The Great Influenza (5 page)

Yet the real point at which modern medicine diverged from the classic was in the studies of pathological anatomy by Louis and others. Louis not only correlated treatments with results to reach a conclusion about a treatment's efficacy (he rejected bleeding patients as a useless therapy), he and others also used autopsies to correlate the condition of organs with symptoms. He and others dissected organs, compared diseased organs to healthy ones, learned their functions in intimate detail.

What he found was astounding, and compelling, and helped lead to a new conception of disease as something with an identity of its own, an objective existence. In the 1600s Thomas Sydenham had begun classifying diseases, but Sydenham and most of his followers continued to see disease as a result of imbalances, consistent with Hippocrates and Galen. Now a new 'nosology,' a new classification and listing of disease, began to evolve.

Disease began to be seen as something that invaded solid parts of the body, as an independent entity, instead of being a derangement of the blood. This was a fundamental first step in what would become a revolution.

Louis's influence and that of what became known as 'the numerical system' could not be overstated. These advances (the stethoscope, laryngoscope, opthalmoscope, the measurements of temperature and blood pressure, the study of parts of the body) all created distance between the doctor and the patient, as well as between patient and disease; they objectified humanity. Even though no less a personage than Michel Foucault condemned this Parisian movement as the first to turn the human body into an object, these steps had to come to make progress in medicine.

But the movement was condemned by contemporaries also. Complained one typical critic, 'The practice of medicine according to this view is entirely empirical, is shorn of all rational induction, and takes a position among the lower grades of experimental observations and fragmentary facts.'

Criticism notwithstanding, the numerical system began winning convert after convert. In England in the 1840s and 1850s, John Snow began applying mathematics in a new way: as an epidemiologist. He had made meticulous observations of the patterns of a cholera outbreak, noting who got sick and who did not, where the sick lived and how they lived, where the healthy lived and how they lived. He tracked the disease down to a contaminated well in London. He concluded that contaminated water caused the disease. It was brilliant detective work, brilliant epidemiology. William Budd borrowed Snow's methodology and promptly applied it to the study of typhoid.

Snow and Budd needed no scientific knowledge, no laboratory findings, to reach their conclusions. And they did so in the 1850s, before the development of the germ theory of disease. Like Louis's study that proved that bleeding was worse than useless in nearly all circumstances, their work could have been conducted a century earlier or ten centuries earlier. But their work reflected a new way of looking at the world, a new way of seeking explanations, a new methodology, a new use of mathematics as an analytical tool.
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At the same time, medicine was advancing by borrowing from other sciences. Insights from physics allowed investigators to trace electrical impulses through nerve fibers. Chemists were breaking down the cell into its components. And when investigators began using a magnificent new tool (the microscope equipped with new achromatic lenses, which came into use in the 1830s) an even wider universe began to open.

In this universe Germans took the lead, partly because fewer French than Germans chose to use microscopes and partly because French physicians in the middle of the nineteenth century were generally less aggressive in experimenting, in creating controlled conditions to probe and even manipulate nature. (It was no coincidence that the French giants Pasteur and Claude Bernard, who did conduct experiments, were not on the faculty of any medical school. Echoing Hunter's advice to Jenner, Bernard, a physiologist, told one American student, 'Why think? Exhaustively experiment, then think.')

In Germany, meanwhile, Rudolf Virchow (both he and Bernard received their medical degrees in 1843) was creating the field of cellular pathology, the idea that disease began at the cellular level. And in Germany great laboratories were being established around brilliant scientists who, more than elsewhere, did actively probe nature with experiments. Jacob Henle, the first scientist to formulate the modern germ theory, echoed Francis Bacon when he said, 'Nature answers only when she is questioned.'

And in France, Pasteur was writing, 'I am on the edge of mysteries and the veil is getting thinner and thinner.'

Never had there been a time so exciting in medicine. A universe was opening.

Still, with the exception of the findings on cholera and typhoid (and even these won only slow acceptance) little of this new scientific knowledge could be translated into curing or preventing disease. And much that was being discovered was not understood. In 1868, for example, a Swiss investigator isolated deoxyribonucleic acid, DNA, from a cell's nucleus, but he had no idea of its function. Not until three-quarters of a century later, at the conclusion of some research directly related to the 1918 influenza pandemic, did anyone even speculate, much less demonstrate, that DNA carried genetic information.

So the advances of science actually, and ironically, led to 'therapeutic nihilism.' Physicians became disenchanted with traditional treatments, but they had nothing with which to replace them. In response to the findings of Louis and others, in 1835 Harvard's Jacob Bigelow had argued in a major address that in 'the unbiased opinion of most medical men of sound judgment and long experience' the amount of death and disaster in the world would be less, if all disease were left to itself.'

His address had impact. It also expressed the chaos into which medicine was being thrown and the frustration of its practitioners. Physicians were abandoning the approaches of just a few years earlier and, less certain of the usefulness of a therapy, were becoming far less interventionist. In Philadelphia in the early 1800s Rush had called for wholesale blood-letting and was widely applauded. In 1862 in Philadelphia a study found that, out of 9,502 cases, physicians had cut a vein 'in one instance only.'

Laymen as well were losing faith in and becoming reluctant to submit to the tortures of heroic medicine. And since the new knowledge developing in traditional medicine had not yet developed new therapies, rival ideas of disease and treatment began to emerge. Some of these theories were pseudoscience, and some owed as little to science as did a religious sect.

This chaos was by no means limited to America. Typical was Samuel Hahnemann, who developed homeopathy in Germany, publishing his ideas in 1810, just before German science began to emerge as the dominant force on the Continent. But nowhere did individuals feel freer to question authority than in America. And nowhere was the chaos greater.

Samuel Thomson, founder of a movement bearing his name that spread widely before the Civil War, argued that medicine was simple enough to be comprehended by everyone, so anyone could act as a physician. 'May the time soon come when men and women will become their own priests, physicians, and lawyers when self-government, equal rights and moral philosophy will take the place of all popular crafts of every description,' argued his movement's publication. His system used 'botanic' therapeutics, and he charged, 'False theory and hypothesis constitute nearly the whole art of physic.'

Thomsonism was the most popular layman's medical movement but hardly the only one. Dozens of what can only be called sects arose across the countryside. A Thomsonian rhyme summed up the attitude: 'The nest of college-birs are three, /
Law, Physic and Divinity;
/ And while these three remain combined, / They keep the world oppressed and blind /' Now is the time to be set free, / From priests' and Doctors' slavery.'

As these ideas spread, as traditional physicians failed to demonstrate the ability to cure anyone, as democratic emotions and anti-elitism swept the nation with Andrew Jackson, American medicine became as wild and democratic as the frontier. In the 1700s Britain had relaxed licensing standards for physicians. Now several state legislatures did away with the licensing of physicians entirely. Why should there be any licensing requirements? Did physicians know anything? Could they
heal
anyone? Wrote one commentator in 1846, 'There is not a greater aristocratic monopoly in existence, than this of regular medicine - neither is there a greater humbug.' In England the title 'Professor' was reserved for those who held university chairs, and, even after John Hunter brought science to surgery, surgeons often went by 'Mister.' In America the titles 'Professor' and 'Doctor' went to anyone who claimed them. As late as 1900, forty-one states licensed pharmacists, thirty-five licensed dentists, and only thirty-four licensed physicians. A typical medical journal article in 1858 asked, 'To What Cause Are We to Attribute the Diminished Respectability of the Medical Profession in the Esteem of the American Public?'

By the Civil War, American medicine had begun to inch forward, but only inch. The brightest lights involved surgery. The development of anesthesia, first demonstrated in 1846 at Massachusetts General Hospital, helped dramatically, and, just as Galen's experience with gladiators taught him much anatomy, American surgeons learned enough from the war to put them a step ahead of Europeans.

In the case of infectious and other disease, however, physicians continued to attack the body with mustard plasters that blistered the body, along with arsenic, mercury, and other poisons. Too many physicians continued their adherence to grand philosophical systems, and the Civil War showed how little the French influence had yet penetrated American medicine. European medical schools taught the use of thermometers, stethoscopes, and ophthalmoscopes, but Americans rarely used them and the largest Union army had only half a dozen thermometers. Americans still relieved pain by applying opiate powders on a wound, instead of injecting opium with syringes. And when Union Surgeon General William Hammond banned some of the violent purgatives, he was both court-martialed and condemned by the American Medical Association.

After the Civil War, America continued to churn out prophets of new, simple, complete, and self-contained systems of healing, two of which, chiropractic and Christian Science, survive today. (Evidence does suggest that spinal manipulation can relieve musculoskeletal conditions, but no evidence supports chiropractic claims that disease is caused by misalignment of vertebrae.)

Medicine had discovered drugs (such as quinine, digitalis, and opium) that provided benefits, but, as one historian has shown, they were routinely prescribed indiscriminately, for their overall effect on the body, not for a specific purpose; even quinine was prescribed generally, not to treat malaria. Hence Oliver Wendell Holmes, the physician father of the Supreme Court justice, was not much overstating when he declared, 'I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind (and all the worse for the fishes.)'

There was something else about America. It was such a practical place. If it was a nation bursting with energy, it had no patience for dalliance or daydreaming or the waste of time. In 1832, Louis had told one of his most promising protegés (an American) to spend several years in research before beginning a medical practice. The student's father was also a physician, James Jackson, a founder of Massachusetts General Hospital, who scornfully rejected Louis's suggestion and protested to Louis that 'in this country his course would have been so singular, as in a measure to separate him from other men. We are a business doing people' . There is a vast deal to be done and he who will not be doing must be set down as a drone.'

In America the very fact that science was undermining therapeutics made institutions uninterested in supporting it. Physics, chemistry, and the practical arts of engineering thrived. The number of engineers particularly was exploding (from 7,000 to 226,000 from the late nineteenth century to just after World War I) and they were accomplishing extraordinary things. Engineers transformed steel production from an art into a science, developed the telegraph, laid a cable connecting America to Europe, built railroads crossing the continent and skyscrapers that climbed upward, developed the telephone - with automobiles and airplanes not far behind. The world was being transformed. Whatever was being learned in the laboratory about biology was building basic knowledge, but with the exception of anesthesia, laboratory research had only proven actual medical practice all but useless while providing nothing with which to replace it.

Still, by the 1870s, European medical schools required and gave rigorous scientific training and were generally subsidized by the state. In contrast, most American medical schools were owned by a faculty whose profits and salaries (even when they did not own the school) were paid by student fees, so the schools often had no admission standards other than the ability to pay tuition. No medical school in America 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.

In the United States, a few isolated individuals did research (outstanding research) but it was unsupported by any institution. S. Weir Mitchell, America's leading experimental physiologist, once wrote that he dreaded anything 'removing from me the time or power to search for new truths that lie about me so thick.' Yet in the 1870s, after he had already developed an international reputation, after he had begun experiments with snake venom that would lead directly to a basic understanding of the immune system and the development of antitoxins, he was denied positions teaching physiology at both the University of Pennsylvania and Jefferson Medical College; neither had any interest in research, nor a laboratory for either teaching or research purposes. In 1871 Harvard did create the first laboratory of experimental medicine at any American university, but that laboratory was relegated to an attic and paid for by the professor's father. Also in 1871 Harvard's professor of pathologic anatomy confessed he did not know how to use a microscope.