Even with all the incredible advances in medicine over the past 70 years, there remain severe deficits in the care of many serious deadly diseases. Pancreatic cancer, multiple sclerosis, glioblastoma, Alzheimer’s, ALS, and ovarian cancer easily come to mind in that desperate category.

However, let’s get a perspective of what it was really like to practice medicine a hundred years ago. What kind of doctors were there? What did they do? What did they have available to use? What was their life like, and how far along was the discipline of medicine? The changes have been so drastic it is worth having an insight into that history.

The post-Flexner revolution

The world of medicine in 1926 had been going through a scientific revolution for the previous hundred years, and the practice and education of medicine had been nearly revamped with the publication and adoption of the Flexner Report of 1910. This disrupting and enlightening study illustrated the generally extremely substandard hospital care and medical school education in the U.S., which resulted in the closing of over half, largely the “for-profit” schools.

New standards for medical education were modeled on the scientifically based German method, and medical schools became nearly all tied to large universities, with Johns Hopkins being the model institution and standard setter.

In 1926, one would find a plurality of physicians practicing, many “old school” docs with minimal modern science or hospital experience and newer, more up-to-date trained physicians. The vast majority of physicians were generalists, as the burgeoning specialties of obstetrics, neurology, and psychiatry had few in numbers.

The limitations of the generalist

Generalists may have had one year of training in a hospital, but many did not. The vast majority worked alone and did most of their care as home visits, evaluating a patient’s illness with their only tools being a stethoscope, blood pressure cuff, and thermometer.

They could diagnose various ailments but had very limited therapeutics, which included morphine for pain, digitalis for heart failure, quinine for malaria, and various cathartics and purgatives. They could perform incision and drainage of skin infections, and they commonly delivered babies in the home.

Some had hospital duties where they saw, counseled, and observed severely ill patients (cancer, stroke, heart attacks, post-op, etc.), but since there were no medicines and no IV treatments, most of the care was comfort and informing the patient and family. Hospitals were thought of as a place where one went to die.

This was the era before antibiotics, IV fluids, other medications, and blood transfusions. Even though EKG machines had been invented, they were rarely used and only in large hospitals; the same was generally true for X-ray equipment. There was no other diagnostic equipment such as CT, MRI, or ultrasounds for another 30 to 40 years.

For the generalists, there were extremely limited lab tests available, and none were automated. Manual CBC, urine dipstick, microscopy, and limited serology for syphilis (Wasserman) and typhoid were around, as was culturing for infections, but again mostly available in hospitals and larger communities, not in rural areas.

Mortality and the insulin breakthrough

Death was commonplace in the hospital and at home then. The maternal mortality rate was nearly 1 percent, with sepsis, hemorrhage, and pre-eclampsia leading causes. The infant mortality rate was falling due to sanitation and milk safety but still was in the range of nearly 10 percent in 1926 due to delivery complications (asphyxia) and pre-term births (today the rate is approximately 5/1000 or 0.5 percent).

However, even surviving childbirth, the rate of young children deaths (age 1 to 4) was quite high due to infectious diseases like whooping cough, diphtheria, enteritis, TB, and measles. It would still be a few years before the diphtheria vaccine became widespread to stop the awful infectious asphyxiation of young children that was common. The only common vaccine used and available was smallpox, which was developed 100 years prior and has been estimated to save more lives than any other health measure ever.

One developing bright spot of therapeutics was the availability of formulations of insulin discovered in 1922 by Banting and Best. It became commercially produced from pig and cow pancreas extracts within a few years for Type 1 diabetics who previously uniformly died a harsh metabolic death at a young age. However, it was often difficult to properly adjust the dosages due to lack of glucose testing and limitations of urine testing, and severe hypoglycemia was a common complication.

Surgery: A risky but evolving discipline

In contrast to generalist practice with its severe limitation of therapeutics, surgery had emerged as a more scientific and evolved discipline with most practitioners having done some form of formal training after medical school, and all were well informed in anatomy. There were a few residency programs around, such as the 5-year program at Johns Hopkins, which eventually became the country-wide model over the following 10 years.

Surgery could be done reasonably safely with sterile technique being universal and use of general anesthesia (ether or chloroform), but endotracheal intubation was not available yet. The use of intravenous morphine allowed post-op pain to be minimalized. However, there were no antibiotics for infections and no advanced imaging, and surgical decision-making was individualized.

The surgical profession was entirely male, filled with “strong” personality types. Without consistent hemostatic techniques (no cautery, etc.), routine blood transfusion, IV fluids, or ICU care, patients could easily die post-op of severe blood loss, sepsis, or wound dehiscence. Post-op infections and complications were common.

It has been estimated that abdominal surgery (gallbladder, stomach ulcer, appendectomy, etc.) carried a mortality rate approaching 25 percent! Operations in the chest or brain were nearly unheard of due to lack of understanding and technical limitations. Despite all this, surgery still had a real chance of saving a life as compared with the mostly passive observations of their medical counterparts.

To me, it is obvious an enormous amount of progress has occurred in medicine in the last 100 years! However, I have often wondered if I would have been interested or survived practicing in that era as a generalist.

George F. Smith is an internal medicine physician and author of Tales from the Trenches: A life in Primary Care.