The 1930s Medicine and Health: Topics in the News

SLEEPING THROUGH SURGERY

The use of anesthetics is one of America's most important contributions to medicine. In 1844, in Hartford, Connecticut, dentist Horace Wells (1815–1848) used nitrous oxide (laughing gas) to sedate patients while extracting teeth. In Boston, in 1846, another dentist, William T. G. Morton (1819–1868), used ether during an operation at Massachusetts General Hospital. In the 1930s, both of these anesthetics were widely used. But gradually, amazing stories about a new generation of anesthetics began to appear in the press. In 1933, a patient in New York read a newspaper during an operation. Surgeons made headlines performing operations on themselves. And during brain surgery, patients were reported to be chatting with nurses and doctors.

At the start of the 1930s, the most effective anesthetic was ether. Chloroform was popular in Europe, but it was dangerous. If the dose was even slightly too high, it could stop the patient's heart. Ether carried risks too. It caused stomach problems and could make patients excitable and difficult to control. Patients who needed several operations became tolerant of ether, so it stopped working at low doses. Worst of all, ether was unstable. Sparks from X-ray machines and other equipment could cause an explosion. Anesthetists became skilled at controlling ether. Patients would be put to sleep using nitrous oxide, then kept under using ether. Nitrous oxide would be used in the closing stages of the operation to stop vomiting. Anesthetists had to watch the patient carefully for signs of problems and reduce or increase the dose of anesthetic depending on the type and sensitivity of the tissue being cut through by the surgeon.

Ether, chloroform, and nitrous oxide were effective, but crude. Causing someone to lose consciousness is in any case highly dangerous, and many patients reacted badly to these basic drugs. In the early 1930s, a French drug called neocaine appeared. When injected into the spine, neocaine allowed surgeons to work on the legs and lower body while the patient was awake. Another new drug, Avertin, arrived from Germany in 1930 and could be used for short operations. Pernocton knocked out the patient safely for several hours and made more complex surgery possible. Pernocton was so safe it was used for surgery on pregnant women and during childbirth. Novocaine, eucaine, and benzyl alcohol were all "local" anesthetics. Novocaine was the drug used by the surgeons who operated on themselves. But most impressive of all was diothane, which appeared in 1938. Developed in Cincinnati, Ohio, diothane was longer lasting than novocaine and was nonaddictive.

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While surgeons became more skillful, anesthetics made surgery more comfortable. Before the 1930s, nurses made sure the correct amount of anesthetic was delivered. While nurse anesthetists continued to work in the 1930s, the job of the anesthetist became more skilled and more complex. As local anesthetics became available, the practice of anesthetics became one of the medical specialties. While surgery became more impressive during the 1930s and surgeons were turned into heroes, it was often forgotten that without anesthetics and skilled anesthetists many operations would have been impossible.

BIRTH CONTROL: PUBLIC NUISANCE OR PUBLIC HEALTH ISSUE?

Working as a nurse in the slums of New York City, Margaret Sanger (1879–1966) realized that proper birth control could save many lives. Deaths during pregnancy and childbirth were common. But more shocking was the fact that a quarter of such deaths happened when women tried to end their pregnancies. Many performed abortions on themselves or went to illegal clinics where hygiene standards were poor. In 1916, Sanger opened a birth control clinic in Brooklyn, New York, with the aim of telling women how to avoid pregnancy in the first place. She was arrested for causing a public nuisance. By 1938, largely as a result of Sanger's campaigning, the right to receive information about birth control methods was part of federal law. Only three states, Connecticut, Mississippi, and Massachusetts, did not allow medical workers to offer such advice.

Until the 1930s, birth control information and contraceptive devices were illegal. The U.S. Penal Code decreed that anyone caught in possession of contraceptive articles could be fined up to $5,000 and jailed for five years. Even married couples were forbidden from buying condoms. Even so, many doctors broke the law and prescribed contraceptives. In 1930, when it was clear that the law had become unenforceable, the National Committee on Federal Legislation for Birth Control recommended that federal restrictions be ended. Their twenty million members filed 325,000 endorsements with Congress. On November 30, 1936 the federal courts of appeal agreed that birth control did not fall under the obscenity laws. In June 1937 the American Medical Association (AMA) approved birth control, advising physicians of their legal rights when they prescribed contraceptives.

In 1938 birth control advice and contraceptives were still forbidden in Connecticut, Mississippi, and Massachusetts. Seven birth control clinics operated in Connecticut and were tolerated by the state authorities, although the use of contraceptives remained illegal. In Mississippi, even spoken advice was banned. Three clinics were raided in 1937, and their staff arrested and fined. The remaining five Massachusetts clinics were closed down. Margaret Sanger (1879–1966) continued to campaign. By the end of the decade, she had succeeded in making birth control an important part of modern medicine. In doing so, she saved many lives.

PAYING FOR HEALTH CARE

Before the Depression, hospitals were funded from several sources. Most of their income came from endowments, which are investments given to them by wealthy supporters. They also depended on charitable gifts and the fees paid by patients. After the stock market crash of 1929, endowment income fell. The Depression also reduced the amount of money coming from charities. Between October 1929 and October 1930, the amount paid to hospitals for each patient fell from $236.12 to $59.26. But most worrisome of all was the drop in income from fees. It was a sign that people were going without proper medical care because they couldn't afford to pay for it. As a way of solving this problem, voluntary hospitals, where patients had to pay fees, turned to insurance schemes to preserve their income. Labor unions and other organizations also offered prepayment schemes. But in the middle of the Depression, few people signed up.

The Blue Cross insurance program was developed by the American Hospital Association (AHA) in 1933. For a monthly fee subscribers could have three weeks of hospital care paid for by Blue Cross. One of the principles of the scheme was that it would not make a profit. All the money went into paying hospital charges. What Blue Cross did not pay for was physicians' bills. In 1939 Blue Shield was set up to cover the cost of surgery and other treatments. Blue Shield began in California, at the same time as another prepayment plan began in Michigan. The idea soon spread around the country.

The Cost of Being Sick

In 1938, the minimum wage was set at forty cents per hour. This meant that a worker making the minimum wage earned around $800 per year. At the same time, medical costs were high. The cost of treatment for common medical conditions was as follows:

The average American could count on being unable to work through illness for eight days in each year. Treatment for a minor respiratory disease cost $5.91, and for a stomach upset, $6.89. The cost of staying in hospital, excluding any medical fees, cost around four dollars a day in a nine-bed ward.

Source: Statistical Abstract of the United States, 1940. Washington, DC: U.S. Government Printing Office, 1941.

By the late 1930s, doctors and other health workers endorsed voluntary health insurance such as the "Blues." The main advantage for health professionals was that it allowed them to continue in well-paid private practice. Insurance companies offered their own schemes, usually at greater cost, but Blue Cross and Blue Shield allowed the fee-for-service health system to survive the Depression. In Europe, countries were moving toward national health insurance schemes run by central governments and paid for through taxation. The success of the "Blues" in the 1930s is the main reason why the United States kept its voluntary hospitals and independent physicians.

Founded in 1846, by 1930 the American Medical Association (AMA) was a powerful political force. It controlled medical schools and dominated private medical practice. The AMA saw insurance schemes as a threat to doctors' freedom. It even argued that if the government or insurance companies paid medical bills, doctors would become bored and unimaginative. Because it supported insurance schemes, the Roosevelt administration was accused of trying to turn doctors into "mere laborers." The Depression made it necessary for state and federal government to be involved in funding medical services. The Farm Security Administration, for example, made deals with local medical associations to keep fees low for farm workers. When this happened, the AMA stepped in to keep fees up. In 1934, the AMA advised medical schools to limit the number of medical students. The effect of this was to reduce the number of doctors and keep fees high.

In the late 1930s, pressure grew for a national health bill. The AMA was strongly opposed to anything it saw as a challenge to physicians' freedom. Fearing that a compulsory insurance scheme would be put in place, the AMA decided to relax its stand on voluntary insurance. Partly through the efforts of the AMA, Senator Robert Wagner's 1939 health insurance bill, which proposed a compulsory national health insurance system administered by the states, was quietly dropped.

SULFA DRUGS

Before the 1930s there was no treatment for infectious diseases such as bacterial meningitis. Many people were killed by diseases that are easily treated in the twenty-first century. In 1932, the German chemist Gerhard Domagk (1895–1964) discovered that a dye called Prontosil killed the streptococcus bacteria. The active ingredient in the dye was sulfanilamide. Prontosil arrived in the United States in 1936. Perrin H. Long (1899–1965) began using it at Johns Hopkins University Hospital.

The sulfonamides, or "sulfa" drugs, seemed to be a miracle cure for a whole range of diseases. But there were problems. Some patients suffered kidney failure when treated with sulfa drugs, while others developed skin lesions and high fever. Certain diseases, such as gonorrhea, began to resist sulfa treatments, while others could not be treated at all. Then, in 1937, a chemist working in Bristol, Tennessee, made a terrible mistake. He discovered that sulfanilamide could be dissolved by a chemical called diethylene glycol. The advantage of this was that it could then be given to patients in liquid form. The "elixir" was tested for fragrance and taste and found acceptable. Unfortunately, diethylene glycol is a poison. By the time the Federal Drug Administration (FDA) found out, approximately 107 people had been killed by the medicine, including many children.

Before 1938, drug manufacturers did not have to disclose what was in their products unless the products contained narcotics. As long as their claims were not fraudulent, drug companies were free to say anything they liked about the powers of their medicines. The sulfa "elixir" scandal inspired Congress to amend the 1906 Pure Food and Drug Act. On June 27, 1938, President Roosevelt (1882–1945) signed the Food, Drug, and Cosmetic Act, one of the last New Deal measures. The Act banned misleading advertising and stated that labels had to carry clear warnings about the risks involved in taking certain drugs. All ingredients had to be listed. Most importantly, no new drug could go on the market until the FDA was happy that it was safe. The new law also applied to processed food and cosmetics. In fact, the first seizure made by the FDA under the new law was an "eyelash beautifier" that could cause blindness.

Catching the Cold Virus

Dr. Alphonse Raymond Dochez (1882–1964) was professor of medicine at Columbia University. He spent many years working on a vaccine against the common cold virus. The problem was that there was no filter fine enough to trap it. Even if there had been, no microscope was powerful enough to see it. In 1935, Dochez managed to catch some of the cold virus. For the first time, he managed to grow the virus outside the body, on a diet of chicken embryos. But making the vaccine was another matter. More than sixty years later, at the beginning of the twenty-first century, there was still no vaccine, and no cure, for the common cold.

THE TROUBLE WITH TUBERCULOSIS AND POLIO

In 1936, the U.S. Bureau of the Census estimated that of every twenty-one deaths in the United States, one was from tuberculosis (TB). Also known as consumption, phthisis, and the "great white plague," TB most commonly affects the lungs. It is transmitted when sufferers cough up the germs, which are then breathed in by others. In the 1930s, cures for TB did not exist. Patients were sent away to TB hospitals, or sanitoriums, where they had plenty of rest, fresh air, and a good diet. Sometimes the diseased parts of the lungs were removed in surgery. But most patients either recovered on their own or died.

With no cure available, the effort to stamp out TB focused on prevention. The earlier the disease was discovered, the more likely it was that the patient would survive. It also meant that people who had the disease could be kept away from those who didn't. X-ray machines already enabled doctors to see when lungs had been infected. During the 1930s, X-ray technology improved dramatically, and this helped doctors slow down the spread tuberculosis. In 1933, an X-ray machine that could take four pictures a minute made it possible for large numbers of people to be screened. School children lined up to be "shot" with portable X-ray machines. It was also discovered that TB could be transmitted through cow's milk. Tubercular cows were destroyed and milk was pasteurized to kill off any bacteria. In 1930, seventy out of every one hundred thousand Americans died from TB. By 1938, the death rate had fallen to fifty-six in every one hundred thousand.

Poliomyelitis, also known as infantile paralysis and polio, is a vicious disease. It can be fatal, but more often it cripples its victims for life. Usually polio has been a disease of the young, but its most famous victim was President Franklin D. Roosevelt (1882–1945). He was struck by the disease at the age of thirty-nine and left a paraplegic. Somehow he managed to conceal the extent of his disability. He wore strong leg braces and walked by swinging his hips while balancing with a cane. During his political career he was photographed in a wheelchair only once. Even so, Roosevelt worked hard for a cure. He spent most of his personal fortune on the rehabilitation organization Warm Springs Foundation and gave his name to a national fundraising campaign that held events on his birthday, January 30.

In 1938, Roosevelt's support for the Warm Springs Foundation helped it expand to the national level. It became the National Foundation for Infantile Paralysis. A lawyer, Basil O'Connor (1892–1972), took charge. His fundraising campaign became known as the "March of Dimes," because it collected small change from millions of donors. At basketball games a canvas would be laid on the court during half time to catch coins thrown by spectators. A Disney cartoon featuring Mickey Mouse, Donald Duck, and others, included the song:

Heigh-ho, heigh-ho
We'll lick old polio,
With dimes and quarters
And our doll-aaars…
Ho, heigh-ho!

The March of Dimes was the most successful health fundraising campaign of the 1930s. It funded research into cures for polio and the ways it was spread. This research would eventually lead to the successful polio vaccine in the 1950s.

SEXUALLY TRANSMITTED DISEASES

By the 1930s, many infectious diseases, such as typhoid, dysentery, and diphtheria, did not pose a major threat to public health. But venereal diseases (VD), transmitted through sexual contact, were out of control. There were no effective drug treatments for the major venereal diseases. Even if there had been, many Americans were too embarrassed or ashamed to seek help. Public health campaigns begun during World War I had all but failed by 1930. In 1935, the sexually transmitted disease syphilis brought disability or death to more than half a million Americans.

The spread of diseases such as syphilis and gonorrhea was made worse by the breakdown of family life during the Depression. Support for research into cures was hampered by the idea that victims of VD got what they deserved. Yet millions of dollars were spent on treatments costing up to one thousand dollars per patient. Recognizing this as a waste of money and human life, Surgeon General Thomas Parran (1892–1968) believed that VD could be controlled by changing people's behavior. By 1938, couples had to have "clean" medical certificates before they were allowed to marry. Postgraduate courses on venereal disease were set up at medical schools to educate doctors. Parran argued for federal funds to fight VD, but public opinion held back reform. In the 1930s, most Americans were ignorant, afraid, and ashamed of VD. It remained out of control for several decades more.

PSYCHOANALYSIS

Psychoanalysis is a system of solving psychological problems by identifying and confronting moments of conflict in the patient's past. It began in Europe at the beginning of the twentieth century and began to catch on in the United States in the 1930s. In 1933, the Nazis labeled psychoanalysis the "Jewish science" and burned literature pertaining to it. Many Jewish psychoanalysts fled to the United States and began to practice there. Immigrant analysts, such as René Spitz, Else Frenkel-Brunswick, Ernst Kris, and Kä the Wolf, helped to revolutionize the study and treatment of personality disorders in the United States. They made the United States the world center for psychoanalysis and psychotherapy.

THE MEDICAL PROFESSION IN THE 1930s

As medical research uncovered new ways of dealing with sickness and disease, medicine became increasingly complex. By 1930, physicians had to

understand a huge range of techniques, treatments, drugs, and ailments. Specialist clinics and hospitals sprang up, and the cost of treatment rose sharply. The difficulty of making sure patients had the best possible care was made worse by the pay-per-treatment system. This system meant that doctors and patients had to choose between the best treatment and what the patient could afford. Another major challenge facing the American medical profession in the 1930s was how to organize itself more efficiently. Health professionals opposed outside regulation, especially by federal government. They managed to avoid it by becoming more specialized and more professional.

General practitioners (GPs) had difficulty collecting their bills during the Depression. Among physicians, they earned the least, while surgeons and specialists earned the most. In 1930, specialist doctors in Wisconsin earned as much as $20,000 per year, around five times the average for doctors overall. As a result of this, tension developed between GPs and specialists. In Britain, patients had to be referred to a specialist by a GP. But in the United States, there was nothing to stop specialists from taking patients on themselves. Many GPs saw this as an opportunity to make money and began calling themselves specialists. It was only in the 1930s that the American Medical Association required specialists to be tested on their skills and abilities.

How to Avoid a Malpractice Lawsuit

By 1935, doctors were increasingly being sued for malpractice. A doctor writing in Clinical Medicine and Surgery gave the following advice on how to avoid being sued:

Never promise a cure.
Always select specialists who know more than you do.
If things have gone wrong, do not tell anyone until you know what the end result will be.
End your relationship with any patient who seems likely to go to the law.
Make sure that any sponges used in an operation are counted before the wound is stitched up."

Source: "Malpractice Protection." Time (November 18, 1935): p. 54.

Under the control of the American Medical Association (AMA), socalled "specialty boards" began to regulate the medical profession. The 1930s saw the birth of the American Board of Obstetrics and Gynecology, Internal Medicine, Surgery, Pediatrics, and many others. Each of these boards made sure that the quality of its members was maintained. Members of the board had to go through three years of training in their specialty after their general medical training or internship. Yet many problems remained. The boards themselves controlled their own standards and were not regulated from outside. Physicians had managed to stay beyond the prying eyes of federal government and the American public. Despite many improvements, the medical profession was still unregulated and disorganized by the end of the decade.