The state of medicine in late 19th & early 20th century America

For obvious reasons I decided to read, “The Great Influenza: The Epic Story of the Deadliest Plague in History” by John M. Barry. The book is an excellent read and in many chapters reads like a novel. The author personalizes the cast of characters intrepid researchers, hapless civic leaders, in a way the brings the story to life.

The first few chapters were among the most interesting as the author contextualizes the state of medicine and the biological sciences in run up to 1918.

Here are some key excerpts from Prologue & Chapter One of the book with a bit of commentary.

Medicine is truly an art and a science:

  • “Medicine is not yet and may never be fully a science.” Page 6.

Medicine has and will always be an imperfect science. Unlike other scientific fields such as physics, the laws of biology are not ironclad. Given this nuance, it is important for researchers and clinicians to think broadly, avoid confirmation bias, learn from failure, and organize theories/experiments into their smaller constituents parts. This becomes relevant in later chapters. For example, for years, scientists thought that the influenza was caused by a bacteria as they found a certain kind present in nearly all flu cases. However, the classic paradox of correlation vs causation was at play. The bacteria was a symptom of the flu and not the cause.

Experimentation and research is very much an art-form, albeit process driven. The author details how one once-famous researcher failed to make progress for years while is colleagues thrived:

  • Unlike Avery, who broke his problems down into smaller ones that could be solved and who learned from each failure, Lewis seemed simply to be applying brute force, huge numbers of experiments.” Goes on to say, “He sought to add other scientists with particular expertise to his team, but he did not define what precise role new people would play.”

Unlike Avery, his contemporary, who “recruited people with specific skills to attack a specific questions," Lewis threw resources at the problem. I couldn't help but think about the applicability of this lesson to growing a business and creating the initial traction.

Modern science is catalyzed by the Spanish Flu

  • Influenza was,“The first great collision between nature and modern science.” Page 5.

  • Hippocratic writings had stated that the physician’s senses mattered far more than any objective measurement, so despite medicine’s use of logic, physicians had always avoided applying mathematics to the study of the body or disease.”

Data driven approaches had only just started in the mid 19th century in France. American medicine lagged far behind that of Europe. Page 6. Author makes the point that the practice of medicine was akin to the “dark arts.” Little to no application of the scientific method and use of weird things like “violent purgatives” and bloodletting abounded. France led the way while American’s poorly trained physicians stumbled quite literally in the dark. Page 30.

The author makes the point to note that America was succeeding in other ways.

  • America excelled at engineering, “Physics, chemistry, and the practical arts of engineering thrived.” (31)

  • “Newly minted Harvard physician killed three successive patients because he did not know the lethal dose of morphine” (page 33). Training, qualification of doctors was minimal.

So why was the United States so far behind it's peers?

Now we get into the systems, one of the more fascinating and broadly applicable lessons

Why was the United States a backwater for science and medicine in the 19th & early 20th century? For this we look to the systems that governed the education and accreditation of doctors and researchers.

  • “Most American medical schools were owned by a faculty whose profit and salaries - even when they did not own the school - were paid by student fees, so schools often had no admission standards other than the ability to pay tuition. No medical school in American allowed medical students to routinely either perform autopsies or see patients and medical education often consisted of nothing more than two four month terms of lectures. Few medical schools had any association with a university, and fewer still had ties to a hospital. In 1870 even at Harvard a medical student could fail four of nine courses and still get an M.D.” (Page 32).

Upon his death, Johns Hopkins bequeaths an endowment for the eponymous university. The quaker estate trustees model this after the more advanced German medical colleges.

  • The ever practical quakers explained, “There was a strong demand, among the young men of this country, for opportunities to study beyond the ordinary courses of a college for a scientific school. The strongest evidence of this demand was the increased attendance of American students upon lectures of German universities.”

How fascinating that the Quakers approached this with such practical wisdom.

Hopkins changed everything.

  • “By the outbreak of World War 1, American medical science had caught up to Europe and was about to surpass it.” (35)

In order to reform, one must understand the underlying incentive structures and the captured interests. Model after the best practices of others, in this case Germany and France. It also never hurts to start anew with an endowment!

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