MEDICINE IN UTAH
Holy Cross Hospital, Salt Lake, 1909
A brief overview of medicine as it developed worldwide provides a context
for the medical history of Utah.
Medicine men and women played, and are still playing, a very important role
in primitive tribes throughout the world. Much real knowledge has accumulated,
and many drugs now in common use in modern medicine, such as digitalis and
quinine, came from this source. Taxol, from yew tree bark, used in treating
ovarian carcinoma, is the most recent addition.
Some evidence of early surgery has been found in skeletons of many primitive
peoples in the form of trephines--surgical holes in the head--which supposedly
allowed evil spirits to escape from the brain. Throughout the Middle Ages,
barber-surgeons performed amputations and other emergency procedures. The
lack of anesthesia until the mid-nineteenth century (chloroform and ether)
prevented the more widespread use of surgery. In general, these early medical
experts tried to follow the primary principle of Aristotle: "First,
do no harm!"
The beginnings of scientific medicine date to 1796 when Edward Jenner, in
England, first vaccinated milkmaids against cow pox. Not until 1840 was
it recognized that certain diseases were transmitted by external agents:
Ignaz Semmelwis in Vienna demonstrated that childbed fever was transmitted
by the dirty hands of physicians; and John Snow in London ascribed an epidemic
of cholera to contamination of water.
The science of bacteriology was initiated in the latter part of the nineteenth
century by Louis Pasteur in France and by Robert Koch in Germany. Their
work led to the identification of the offending organisms that caused pneumococcal
pneumonia, typhoid fever, and cholera, among other diseases.
In 1905 Schaudin and Hoffman identified the specific cause of syphilis.
Four years later, Paul Ehrlich initiated treatment of the disease with Salvarsan,
an arsenic compound--the first application of a specific drug in the successful
treatment of an infectious disease.
Despite the development of certain vaccines and the steadily improving hygiene
and public health, the average life expectancy did not increase significantly
during the nineteenth century. Infectious diseases continued to dominate
the practice of medicine and be the primary cause of death until the mid-1930s
when sulfonamides, the first of the antibiotics, came into use.
Medical Education in the United States and Canada
In 1870 there were 474 medical schools in the United States and Canada,
three to four times as many as there are today. Most were proprietary--groups
of doctors banding together more to enrich themselves than to educate future
physicians. Utah was no exception. In 1880 a forty-three-year-old physician,
Dr. Frederick Kohler, established the state's first medical school in Morgan,
Utah, forty-two miles northeast of Salt Lake City. In 1882 the "college"
honored its only graduating class of six students and then closed its doors.
In 1904 the Council on Medical Education of the American Medical Association
(AMA) suggested standards of six years for medical education beyond high
school and devised a classification system for rating the existing schools.
Only 82 of the 160 schools then in existence were found to be acceptable;
many others had already closed down. In 1908 the Carnegie Foundation commissioned
Dr. Abraham Flexner to assess U.S. medical schools. His report, issued in
1910, revolutionized North American medical education.
Utah Territorial Medicine (1850-1896)
During the first twenty to thirty years after the pioneers settled the Salt
Lake Valley, the only healers were "Thomsonian" doctors who acquired
their knowledge and "license" by paying $20.00 to a "Dr.
Thomson" for a book on herbal medicine and the right to dispense his
herbs. Others followed the maxim of "puke 'em, sweat 'em, purge 'em."
No wonder Brigham Young advised the Saints to heal each other by the "laying
on of hands."
Rising maternal and child death rates prompted Brigham Young to encourage
some women living in polygamy who had already borne children to study medicine
at the Woman's Medical College in Philadelphia; but there was no provision
for their financial support. When these women returned home in the summer
to earn money to support themselves during the school year, many became
pregnant again, which added to their financial and emotional woes. Ellis
Shipp began medical school in 1872 and took advanced training in obstetrics
and gynecology. The "grand old lady of Utah medicine" is credited
with founding a school of midwifery, and she delivered thousands of babies
and published widely in the areas of hygiene and public health. Another
woman, Dr. Romania Pratt, took special training in ophthalmology and performed
the first cataract operation in the territory.
However, the early prominence of women in Utah medicine lasted for only
one generation. A significant increase of female students and physicians
did not begin until the 1970s and 1980s, but with only 17 percent female
medical students in the early 1990s, Utah remains below the national average
of thirty-five percent.
Statehood (1896) to the Present
The University of Utah was founded in 1850. Fifty-five years later, in 1905,
the school's Department of Medicine was formed with six professors and an
annual budget of $10,000. The name was changed to University of Utah Medical
School in 1912, but the program was still limited to only the first two
years of a full medical course. Graduates were required to transfer to four-year
schools in the East or Midwest to complete their training.
In 1920 a new red-brick building on the university campus, constructed by
the army as a dormitory for military officers during the World War I, was
turned over to the medical school and served as the basic science building
until 1965. With the nation's entry into World War II in 1941, pressure
was exerted by the AMA and the U.S. Army to convert the two-year school
to a full four-year medical school, since none existed between Denver and
The expansion was approved in 1942, and the Salt Lake General Hospital at
21st South and State streets, the state's only public hospital, was designated
as the university's teaching facility. Dr. A.C. Callister, a practicing
surgeon appointed part-time dean in 1942, was surprisingly successful in
recruiting a small but outstanding group of physicians, teachers, and researchers,
in spite of the appalling lack of funding and facilities and a severe nationwide
shortage of physicians.
Conditions at the Salt Lake General Hospital were poor. An interesting incident
is characteristic of the early years: in 1944 the chief resident in surgery
was performing surgery on a patient when, in the middle of the operation,
all lights went out. He called out for the hospital engineer, who was the
only person familiar with the antiquated wiring and plumbing of the decaying
structure. Suddenly, the staff remembered that the engineer was the patient
on the operating table. The procedure was completed by flashlight illumination,
and the patient recovered satisfactorily.
The nucleus of the four-year faculty arrived between 1943 and 1945. Dr.
Philip Price and Dr. Maxwell Wintrobe came from Johns Hopkins; Drs. John
Anderson, Robert Alway, and A. Louis Dippel, Emil Holmstromb, and Dr. Leo
Samuels, came from the University of Minnesota; Dr. Louis Goodman and Dr.
Thomas F. Dougherty came from Yale.
From the very beginning, this was no ordinary medical school. The commitments
to teaching, quality of patient care, and research were remarkable. The
school started with a dreadfully inadequate physical plant and a minimal
budget supported by a state population of only 600,000. Outstanding teachers
included Drs. Lou Goodman, Max Wintrobe, and Tom Dougherty. Goodman (pharmacology)
was the author of the textbook The Pharmacologic Basis of Therapeutics,
used the world over, then and now; more than one and a half million copies
have been printed, in sixteen languages. Max Wintrobe, author of the pioneer
textbook on hematology, was an outstanding teacher, researcher, and administrator.
A hard-working, strict disciplinarian who set very high standards, he required
demanding individual case presentations. He refused to accept married house
officers, with the explanation that "you can only have one love--medicine."
After a senior resident got married secretly, for fear of being fired, the
unwritten rule was rescinded in 1950. Tom Dougherty was a man of ideas.
He posed questions that stimulated others to initiate research projects
and was prolific in his own output as well.
At the end of World War II, Leo Marshall, professor of public health and
twice acting dean of the University of Utah Medical School, suggested to
Senator Elbert Thomas of Utah that it would be very useful if wartime support
for scientific research given to the armed services could be adapted to
the support of civilian scientific institutions through the public health
service. As a result of Senator Thomas's efforts, Congress appropriated
$100,000, but 100 grant applications were received. Senator Thomas prevailed
in awarding the entire $100,000, then a princely sum, to the University
of Utah. The grant was renewed for twenty-eight years under Dr. Wintrobe's
direction and amounted to many millions of dollars.
The initial town-and-gown relationship between practicing physicians and
the university faculty left something to be desired. Some physicians actually
opposed the formation of the four-year school, fearing competition for their
patients. Dr. Hans Hecht, pioneer academic cardiologist, and Dr. Ernst Eichwald,
pathologist and early expert on tissue transplantation--both graduates of
German medical schools--were required to enroll as senior students in the
medical school to obtain American M.D. degrees in order to be licensed in
Utah. The Utah State Board of Examiners was unwilling to grant an exemption
in spite of the outstanding contributions both men were already making in
their respective fields. Fortunately, this tension disappeared as some of
the oldtimers died out and graduates of the University of Utah formed a
large majority of the area's practicing physicians.
Hans Hecht exemplifies the ingenuity, modesty, and commitment of the early
faculty. When he arrived in 1944, at a salary of $2,000 per year, no space
could be found for his activities. He noticed an auditorium in the infirmary
and suggested having the floor rebuilt. The triangular space created served
as the heart station and Hecht's research laboratory for many years.
The growth of the medical school profoundly affected the quality of medicine
in Utah and especially in the Wasatch Front communities. The presence of
the four-year school not only brought many well-qualified experts to the
faculty but also acted as a powerful magnet to attract well-trained specialists
from many other centers to practice in the community and to seek clinical
(teaching) appointments in the medical school. More and more of the best
medical students from Utah were guided by the faculty to the best post-graduate
training programs in the East and Midwest. The new doctors returned to fill
vacancies on the faculty or to relieve shortages in the community. The medical
school also stimulated an unusual amount of research in the local private
hospitals. The increasing number of training programs at the University
of Utah Medical School provided more and more specialists in Salt Lake City,
Ogden, Provo, and eventually throughout Utah and the entire Intermountain
The original postwar faculty of six members in the Department of Medicine
covered the entire field of internal medicine, took care of all medical
patients, taught medical students on a four-quarter schedule, and initiated
significant research programs. Drs. Max Wintrobe and George Cartwright concentrated
on hematology, Hans Hecht on cardiology, Frank Tyler on endocrinology and
metabolism, Val Jager on neurology and syphilology, and Utah native John
Waldo on infectious diseases. Two additional departments have since been
created: Neurology and Family and Preventive Medicine. By 1992 the Department
of Medicine had grown to 202 members in thirteen divisions. The Department
of Surgery, consisting of three full-time members in 1947, now comprises
eighty-one members in ten divisions, and two divisions have become separate
departments: Ophthalmology and Neurosurgery.
Practice of Medicine
The general practitioner was the main supplier of medical care throughout
the first half of the twentieth century. After graduation from medical school,
he (or much less frequently, she) spent one or two years in an internship
and frequently apprenticed himself for a few years to an older practitioner.
He took care of all members of the family, regardless of age, delivered
babies, diagnosed and treated medical illnesses, and performed a fair amount
of surgery. The family doctor, as a valued friend and counselor, made many
house calls and often was loved and respected.
Specialization in internal medicine and surgery began after World War I.
Many physicians assigned to specialty wards in military hospitals proceeded
to take special training after their discharge, often working at the fine
medical centers in Europe--Berlin, Vienna, London, and Edinburgh. Specialty
boards began to be formed in the 1930s and 1940s, and formal three-to-five-year
residencies were soon required in many fields. Some Utah physicians who
had restricted their practices to certain specialties before World War I
were the key organizers of several clinics in Salt Lake City, notably the
Salt Lake Clinic (1915), Intermountain Clinic (1917), Bryner Clinic (1941),
and Memorial Medical Center (1953).
The specialization process was vastly accelerated by World War II. The G.I.
Bill of Rights enabled many veteran physicians to enter specialty training
and qualify for board examination, changing the character of medical practice
in the late 1940s and 1950s.
The general internist began to replace the general practitioner as the primary-care
physician, especially in urban areas, and also became the consultant to
the general practitioner in more complicated problems of diagnosis and treatment.
The increasing subspecialization of surgery into orthopedic, eye, ear-nose-throat,
chest, neuro-plastic, pediatric surgery, etc., continued to erode the field
of the general surgeon.
In the late 1950s and 1960s, further subspecialization of internal medicine
changed some areas from predominantly "thinking" to "doing"
fields. The gastroenterologist learned to pass scopes through the mouth
and the rectum, and the pulmonologist started to use the bronchoscope. The
cardiologist began implanting cardiac pacemakers and passing catheters.
The increased compensation for these procedures helped to lure young physicians
into the subspecialties, and the general internist became an endangered
Fortunately, the Department of Family and Preventive Medicine at the University
of Utah, formed in 1970 by Dr. C. Hilmon Castle, created a three-year residency
in Family Practice leading to medical board certification. This program
stresses the areas of medicine and pediatrics but also provides some training
in obstetrics, surgery, and psychiatry, tailored to some degree to the location
of the intended practice. From 1970 to 1992, 262 family practice physicians
were graduated, of whom half chose to practice in smaller communities and
rural areas to replace the vanishing general practitioner.
Since the 1970s and 1980s, preventive medicine has suffered from the lack
of primary-care physicians. Patients without a family doctor and those who
have no insurance and can't afford preventive medical care have been flocking
to hospital emergency rooms, having neglected early warning signs. There,
with no previous acquaintance with the physician and no medical "history,"
they receive the most expensive and most impersonal form of medical care.
While "hanging out a shingle" was the expected step following
medical training in the past, fewer and fewer young physicians now go into
solo practice or join another physician. The cost of setting up an office
after having incurred considerable debt going to school, as well as the
prospect of having to be at the beck and call of patients at all hours and
on weekends, directs many young M.D.s to seek employment by hospital emergency
rooms, existing clinics, or health maintenance organizations (HMOs).
Family Health Plan (FHP), the first and largest Utah HMO, began operations
in Utah in 1976 and by 1992 cared for 140,000 patients annually. HMOs are
attractive to the employer who pays much of the cost of employees' health
insurance because of their generally lower rates and broader coverage. The
patient chooses a primary-care physician--internist, family practitioner,
or pediatrician. These doctors see the patients first and decide on procedures
and, if necessary, refer them to specialists. Another physician is frequently
substituted, particularly when a patient is hospitalized, since the physician
is obligated to work only 40 to 44 hours per week. Physicians are on salary
but are rewarded for keeping costs down. The average age of patients covered
by HMOs is significantly lower than that of the population at large.
Primary Children's Hospital, Salt Lake, 1946
Some Outstanding Research Accomplishments
Utah physicians and medical researchers have made many important contributions,
locally, nationally, and internationally. A few significant landmarks are
In 1900 the major causes of death were infectious diseases such as pneumonia,
tuberculosis, and the childhood diseases. By mid-century heart disease,
stroke, and cancer had climbed to the top of the list, with infectious diseases
at the bottom. Technological advances in public health (such as water- and
sewage-treatment plants) played a major role in nearly eliminating intestinal
infections in the United States, and vaccination accomplished wonders in
reducing childhood diseases. Simultaneously, however, increased tobacco
and alcohol use, and other lifestyle changes, as well as rapidly increasing
pollution by chemicals and radiation, contributed to the increase in cancer
and heart disease.
In the 1940s and 1950s, a concerted effort by several cooperating departments
of the University of Utah Medical Center, under the leadership of Dr. Leo
Samuels, resulted in significant new knowledge concerning the chemistry
and physiology of the adrenal glands.
Dr. Frank Tyler and his associates in the Department of Medicine laid the
groundwork for later genetic studies through their investigation of several
familial diseases such as muscular dystrophy, phenylketonuria, polyposis
of the bowel, and others. Geneticist Eldon Gardner studied familial polyposis
of the large bowel associated with benign subcutaneous tumors (Gardner's
Syndrome). Radiologist Henry Plenk discovered multiple bony tumors associated
in all patients with this condition (Plenk-Gardner Syndrome).
The hematology section explored the mechanisms and treatment of various
anemias and supported Wintrobe's pioneering efforts in treating lymphomas
and leukemias with chemotherapy. Utah was selected as one of four centers
funded to develop a polio vaccine; the breakthroughs came in Pittsburgh
in 1953 and in Cincinnati in 1954. Through inventive public-vaccination
campaigns, poliomyelitis was effectively wiped out. The infectious disease
section played a major role in the recognition of toxic shock syndrome in
women and its relationship to a brand of "super" tampons being
In gastroenterology, the development of newer drugs to reduce gastric acidity
reduced the need for gastric resection of peptic ulcers. The development
and perfection of upper and lower gastrointestinal (G.I.) flexible endoscopy
revolutionized the diagnosis and treatment of many diseases of the G.I.
tract and allowed biopsies and removal of polyps without major surgery.
In pulmonary medicine, a drive to eradicate tuberculosis by early diagnosis
and chemoprophylaxis with the drug Isoniazid led to a dramatic reduction
of the disease, particularly among the state's Native American population,
and the eventual closing of the State Tuberculosis Hospital in Roy, Utah,
LDS Hospital played a leading role in pioneering a pulmonary function laboratory
and setting up the first shock/trauma intensive care unit (ICU). In conjunction
with the University of Utah, LDS created a program in occupational and environmental
health and critical care. Life Flight by helicopter or fixed-wing aircraft
speeded up the initiation of critical care.
The institution of hemodialysis for renal failure prolonged many lives,
but kidney transplants eventually proved not only more effective but also
less expensive. The first renal transplant in Utah was performed at Salt
Lake General Hospital in 1965, and the patient was still living in 1992.
Dr. Willem J. Kolff, the originator of hemodialysis, the artificial kidney,
and artificial heart, joined the University of Utah Medical Center in 1968.
This major boost to the artificial organs program resulted in the implanting
of an artificial heart in dentist Barney Clark in 1982. Pioneering artificial
eyes, ears, and arms have been additional tangible results.
Dr. Ray Rumel was the pioneer thoracic surgeon. His removal of a lobe of
the lung for cancer at LDS Hospital, resulting in a nineteen-year survival
for the patient, was a truly innovative procedure in 1942. Then came open-heart
surgery to correct congenital cardiac abnormalities and to replace defective
valves. Reconstruction of narrowed blood vessels, aorta, renal arteries,
and coronary arteries prevented many complications of arteriosclerosis.
Continued progress in thoracic surgery led to the formation of a team of
surgeons doing heart transplants in four hospitals. The survival rate of
90 percent one year after surgery in 412 transplants performed from 1985
to 1992 is one of the best in the country.
Homer Warner deserves credit for developing the most sophisticated system
of utilizing computers in total patient care, making LDS Hospital a model
for the world.
One of the most far-reaching new tools, the laser, was applied to medicine
by John A. Dixon. The laser is now used in most surgical specialties worldwide
to stop bleeding and to destroy malignant tissues, among other uses. Between
1982 and 1992, more than 1,500 patients were treated with his new device,
and more than 1,500 physicians from all over the world were trained at the
University of Utah to use the method successfully. Except for some minor
burns, no serious complications were encountered during the development
of the procedures. The dramatic decrease in neonatal deaths from fifteen
to three per 1,000 live births in Utah during the twenty-year period from
1968 to 1988 was due in great part to the efforts of Dr. August L. Jung,
who created neonatal intensive care units (NICUs) first at the University
of Utah, Primary Children's Medical Center, and LDS Hospital, and then in
all major hospitals in the area.
Dr. David Bragg (appointed in 1970) changed the character of the Department
of Radiology at the university and the practice of radiology in the state
by introducing many modern methods such as angiography, CT and MRI scanning,
and interventive radiology. Through his success in attracting massive research
grants, his staff has produced a prolific scientific output (150 to 200
papers per year) as well as some fifty textbooks.
The first modern radiation therapy facility between Denver and the Pacific
Coast was established by Drs. Henry P. Plenk and Richard Y. Card at St.
Mark's Hospital in 1960. The Tumor Institute became the Radiation Center
when it moved to a yet more modern facility at LDS Hospital in 1969. Plenk
pioneered in the use of two procedures to enhance the effect of radiation
on tumors: hyperbaric oxygen and hyperthermia. Intraoperative radiation
therapy was another major innovation fostered by Drs. William T. Sause and
R. Dirk Noyes at LDS Hospital.
The Division of Radiation Oncology at the University of Utah was instituted
in 1971 with the appointment of Dr. J. Robert Stewart, who established a
productive section in radiation biology. He and his staff became very involved
in hyperthermia. In 1986 Stewart became director of an important cancer
center at the University of Utah and affiliated hospitals.
Sports medicine emerged in the early 1970s, largely as a result of the development
of arthroscopy by Dr. Robert Metcalf, team physician at Brigham Young University
and later a University of Utah Medical School staff member. The procedure
revolutionized knee surgery and is now used in shoulder surgery as well.
Prosthetic replacement of hips and knees was also a major advance.
Among the many advances in general surgery, two innovations deserve special
mention: the use of staples in place of sutures, and the use of the peritoneoscope,
first to explore the abdomen and more recently in the performance of actual
procedures such as removal of the gallbladder or uterus.
From the beginning of the computerization by Dr. Mark Skolnick of the genealogical
library of the LDS Church, Raymond Gesteland, Ray White, and colleagues
have been very successful in proving the genetic origin of many disease
and in pinpointing specific locations of important disease genes. The Institute
of Human Genetics houses three major programs: the Department of Human Genetics,
the Human Molecular Biology and Genetics Program, and the Center for Human
Genome Research, one of six such centers in the United States.
Medical Practice: Then, Now, and in the Future
In spite of the phenomenal progress in the science of medicine and
the many contributions of Utah physicians, the art of medicine nationwide
took a step backward in the late twentieth century. Prior to the initiation
of Medicare in 1966, physicians felt responsible for taking care of all
patients, regardless of their ability to pay, either in tax-supported hospitals
or in their offices. Even many private hospitals had charity services.
Medicare certainly had a profound effect on the practice of medicine by
removing the elderly and many widows from the medically indigent group,
while high inflation during the 1970s and 1980s, rapid progress in medical
technology, and further implementation of technical procedures boosted the
cost of medical care. A significant increase in the number of medical school
graduates with an even higher percentage training in the subspecialties
rather than the primary care areas (internal and family medicine, pediatrics,
and obstetrics) contributed to rising costs.
Three further events had a devastating effect. First, a ruling by the Federal
Trade Commission in 1979, supported by a Supreme Court decision in 1982,
declared medicine (as well as law) a "business" rather than a
"profession." This opened the floodgates to advertising by physicians
and hospitals, which fostered excessively luxurious buildings and facilities
to compete for physicians and their referrals. Second, administrative costs
skyrocketed because of government regulations and insurance requirements,
eating up more than twenty percent of the medical dollar. Third, the abandonment
of the tightly controlled "certificate of need" in 1985 deregulated
local decision-making regarding requirements for new facilities and equipment
and allowed a very wasteful duplication of hospitals and expensive machines.
Six new psychiatric hospitals were quickly built in Utah, whereas, only
a short time before, a few wards had filled the need.
The result of these errors and omissions was that thirty-five percent of
the population was without any health insurance coverage, and sixty to seventy
million people nationwide were without adequate access to high-quality medical
Reform of the medical care system was an important issue in the 1992 election
campaign. Numerous plans were supported by the candidates and discussed
in congressional committees. The American College of Physicians, the largest
medical organization in the United States after the AMA, supported the concept
that adequate medical care is a right, not a privilege, and that universal
access can be achieved only through system-wide reform. It suggested four
principles: (1) assuring access to care; (2) assuring high-quality, comprehensive
coverage; (3) promoting innovation and excellence; and (4) controlling costs
by a combination of employee-sponsored and publicly sponsored insurance
covering the entire population. To bring these changes about, private insurance
companies would need to provide benefits identical to those in publicly
sponsored plans. All patients would be eligible regardless of prior existing
conditions; coverage could not be canceled and could be transferred to other
It was considered imperative by policy makers and practitioners that national
health care spending be capped at the 1992 level of $800 billion. The savings
gained by eliminating inflated administrative costs, needless duplication
of facilities, overpriced care, and unnecessary malpractice suits would
provide for complete coverage of the entire population.
In the early 1990s, several communities and some states were well on their
way to achieving these lofty goals. The state of Hawaii has been very successful
in providing comprehensive coverage to an increasing segment of the population
since 1975. By 1992, 98 percent of the population was included, and a goal
of 100 percent was anticipated. Hawaii's system stresses primary and preventive
care and eliminates elective procedures and much high-tech tertiary care,
especially in the terminal patient.
For many Utahns as well as other Americans, health and medical care had
replaced war and the threat of nuclear destruction as the most important
issues facing the nation at the end of the century. Those decisions made
in the coming years will undoubtedly affect every citizen.
See: Henry P. Plenk, ed., Medicine in the Beehive State: 1940-1990.
Henry P. Plenk