The late forties and early fifties: A memorable time in medicine

Do you remember when cardiac pacemakers were bigger than car batteries and sat on the floor next to the patient's bed? Did you ever treat intractable peripheral edema with Southey tubes? Were intravenous fluids made in the hospital where you worked, and were those fluids administered through reusable rubber tubing? Was poliomyelitis rampant in your day, and did you ever have a patient in an “iron lung”? If you answered “yes” to any of these questions, you probably trained in the late 1940s or, as I did, in the early 1950s. Medicine in those days was much different from what it is now, as further illustrated by the following examples: Most medical students and house officers were unmarried, and only about 5% of them were women. On each teaching unit, there was a small “student lab” where medical students, interns, or both, did all of the initial and follow-up blood counts, urinalyses, stool guaiac tests, stains of sputum and various other specimens, and microscopic evaluation of pleural, peritoneal, cerebrospinal, pericardial, and joint fluids. House officers had no formal contracts—just a handshake and a spoken pledge to work diligently. Trainees who lacked unflagging commitment, honesty, or sufficient competence were fired—sometimes on the spot and without warning. Because of the pyramid system of advancement, only the most skilled house officers survived the yearly cut. Interns lived in or close to the hospital and typically worked every day and every other night. In a few training programs, however, interns were always on call and never had a day off (except for a 1- or 2-week scheduled vacation). Intern compensation ranged from room and board to (as in my case) a stipend of $50 a month. The on-call intern drew morning blood samples from all of the ward patients—usually about 30, sometimes more. Syringes were made of glass, were frequently ill-fitting, and were easily broken. Needles were not disposable and, therefore, were frequently blunt. Measuring venous pressure in the antecubital space and determining the circulation time were standard procedures for evaluating cardiac inpatients. Serum potassium levels and blood-gas analyses were available once a week from research laboratories. Liver function tests included a thymol turbidity analysis, a cephalin flocculation study, and a bromsulfophthalein-dye clearance. Intensive care and coronary care units did not exist, and life-support equipment was crude. Monitoring seriously ill patients required the use of one's brain and sensory faculties, coupled with frequent trips to the bedside and long bedside vigils. Lumbar puncture and skull films were part of the standard work-up of all “stroke” patients. House officers performed liver biopsies, pleural biopsies, sternal bone marrow aspirations, and all electrocardiograms. Autopsies were common, took place at all hours of the day or night, and served as the ultimate teacher. A high autopsy rate was a requisite for the accreditation of teaching hospitals. Weekly grand rounds consisted of 2 or 3 case presentations with the patients present in the conference room for everyone to see and for a privileged few to question and examine. House officers always presented the cases and sometimes served as the discussants. Radiologists wore red goggles. Syphilitic aneurysm of the thoracic aorta was a leading cause of superior vena cava syndrome. House calls were still part of some practitioners' daily routines. The physician of record always controlled the patient's care and was the only person who wrote orders for the patient. Consultations were sought to gain new information or a new perspective—not to save time or thought, to protect against litigation, or to repay colleagues for favors. Consultants rendered opinions, not mandates. The referring physician and the consultant met at the bedside to talk with and examine the patient together. Patients with advanced rheumatic heart disease, including some with acute rheumatic fever, occupied many hospital beds. Patients with myocardial infarction were kept at absolute bed rest for up to 3 weeks and typically were not allowed to feed themselves. Their ambulation was gradual, and their return to normal activities often took 2 to 3 months. Patients with bleeding peptic ulcers routinely received a Sippy diet—small amounts of milk alternating every 30 minutes with small amounts of cream by mouth, until the bleeding stopped. Diagnosis in these patients required a barium swallow. Flexible endoscopy came along years later. For patients with diabetic acidosis, the amount of regular insulin administered depended on the degree of acidosis, which was determined by diluting the serum until it no longer gave a strongly positive ketone reaction. In most cases, the initial dose of insulin ranged from 50 to 200 units given subcutaneously, repeated every hour or so until the hyperglycemia and acidosis began to clear. If the patient was hypotensive, the insulin was administered intravenously. Health insurance was affordable and easy to obtain. Medical malpractice suits were virtually unheard of, and lawyers were physicians' friends. Pulse oximetry, ultrasonography, renal dialysis, Xeroxing facilities, and fax machines were not available. An “echo” was something that you might hear after shouting in a canyon, MRI referred to moderate renal insufficiency, and a CAT scan meant stealing a glimpse of your feline pet. Cell phones, iPads, and the Internet were yet to come, but everyone did have a personal computer—the one between the ears. Taking a good medical history and performing a good physical examination were essential steps in everyone's quest for excellence, the norm of the time. Trainees, faculty members, and practitioners considered it a privilege to be a doctor. Everyone understood and firmly believed that medicine is a calling, not a business, and that the patient comes first, always. In summary, the late '40s and early '50s were patient-centered years in which the patient was the master and the doctor was the servant. Because federally mandated regulations were minimal and constraints from insurance companies were few, physicians had the autonomy to deliver highly personal health care. As a result, the patient-doctor bond was strong. Accountability, professionalism, and devotion to duty were mainstays, and, despite hard work, long hours, and substantial challenges, practicing medicine was fun. Physicians had the public's respect, enjoyed prestige, and were proud of their noble profession. Yes, for those of us fortunate enough to have been a part of it, medicine at that time was truly memorable.