help a soldier whose nose had been shot off, if only a bit of loose skin remained in the middle of his face. Doctors could "grow" a new nose for the victim by stretching the remaining skin little by little over a set period, and then grafting bone from the victim's wrist onto his face where it eventually took hold. Not every disfigured soldier could be helped through surgery. Many held no hope of replacing shot-off cheeks, jaws, or noses. To help such individuals, French sculptors created wax face molds that covered part or all of a wounded man's face. Although the covering did not look quite natural, it saved the soldier from having to publicly display his disfigurement.

Early in the decade, surgeon Hugh H. Young (1870–1945) introduced advances in the field of urology (the science that deals with urinary and genital tract diseases). Young invented a "punch operation" to remove tumors from the male prostate gland. In 1912, he successfully performed this surgery on James Buchanan "Diamond Jim" Brady (1856–1917), a powerful railroad tycoon who was famous for being an extravagant spender. In gratitude, Brady gave generous funding to endow the James Buchanan Brady Urological Institute at Johns Hopkins Hospital.

As the 1910s began, X rays (electromagnetic radiation of wavelengths) already were in use as a means of diagnosis and therapy. In 1913, the first efficient X-ray tube was developed by William David Coolidge (1873–1975), replacing old-fashioned gas tubes. During World War I, "Coolidge tubes" were manufactured at the General Electric plant in Schenectady, New York, and sent to the European front for use in treating wounded soldiers. As with so many other wartime advances, the X ray became even more efficient through postwar developments for civilian use. Coolidge went on to become head of the research laboratory at General Electric from the early 1930s until the closing days of World War II (1939–45).

THE TUBERCULOSIS MORTALITY RATE DECLINES

Tuberculosis spreads through bacterial infection. It is a highly contagious disease. If a person's white blood cell count cannot ward off the infection, then a victim will suffer lung tissue damage. Symptoms of the disease include coughing up blood, fever, weight loss, and tiredness. In 1906, tuberculosis killed one in every five hundred individuals in the United States. Throughout the 1910s, it caused more deaths than any other infectious disease.

Victims of tuberculosis were isolated and ordered to rest in sanatoriums. Sometimes these rests lasted months, as patients lay dormant, usually reading and sleeping. Treatment included the injection of nitrogen into one lung to make it collapse. That way, the collapsed or inactive lung might heal, while the second lung worked. This procedure, which never was properly evaluated, was called artificial pneumothorax. Fresh air and sunlight also were part of the treatment, so many sanitariums were located in resort areas or in the countryside. During the decade, there were approximately four hundred private, state, and municipal sanitariums in the United States. The National Tuberculosis Association lead a publicity campaign to inform the public about the disease and its dangers.