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Week6_Rosenberg1 - THE CARE OF STRANGERS The Rise of....

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Unformatted text preview: THE CARE OF STRANGERS The Rise of. America’s Hospital System Charles E. Rosenberg “as 1 lopmna aversfiy 1 1:3: Baltimore and London CHAPTER 6 The Promise of Healing: Science in the Hospital In 1866, the New York Hospital closed: its building on Chambers Street was old, operating revenues were inadequate—and its land was too valuable. For a decade the hospital’s trustees medical staff debated the institution's future. Where should the Board of Governors build a new hospital to fulfill its historical obligation to provide medical care, and what kind of building should they ap- prove? It was not simply an esthetic or economic debate, nor simply a conflict between medical staff and laymen—though it was in some measure all these things. Ideas about germs and fevers were to play a key role in these deliberations, along with the schedules of clinical teachers and attending staff. Differences over the cause of hospital infection were not the abstract concern of scholars, but structured into matters as practical as the disposal and acquisition of real estate, the design of windows and heating ducts, the dressing of a wound. No question was more important than that of choosing a proper site. Well-informed laymen as well as medical men unconnected with the New York Hospital felt their new building should be removed from the city’s crowded center to a more salubrious—and cheaper—site where the expansive principles of pavilion design could be applied. "Ease of access to patients for physicians and students,” as a Bostonian had expressed the reform consensus as early as 1861, “has hitherto determined the site of most of our large hospitals; and a central location has been too often secured at the enormous sacrifice of pure air and good drainage/’1 The New York a i” t P , The Promise of Healing: Science in the Hospital 143 Hospital’s prestigious consulting staff was not entirely comfortable with the practical implications of such teachings. Hours spent in unpaid ward rounds were prestigious, but necessarily marginal to an established practitioner’s busy schedule. Most of the attending staff wanted to remain close to their teaching, their private practice, and, they argued, to the working-class districts served by the hospital. When the New York Hospital finally opened its new building in 1877, the ceremony was an occasion of controversy as well as cele- bration. Its leaders and their architect had ignored the central axi- oms of contemporary hospital architecture, building a "seven-story building . . . on a space of ground only seventy feet by one hundred and seventy-five in extent," in a crowded part of the city.2 Critics charged that the hospital’s Board of Governors had scorned the most fundamental teachings of sanitary reform and allowed the demeaning logic of real estate costs and the convenience of attend- ing physicians to outweigh the safety of patients. Staff members were prepared to defend their design. Their archi- tect argued that he had sacrificed esthetic considerations in order to maximize ventilation. Consulting surgeon William H. Van Buren, a spokesman for the hospital’s staff, defended their design choice in more novel terms. If the findings of Pasteur and the procedures Joseph Lister had based on them proved correct, Van Buren argued at the new- hospital’s inauguration, then the absolute number of patients and the structure’s interior design need not be crucial. "It has been shown how we can keep wounds sweet and healthy, and conduct them to a favorable ending by a shorter and surer route than that heretofore followed, and thus prevent hospital patients from poisoning each other.”3 Antiseptic procedures could prevent wound infection in any sort of building, no matter how tall or how constricted its grounds.‘l These new insights justified a high-rise structure in a site convenient to the city’s business and residential center. To many contemporaries, of course, Van Buren’s words seemed no more than the strained defense of ashort-sighted and economi- cally biased decision. Lister was still an extremist, an enthusiast who, as the editor of New York’s leading medical journal put it, ". . . has a grasshopper in his head.”5 It was to be another decade before antiseptic surgery and the germ theory upon which it was L---) nuc— --_-_-l ----..A._._..- L. LL- .uvL'mJ "nu-1.1 vuacu WUII 5:110:11 aLLcyuuch ul lllc MICHLLN vvvaau. But despite such contemporary misgivings, it is clear that scien- tific knowledge and, equally important, the image of science had 144 A New Healing Order, 1850—1920 already become deeply embedded in the social process of delivering medical care. Subsequent social change in the hospital was in good measure to turn on the assimilation of intellectual change—on the reshaping of a welfare institution into a seeming laboratory of heal- ing. General structural factors such as urbanization and industriali- zation were, of course, fundamental, while nineteenth-century medical science offered as much rhetorical promise as clinical effi- cacy. But without that promise the scale and substance of subse- quent hospital development could hardly have been imagined." The actual place of science in American clinical medicine has always been ambiguous and conflicted—yet that ambiguity has never significantly undermined the faith of most educated Ameri- cans in the promise of that science. It was a faith shared by the most influential and ambitious in the medical profession. Both physicians and their hospitals were to cloak themselves in the mantle of an ever—improving, increasingly effective, and necessarily unselfish medical science. By the beginning of the present century, the hospi- tal and the American medical profession would never look back; scientific medicine was to provide a new plausibility for physicians and their institutions. No single aspect of this new knowledge was more important in reshaping the hospital than the germ theory and antiseptic surgery. Banishing Infection.- The Measured Triumph of Anfisepsis In retrospect, the relationship between antiseptic surgery and the modern hospital’s development seems neat and logical. For Lister’s medical contemporaries the perceived reality was rather more com- plicated. Few were immediate converts to this radically new way of understanding infection.7 Few anticipated the fundamental nature of the changes that were to overcome medical practice. As we have seen, surgery was a minor aspect ‘of the mid-century hospital’s clinical routine. Even with the stimulus of anesthesia, operative procedures, aside from the treatment of ever-increasing incidents of trauma, were still a minor part of the hospital’s therapeutic work in the 1860s and 18703. Most surgical admissions were still minor wounds and lacerations, fractures, hernias, or persistent skin le- sions. "Important operations,” as contemporaries termed anything l a E The Promise of Healing: Science in the Hospital 145 more severe, loomed far larger in terms of drama and an individual surgeon’s status than they did in an institution’s day-to-day routine. The quarter century after the introduction of anesthesia wit- nessed no revolution in surgical efficacy. Ether and chloroform facilitated longer and more elaborate procedures, but in so doing may have increased the likelihood of surgical infection.“ Well-mer- ited fear of such infection allied with a limited understanding of shock and related physiological problems made surgeons cautious in expanding their traditional repertoire. Intrusive voluntary proce- dures remained infrequent and limited to a comparative handful of operations. Hospital rules still routinely called for a formal consul- tation before any life-threatening procedure could be undertaken.9 When operating on a strangulated hernia, a prominent clinician recalled, it was considered impolite not to invite every bystander to examine the wound; "my surgical colleague,” he added, "amputated the limb of a corpse and a limb of the living in the same forenoon, on the same table, in the same purple gown.”1° It was not surprising that even minor operations could develop fatal complications or that hospitals could be recognized by their stench, "predominant among which was that of stale pus. It was something which could be recognized hundreds of yards away from the institution."11 Wound infection was seen by mid-nineteenth-century surgeons as an intractable difficulty, to be minimized though perhaps never entirely overcome.12 In the 18605 and 1870s, dozens of prominent surgeons in England and on the Continent as well as in the United States experimented with wound-dressing procedures that would— they hoped—minimize infection. "Cleanliness" was universally if impreciser endorsed, while individual surgeons fixed on pet sys- tems of dressings and drainage to achieve that cleanliness and sup- port the body’ 3 recuperative powers. Traditional holistic assump- tions also dictated that rest, diet, and "evacuations" be carefully monitored both before and after an operation. It seemed obvious that a well-nourished and rested patient had the best chance of resisting infection. There was also much interest in the possible utility of "antisep— tics” in discouraging infection. As we have seen, most mid-century physicians believed that some "zymotic" or ferment-inducing sub- stance in the atmosphere, often originating in accumulated organic matter or the exhalations of the sick, was somehow responsible for hospital infections and fevers. Antiseptics were chemicals that held 146 A New Healing Order, 1850—1920 the promise of neutralizing such substances, of somehow combating sepsis. Since at least the second half of the eighteenth century, physicians had experimented with such agents for use in hospitals, ships, and other crowded, enclosed, and potentially dangerous places.13 Since the 1830s, for example, chlorine compounds had been widely advocated for their disinfectant properties, and Ameri- can surgeons had used bromine and chlorine solutions for similar hospital purposes during the 'Civil War. In this context, Lister‘ s system seemed in some ways little distin- guishable from its numerous competitors in the late 18605. Even his choice of carbolic acid as disinfectant was not entirely novel, al— though the consistency and energy with which he applied it seemed peculiar to many skeptical contemporaries. Mid-nineteenth-cen- tury surgeons thought in terms of procedures, not pathological mechanisms: what sort of dressings should be used, how frequently should they be changed, how should drainage be managed. Few understood and accepted Lister's theoretical rationale for his idio- syncratic technique. It was hardly surprising that to many clinicians in the early 18705, Lister’s "system" reduced itself to an obsessive and arbitrary reliance on a particular chemical. It was also complex and expensive in a generation accustomed to casual procedures and meager budgets, when surgical costs were traditionally limited to the initial expense of purchasing a case of instruments.“ The toxic- ity of carbolic acid seemed only to underline the arbitrariness of the Glasgow surgeon’s program with its novel emphasis on operating in a spray of carbolic acid vapor. Lister’s prior conversion to Pasteur’s views was ignored by some and rejected as sectarian by others. Even if one believed that carbolic acid was effective in fighting wound infection, its precise mechanism remained obscure. Did it simply impede putrefaction in the exposed tissue? Or did it somehow de- stroy the microorganisms responsible for that putrefaction? Critics had argued for years that the finding of "parasitic forms” in an infected wound did not prove a causative relationship; the microor- ganisms might well be "a consequence of it, which furnished a nidus for their rise and development.”15 The editorialists who criticized the New York Hospital’s reliance on Listerian antisepsis in 1878 expressed no more than the prudent common sense of the matter. In the mid-18705, Lister’s views were still controversial—not lacking in merit, but not necessarily differ- ent in kind from numerous competitors. Prudent surgical staffs adopted many of his suggestions in the 18705, but saw them as part 771a Promise of Healing: Science in the Hospital 147 of a multidimensional attack on infection. A study of surgery in the Pennsylvania Hospital, for example, boasted proudly in 1880 that only 17 of 108 amputation patients had died between 1875 and 1879. The authors attributed these good results and an unaccus- tomed freedom from "pyemia," or blood poisoning, to better venti- lation, the "free use of carbolic acid,” scrupulous cleanliness, and the dressing of wounds with flowing water.“ The Transformation of Hospital Surgery _ It was hardly surprising that it took a generation for surgeons to incorporate this new understanding of wound infection and build it into a standard set of operatingvroom procedures. As we have seen, it demanded a radical change in fundamental views of the nature of disease and its origins, in particular a rejection of the older, aggregate model of infection. And it implied as well a gradual de- cline in a centuries-old faith in the primacy of the atmosphere in promoting infection, a faith so strong that it had guided even Lister’s own early work. One need only recall the carbolic acid spray that suffused operating theaters in the first decade of antiseptic surgery. The two decades after Lister’s original publications in the mid- 18605 brought a gradual modification of his original procedures: the evolution of antiseptic into what came to be called aseptic surgery. By the mid-18805, Lister’s stature had been generally accepted, even as his techniques were being recast. "Lister’s method has been cur- tailed,” as one enthusiast explained in 1884, modified, indeed in some ways every limb, so to speak, has suffered high amputation; but the grand trunk, the vital principle, still lives, still is acknowledged, that in some way, some how, by some means, it matters not what, wounds must be kept from first to last surgically clean.17 This shift from Lister’s original antisepsis to asepsis was more pro- cess than event, for it presupposed the elaboration of an integrated assortment of techniques, tools, and procedures aimed at keeping bacteria from coming in contact with exposed tissue. Even surgeons who considered themselves convinced advocates 148 A New Healing Order, 1850—1920 of antisepsis were at first dismayingly imprecise in their application of these new teachings. Surgeons in the 18803 might drop instru- ments on the floor, pick them up, and after wiping them on a sleeve continue their procedure. Bandages and sutures were used without being sterilized, and natural sponges were used, washed, and used again. One jacket might serve as operating room garb for as long as a year. In a few prominent institutions, staffs were split, with some attending surgeons following what they assumed to be antiseptic procedures, while others forbade them on their services.m Hardly an autobiography of a physician trained during these years is with- out such anecdotes.19 But the trend toward the elaboration and adoption of aseptic surgery was inexorable. By the 1890s, the intro— duction of autoclaves, sterilized dressings, and the rubber glove had made surgeons more inventive and confident. Most important, rapid progress in bacteriology clarified the mechanisms underlying Lister’s empirical suggestions. “The principles upon which aseptic surgery is established are firm,” an authority explained in the mid— 18905, "since the theories which have led the technique to its pres- ent state of perfection are confirmed by bacteriological tests.” This change, however, cannot disturb the glorious foundation laid by Joseph Lister. To Lister we owe the mother, Anfisepsis, who, though she died in parturition, brought forth her idealization, ASEPSIS.2° The world of surgical possibilities had changed dramatically. The body cavities were no longer forbidding obstacles, for exam- ple, but enticing opportunities. As early as 1886, the Massachusetts General Hospital’s staff urged the institution’s trustees to establish a special ward for abdominal surgery, one with an adjoining operat- ing room in which rigid antiseptic measures could be enforced. Dangers that had seemed overwhelming only a few years before had, they argued, "been reduced to a In our Wards Ery- sipelas is rare, Pyaemia &. Saepticemia seldom seen & Hospital gan- grene has been stamped out."21 The stakes were high for ambitious young clinicians. "Abdominal surgery is now the field where the most brilliant successes are to be attained," as one such surgeon argued two years later. "No branch of surgery can compare with it for a moment. . . . It is from the work we are now doing & hope to do in abdominal surgery (& . . . cerebral surgery as well) that the Hospital must gain its position among the hospitals of the world at the end of the next ten years. We have the choice,” he warned and sa..~.........u<.< .9 A . . . .. 77w Promise of Healing: Science in the Hospital 149 enticed, "now to take the lead.”22 Technical virtuosity was being inextricably related to status—for institutions as well as individuals. By the turn of the century, the increasing compleadty and effec- tiveness of aseptic surgery, the advantages of the x-ray and clinical laboratory, the convenience of twenty-four-hour nursing and house staff attendanCe were making a hospital operating room the most plausible and convenient place to perform surgery. To many surgeons, in fact, it was beginning to seem the only ethical place to practice an increasingly demanding art. Though the prestige of surgery constituted an ever more powerful inducement, middle-class patients remained hesitant to enter hospi- tals. Until the 19205 surgery was often performed in private homes, and babies were in many cases still delivered in the mother’s bed- room, whether attended by a family physician or midwife.23 But despite the slow and grudging growth of public acceptance, a trend toward hospital surgery had become increasingly clear. By the turn of the century in fact, critics of surgical euphoria were already warning against excessive and unnecessary resort to the scalpel. Appendicitis was the most obvious example; " ’Belly-ache’ is now a surgical disease,” one prominent clinician complained.“1 And the extraordinary number of appendectomies performed at the very end of the nineteenth and beginning of the twentieth centuries indicates that the procedure was almost certainly being abused.25 But such reservations had little effect in moderating the trend to- ward increased surgery. In hospital after hospital, the proportion of surgical to medical admissions increased, as did the percentage of voluntary procedures among those surgical admissions. At the Pennsylvania Hospital, for example, over eight hundred and fifty operations were performed in the year between May, 1899 and May, 1900, more than the total number of operations performed at the same hospital between 1800 and 1845.26 Surgery meant an activist, intrusive style of practice and a de- creasing emphasis on the conservative or expectant management of many syndromes. New York’s Hospital for the Ruptured and Crip- pled provides an exemplary case.27 James Knight, the leading spirit in its founding and its surgeon-in-chief from 1863 to 1887, was a physician who assumed a holistic—and patemalistic—attitude to- ward his patients and the hospital’s work generally.” He placed little emphasis on operative procdures and a great deal on diet, exercise, fresh air, bandages, and appliances. Knight saw local le- sions as aspects of more general conditions, just as he saw the child 150 A New Healing Order, 1850-1920 as potential citizen of a larger society and concerned himself with his little patients’ moral education and future job prospects. Knight lived in the hospital and served as father of an extended family. By 1887, Knight had become an anachronism. He was succeeded by Virgil Gibney, a youthful and energetic orthopedist. Numbers of operations increased rapidly and lengths of stay decreased; Gibney himself lived outside the hospital. The surgeon was no longer con- tent to guide and monitor, to negotiate a multidimensional path to physical and social health. Aseptic surgery had far more to offer many patients than the bandages, regimen, and braces of mid— century, but the new-model surgery construed its responsibilities in increasingly narrow and procedure-oriented terms.29 By the 1920s surgical admissions outnumbered medicals”o Ordi- nary Americans had not only begun to accept the hospital, they had come to associate it with the surgeon. Hospital plarmers could as- sume that private surgical beds would always outnumber their medical counterparts.31 Prospective patients were influenced not only by the hope of healing, but by the image of a new kind of medicine—precise, scientific, and effective. For the first time, pa- tients came to their physician with the hope—and increasingly the assumption—that he might impose and not merely facilitate heal- ing. The new surgery helped change physicians’ expectations as much it did those of laymen. Most practitioners were as impressed as their patients with the achievements of modern surgery. It was no wonder that the specialty attracted so many bright and ambi- tious young men. Surgery had always played a disproportionately dramatic role in the world of medicine and medical education, and now it could claim a potential for healing that overshadowed the more humble and inconclusive efforts of internal medicine. It seemed to represent the innovative spirit of science made clinical reality. Not everyone agreed as to what that science actually was or should be——or how it might best be related to the clinician's mun— dane tasks. But such imprecision did little to moderate the impact of appeals to the laboratory or undercut the role of science in the forging of a new style of medical identity. Quite the contrary, a lack of precise meaning has rarely interfered with the efficacy of appeals to science and the promise of its application. The Promise of Healing: Science in the Hospital 151 New Definifions of Disease In retrospect it is clear that the expanding clinical role of surgery was consistent with other trends in medical thought.32 One was toward a belief in the specificity of disease, toward seeing particular ailments as predictable sequences of symptoms grong out of lo- calized lesions or well-defined malfunctions in some physiological process. Diseases were, in other words, entities that could now be conceived of apart from their manifestation in particular individu- als.” As we have seen, this novel understanding of disease grew out of developments in clinical medicine and pathology, culminating in the work of the Paris clinical school during the first half of the nineteenth century. To these scholars and their followers in Paris, Vienna, and the British Isles, there seemed no necessary connection between the reality of these newly agreed-upon disease entities and a parallel agreement as to their precipitating cause. It seemed possi- ble, if not likely, that the cause of disease would never be under- stood; for the moment it was enough that medicine delineate the natural history of particular syndromes in life and death.34 In demonstrating a connection between particular infectious ills and particular microorganisms, the germ theory underlined and ex- plained the unity of disease patterns already demonstrated by three generations of clinicians and pathologists. But this new knowledge did more than that. It changed public attitudes toward the medical profession and raised expectations, even before laboratories could do much to transform the shape of everyday practice. If therapeutics was at first little altered, the same could not be said of public health. By the first decade of the present century, the laboratory had informed and revised pre-existing efforts to control the spread of infectious disease. Bacteriology had illuminated the role played by healthy carriers, while field and laboratory research had exposed the role of insects in the transmission of other ills. Laboratory insight had helped make water purification more than a rough empirical procedure and justified pasteurization of milk, even lowered the cost of food by helping rationalize the processing and preservation of foodstuffs. All these effects were ultimately to play a role in altering disease incidence and thus the experience of medical care.” Physicians and hospitals encountered fewer cases of typhoid, for example, even though they were still without an effec- tive treatment for those cases that did occur. 152 A New Healing Order, 1850—1920 These new ideas about disease and the role of science helped undercut traditional styles of practice even before (as in the case of typhoid) the laboratory provided the physician with effective thera- peutic tools. An understanding of the patient’s physiological in- dividuality was to seem less and less important, an understanding of the disease from which he or she suffered more important. In this sense, patients were inevitably seen in terms that transcended their individuality, as instances of more abstract, yet somehow more real syndromes that manifested themselves in countless other men and women. Prognosis and therapeutics turned increasingly upon iden- tification of the ailment that assailed an individual patient and not upon a nuanced evaluation of his or her biological and psychological individuality. The doctor began to treat diseases, in the words of a familiar aphorism, not patients. We must be careful not to overstate the abrupt and categorical quality of this change. In earlier generations, physicians often prac- ticed in rote cookbook fashion, while twentieth-century physicians have not uniformly lost sight of the patient as individual. Neverthe- less, there is clearly an element of truth in this particular truism. The pathology-based and legitimated picture of disease grew increas- ingly prominent in medical thought, and the traditional emphasis on individuality and idiosyncrasy faded proportionately. The hospital had, moreover, always provided more impersonal medicine than had private practice, an inevitable effect of class relationships and staffing ratios as well as the episodic quality of institutional care. The very impersonality of hospital treatment and the accident of its being provided by a physician ordinarily un- known to the patient made it vastly different from the general pattern of late nineteenth-century medical care. Private patients and their families were still treated by a familiar physician in the home.“ Emphasis on disease specificity and "objective," labora- tory-aided diagnosis may well have exacerbated unpleasant institu- tional realities for the poor. But they had never expected much in the way of individual attention. It was the middle-class patient who was to face a very different sort of experience in the twentieth— century hospital. With the gradual acceptance of disease specificity, it became in- creasingly easy to see and treat patients as exemplifications of those categories. Hospital records indicate this in a number of ways: the increasing uniformity and studied impersonality of mitten records, the growing emphasis on specific diagnosis, and a corresponding W .5 ., _. The Promise of Healing: Science in the Hospital 153 rejection of terms describing general physiological states.” Admit- ting diagnoses such as “senility,” "failing," or "marasmus" gradu— ally disappeared in the 18805. They had already become uncommon in self-consciously advanced institutions. At New York's Roosevelt Hospital, for example, a minority of patients were still admitted in 1878 with diagnoses such as "constipation," “destitution,” and "de- bility from various causes.” In 1882, significantly, the hospital's aggregate admission figures did include an entry for "debility," but it was followed by the words "diagnosis uncertain.” The addition of those telling words encapsulates a fundamental aspect of the new-model hospital. Diagnosis—and the admission process—could be understood and legitimated only in terms of “objective” disease entities.“ Objectivity was no new goal in clinical medicine, but physicians had never possessed the tools to implement that elusive ideal. For the first time in man's history, it appeared in the late nineteenth century that "instruments of precision,” as Philadelphian S. Weir Mitchell termed. them, would allow the physician to measure the body’s activities in health and disease, to make clinical medicine increasingly a science, less and less an art.39 The personal equation was increasingly a factor to be reduced to its component mech— anisms, not romanticized. The late nineteenth— and early twentieth-century hospital was in part being transformed by new diagnostic tools. The clinical labora- tory and x-ray promised to raise prognosis and diagnosis (if not therapeutics) to new levels of consistency. The physician would no longer be entirely dependent on the patient’s appearance and sub- jective perceptions. By the beginning of the present century, he or she could call upon the results of chemical and bacteriological tests, the appearance of x-ray plates, the findings of microscope, stetho- scope, opthalmoscope, and otoscope. Such tools were not applied routinely in private practice and, in most areas of internal medicine, could do little to guide an effective therapeutics. But they played a far more important symbolic role, representing to both doctor and patient the increasingly scientific character of medicine. In regard to the hospital, they were crucial, cumulatively suggesting that it was an appropriate, in fact necessary, site for the provision of medical care to all Americans and not just the urban poor. 154 A New Healing Order, 1850—1920 The Rise of Cliniml Teehnology Physicians had always sought to see beneath the skin. What was it that constituted health and disease and what were the physiologi- cal processes that explained, perhaps constituted, life and death? It is no accident that traditional medicine should have concerned itself with the appearance of urine and feces, of drawn blood, of the tongue and eyes. All offered evidence of mechanisms otherwise opaque and supplemented the patient’s own rendition of his or her symptoms. After death, the postmortem room could provide addi- tional insight by revealing lesions that had caused symptoms during life. Knowledge of gross pathology began to accumulate from the seventeenth century on, but it was not until the nineteenth century that medicine began to find an array of tools that allowed it to begin the systematic investigation of the mechanisms that underlay the felt symptoms of disease. Physical diagnosis provided one kind of insight, allowing the acute clinician to use his own senses, his fingertips and hearing, and to learn something of the state of a patient’s heart and lungs, or of a fetal heartbeat. The stethoscope provided a further enhancement of those senses. By the 1870s, hospital physicians were generally familiar with the stethoscope and physical diagnosis—although they tended to use these techniques in only certain categories of illness, such as diseases of the chest.40 The meaning of this more abundant sensory data was inevitably construed in terms of gradu— ally accumulating postmortem findings. Another path to medical insight grew out of chemistry. It was natural enough for traditional humoral ideas to shift gradually into chemical guise. The components of the body, the process of diges- tion, even the mechanisms that underlay disease could often be seen inchemical terms. The albumin in the urine of a patient suffering from Bright’s disease, the sweetness in a diabetic’s urine, the altered composition of the urine of a patient suffering from gout all pointed toward the promise of medical chemistry.“1 "Great discoveries,” as one enthusiast put it in 1871, "in therapeutics and physiology are to be made only by renewing the bond which makes the Physician and Chemist one: and may we not truly say that if every chemist is not a doctor, every doctor must be a chemist, if he would march in the van of the great army of those who by searching would find out the truth/’42 77w Promise of Healing: Science in the Hospital 155 Such hopes implied the need for cooperation between the ward and laboratory. As early as 1842, for example, a small laboratory and two connecting wards at Guy’s Hospital in London had been set aside for the clinical and chemical study of patients suffering from chronic kidney disease.“3 This arrangement was by no means typi- cal; even in university hospitals it was not to become commonplace until well into the twentieth century. Nevertheless, the allure of laboratory-defined certainties was very real, even in an Anglo- American medical world in which government, universities, and private philanthropy had yet to provide support for clinical investi- gation. Efforts to bring systematic scholarship into the nineteenth-cen- tury hospital were, in fact, most pervasive in the area of pathol- ogy.“ Pathology waslthe most intellectually exciting frontier of medicine in the 18305 and 1840s, reflecting the prestige and accom— plishments of the French clinical school during the first third of the century. A nucleus of eager young clinicians returning from medical study in Paris had sought to duplicate in a small way facilities they had enjoyed in the French capital. Medical staffs of the older and better-established hospitals worked to found pathological cabi- nets—collections, that is, of representative, rare, or atypical patho- logical specimens. Such collections, like a hospital’s library, had been used since at least the late eighteenth century as instructional aids and signs of an institution’s aspirations and accomplishments. A minority of ambitious attending physicians and house officers had also sought—with varying degrees of enthusiasm and effective- ness—to maximize the number of postmortem examinations per— formed at their institutions. Even an unpaid position as pathologist or curator of a hospital's pathological cabinet might allow zealous medical men the opportu- nity to utilize "pathological materials" provided by the institution's charity patients. It was a professionally appropriate stop on the path to intellectual distinction and institutional security. But the relationship between institutional preferment and intel- lectual achievement was neither consistent nor predictable. The structure of nineteenth-century career options dictated that such intellectual interests could be most appropriately pursued in the odd moments of a young man’s career or cherished as a badge of elite status in an older practitioner’s spare hours. The ordinarily unpaid office of pathologist was normally vacated by young men as they rose in the hospital’s clinical hierarchy. It was a plausible and possi- 156 A New Healing Order, 1850—1920 bly advantageous way of marking time and occupying a lower rung on a well~understood ladder of advancement—but not a career m itself. Unpaid and lacking the status connected with membership on a hospital’s clinical staff, incumbents ordinarily resigned pathology posts when private practice grew demanding. In 1855, for example, a committee of New York Hospital physicians urged the Board of Governors to pay a small salary to the curator of their pathological cabinet. A series of young men had held the position for short periods of time and, "Receiving no pecuniary remuneration they could not afford to forgo opportunities of professional advancement . . .” The results had been unfortunate. In retrospect, however, the attending physicians’ justification for their request is even more significant than its occasion. "Humanity and true Medical Science alike,” the staff committee argued, "demand that provision should be made for the support and increase of a collection like ours which may be made to contribute in so important a way to the elucidation of the nature of disease and the instruction of the medical profes- sion.” Even in 1855, such arguments had an immediate appeal: how could one not be enticed by the prospect of solving the mystery of disease or opposed in principle to the clinical training of physicians?“5 Most of the older American hospitals did make gestures in the direction of recognizing such interests in the first half of the nine— teenth century, usually by creating a pathological cabinet and ap- pointing a curator. In the 18705 and 18805, appointment of a hospi— tal pathologist became increasingly common.“ (Trustee support of systematic postmortems was, as we have seen, a good deal more problematic.) In few institutions, however, did the work of such pathologists or microscopists amount to much. So-called laborato- ries were often dark and dirty rooms, almost bereft of equipment and tucked into basement or attic comers. Short tenures and lack of specialized training almost guaranteed that pathologists would pro- duce little. - 1 Hospitals were hard-pressed to pay the costs of patient care (heat, light, and food) and could spare little to support scientific frills. And frills they certainly did seem to be. The insights of the postmortem room and microscope offered little to the practicing clinician. It might be interesting to establish the characteristic appearance of a diseased liver that killed one’s patient, but such knowledge offered little guidance in treating similarly afflicted patients in the future. The Pennsylvania Hospital Board of Managers was only typical, if The Premise of Healing: Science in the Hospital 157 ingenuously candid, when it congratulated itself on creating the unsalaried position of Pathological Chemist in 1870; "where we can promote the cause of science,” they explained, "without any ex- pense on the part of the Board we consider it our duty to do so.”47 But there was always a minority of staff members eager for in- creased laboratory facilities. Even in the mid-nineteenth century a handful of attending physicians were already urging the establish- ment of chemical laboratories and the appointment of microsco- pists.“ They sought to enlist these new laboratory tools in the aid of diagnosis and treatment—to add an understanding of the disease process in life to the retrospective insight provided by the postmor- tem. "If pathology is to merit the title of the science of medicine," as one prominent medical editorialist argued in 1871, "it must be in its bringing together, in one connected series, etiology, diagnosis, and morbid anatomy—an exhibition of the phenomena of disease from its inception to its close, . . . Mere dead-house pathology” was clearly inadequate.” No clinical history could be considered com- plete, another enthusiast charged in 1868, ". . . while in a large number we can hardly be considered as having performed our duty as physicians, without a microscopical and chemical examination of the blood and more important secretions and excretions of the body.”5° Chemistry and the microscope had already provided a battery of procedures that could be applied to urine, blood, and even tissue samples. But such tests remained in fact academic curiosities; only the thermometer and a few urine analyses had become an accustomed part of hospital routine before the end of the century. It was not until the late 18905 that the clinical pathology labora- tory became part of everyday patient care even in America’s most self-consciously advanced hospitals.51 And medical schools had done little to build laboratory skills into curricula. Nevertheless, medicine’s technical resources increased steadily, with much of such innovation coming from Germany’s fertile laboratories. By the First World War, diagnosis of an individual patient might be aided by serological tests, careful temperature readings, chemical and micro- scopic evaluation of blood and urine, and by x-ray examination, where relevant. The laboratory’s findings, as the New York Hospi- tal’s medical board contended in 1903, could now deal “not only with the problems presented by the dead body but also contributes ' A 1... LL A:..--..-.I 1...; has... to the soluticn of problems presented of me wocaacu Uut mung body."52 Yet, as some turn-of-the-century critics contended, the abundance and ingenuity of available tests was not matched by 158 A New Healing Order, 1850—1920 their relevance to everyday practice. Costs also discouraged hospitals, even the comparatively modest expense of laboratories in a period of simple technologies and low-paid or volunteer labor. At first, the laboratory seemed only a drain on already tight budgets: scientific diagnosis did not automatically translate into finanCial returns for America’s voluntary hospitals.53 I . Even private patients were accustomed to paying a smgle daily charge that included every aspect of care (except private-duty nurs- ing and a physician’s fee). It was only gradually that hospitals began to bill separately for blood and urine tests, x-ray plates, anestheSia, the use of operating rooms—and thus underwrite the cost of operat- ing a laboratory. With the ability to define costs and charges, it was inevitable that the laboratory would become a "profit center’ . well before that now omnipresent term came into use. Such facihties were at first suited only to large urban institutions-they did not become general in smaller and more isolated institutions until the second and third decades of the present century. . Nevertheless, a growing minority of early twentieth-century physicians was enticed by the laboratory’s promise—even while its relevance to everyday practice remained questionable. The test tube, microscope, and Petri dish offered ambitious young men new and reassurineg positive tools for use in studying disease in doing so the opportunity to "accomplish some work-of an'ongma’l character.”54 It is no accident that the term "clinical investigation became widely accepted in this period. Although the great of early twentieth~century and late nineteenth-century climcal re- search might seem crude and simplistic in retrospect, it prOVided a new kind of credential, helping separate the specialist-oriented and intellectual young man from his less elevated peers. At first, such investigation had more to do with the definition and elaboration of academic careers than with care of the sick. For the medical profes- sion more generally, the availability of scientific .tools proce- dures legitimated an impressive new style of medical identity: that of master of laboratory science and "instruments of precismn .as contrasted with the more traditional ideal of wise and intuitive manager of elusive and idiosyncratic clinical situations. . In this sense, the new tools of diagnosis “worked” in their capac- ity to inspire the medical man with self-confidence and his patients. with a parallel faith in his ministrations. Ultimately, 01 course, they were to help provide an increasingly substantive iinderstanding of the biological mechanisms that underlie many chmcal syndromes. 3 The Promise of Healing: Science in the Hospital 159 But this was a gradual and elusive achievement. The alliance be- tween science and clinical medicine remained shaky and ambiguous before the First World War.55 Even as the elite in medicine grew increasingly enamored of what it called medical science, this new source of knowledge had in fact provided little beside aseptic surgery to change the hospital’s thera- peutic options. A bright young Johns Hopkins resident might be able to demonstrate characteristic white-blood-cell counts in lobar pneumonia, but still do little to treat the unfortunate patient. Before 1900, only diphtheria antitoxin seemed to offer the possibility of intervening decisively in the course of an acute nonsurgical ailment. One of the consequences, in fact, of an increasingly positivistic and reductionistic spirit in medicine was a growing skepticism in regard to the efficacy of aggressive therapeutics. Nursing, rest, and diet were highly valued by every sophisticated n de sie‘cle practitioner— even as he or she prescribed the “modest doses of cathartics or analgesics patients expected. Digitalis, quinine, and especially opium and its deiivates remained the profession’s most effective drugs at the end of the century, as they had been a half-century earlier.“ Pasteur’s prophylactic treatment of rabies (1885) and Behring and Kitisato’s diphtheria antitoxin (1891) remained atypi- cal. And both, especially rabies, had little immediate impact in reshaping broad patterns of morbidity or mortality. The introduc— tion of serological tests for typhoid (1897) and syphilis (1906) were impressive achievements, but were more relevant to prevention than treatment. These discoveries did have an enormous eEect on public opinion, however. One need hardly emphasize the social impact of a rabies treatment, for example, even if its effect on mortality rates was trivial. Like polio in the twentieth century, the emotional promi- nence of rabies belied a less formidable demographic reality. A similar observation can be made about diphtheria. Here was a dis- ease particularly fatal in children and with an extremely high (if erratic) mortality rate. Then in the 18905, it became clear that Behr- ing’s serum could be injected into a sick child and make the differ— ence between life and death. The discovery had an enormous im- pact. Physicians differed about appropriate levels of antitoxin and the clinical situations in which it was most effective. Public health authorities experimented with the production of antitoxin. Skepti- cal historians question its actual efficacy in the 1890s, but the public was left with an image of the physician as healer, as capable of 160 A New Healing Order, 1850-1920 intervening in the course of a life-threatening illness. Pasteur’s treatment for rabies and Behring’s diphtheria antitoxin burst into the public consciousness, moreover, soon after the debates on anti- septic surgery and Koch’s discoveries of the tuberculosis and chol- era organisms (1882 and 1883). At one stroke, the German bacteri- ologist had demonstrated the cause of the century's most widespread and mortal endemic disease (tuberculosis) and its most fearsome epidemic ailment (cholera). The laboratory was coming to be seen as the source of medicine’s new explanatory powers, while the great majority of laymen were incapable of making a consistent distinction between the laboratory worker, the practitioner who applied the laboratory’s findings in patient care, and the epidemi- ologist or public health worker who sought to use knowledge in halting the spread of infectious disease. The hospital, like the practitioner, gradually assumed a new image of technically based efficacy, but the reshaping of the hospital as a living social institution was to be a far more difficult undertak- ing. Middle-class patients were slow to enter hospitals, no matter how enthusiastic their response to medicine’s new capabilities. And aside from aseptic surgery, there was no reason to assume that any of the then available diagnostic or therapeutic devices implied hos- pitalization. The hospital might be associated in a general way with technical progress in the 18905, but this did not mean that middle- class Americans assumed it had anything to do with their medical care. The hospital itself changed slowly and grudgingly in its orienta- tion toward scientific medicine. The late nineteenth- and early twen— tieth-century hospital remained a fickle home for the pursuit of scientific medicine and the training of a new generation of medical men. Until the last decades of the century, there was simply no place for the would-be medical scientist in America’s hospitals (or in general in its medical schools). The laboratory could still be seen as a will-o-the-wisp, leading young men astray from the clinical work that would necessarily be their bread and butter. Science was still regarded as a young man’s mistress, clinical practice his wife: few could afford the demands of both. Even such pragmatic tools as the x-ray and clinical pathology were slow to find a secure home in many of America’s poorly endowed hospitals, and no physician could realistically hope to attain professional security through the mastery of such technical skills alone.57 At the beginning of the twentieth century, American hospitals offered only a handful of vm film i i l l i I l l y l 2 l i 3 g g 2 ,3 The Promise of Healing: Science in the Hospital 161 paid staff positions. Almost all medical school faculty members earned their bread as practitioners; attending physicians at even the most prestigious hospitals still served without pay and fit ward rounds into a busy clinical schedule. The conflict between ideals of research and the mundane realities of practice had existed for gener— ations; they could only intensify at the end of the century as the achievements and allure of research increased. The Grail of Science American society provided virtually no support for the Would-be medical researcher. The governmental support enjoyed by French and German professors could hardly be expected onthis side of the Atlantic. Even the meaning of "science" and "medical research” remained unclear. Yet since at least mid-century, an energetic if tiny minority of English and American physicians had sought to bring change to medicine through 1’original investigation.” It seemed probable, as an English advocate of research put it in 1855, ”. . . that all future improvement in the treatment of disease must be based upon a careful and minute investigation into its nature, . . .” A knowledge of the natural sciences was thus as important to surgery and medicine as an understanding of grammar to a study of the classics, but he concluded that such work could at present in En- gland, ”only be effected by the careful private study of different members of the profession/’558 Conditions in America were if any- thing less congenial to original work. Nevertheless, a cadre of young men accepted the validity of such demands, contrasting the ephemeral nature of material success with the more lasting rewards of scholarly achievement. It was embar- rassing to travel in Europe and realize that many prominent Ameri- can practitioners were unknown to the leaders of French and Ger- man medicine. It was not what a man earned but what he wrote that made a permanent reputation.59 But for the generation of Ameri- cans who came of age before the Civil War, practice provided the only real option for professional survival. Yet success in practice inevitably “robbed” science of workers it could not "easily spare.”“'° More than a lack of support hindered the development of medical research. Definition of scholarship had to change as well: the tradi— / 162 A New Healing Order, 1850—1920 tional library mastery of a subject matter was no longer adequate. “Investigation” implied disciplined hours spent in the laboratory, the autopsy room, or hospital ward. The growing dominance of German medicine in the last third of the century underlined the inadequacy of an exclusively clinical and private practice orienta- tion. A love of acquiring new knowledge for its own sake and the willingness of society to accept and support that devotion set Ger- man medicine apart from the Anglo-American professions. In En- gland and America, as the eloquent William Osler put it in 1890, ". . . the young man may start with an ardent desire to devote his life to science, [but] he is soon dragged into the mill of practice, and at forty years of age, the 'guinea stamp’ is on all his work.”‘51 By the end of the nineteenth century such arguments had become com- monplace among an elite minority of American physicians. Obviously, their arguments and attitudes were not those of the average practitioner, but advocates of medical science argued that even the commitment of a minority to investigation would benefit the entire profession. By the 1870s, prescient reformers were pre— dicting that an increasingly enlightened public would in time learn that science set the regular profession apart from its sectarian com- petitors: had homeopaths or botanic doctors ever made an impor- tant discovery?"’z And by the end of the 1870s, a few conservative, and equally prescient, medical men were already alarmed at the growing prestige of research and an increasingly technical style of practice. "The desire of the time,” one such nay—sayer warned in 1879, "seems to be to make students histologists, pathologists, mi— croscopists, rather than sound practitioners, full of the humble but necessary knowledge of the practical departments of our art and science.”63 More petulant than accurate, this warning does indicate the steadily growing power of science as image and goal—if not as yet reality. The hospital was inevitably to be a battleground for such differ— ing views of medicine’s appropriate role. If systematic clinical inves- tigation was to be accomplished, the hospital’s wards and postmor- tem room would have to be the profession’s laboratory. Medical progress, as a Philadelphia editorialist contended as early as 1874, ”. . . rests largely on the use which men make of hospitals, since very little valuable study of disease can be done in private practice.” Americans had thus far acquitted themselves with little honor in attaining this goal: ”. . . the prestige of a city which claims to be g. 31 3i L t ,‘u r ,i W l p l r The Promise of Healing: Science in the Hospital 163 called, . . . a great medical centre, must always depend upon the amount of original work which it evolves; and it is just this which everywhere in America has been sadly wanting.”6‘1 The same editorialist urged those planning the University of Pennsylvania’s new hospital to accept as a matter of principle ”. . . that all proper facilities for original work should be furnished, and that the per- formance of such work should be a recognized part of'the duty of the staff/’65 Hospital trustees and laymen generally had long accepted the idea that the institutions they supported and administered had a two- fold function: care of the dependent sick and medical education. Now a small but vocal group of reformers sought to instill a third goal: the use of the hospital as' a laboratory for clinical research.66 They endeavored as well to recast traditional definitions of the hospital’s long-accepted functions along more “scientific” lines: without modern laboratory facilities neither care nor teaching could be properly undertaken. “The hospital wards should furnish the material,” a Harvard physician—bacteriologist contended, "the laboratories the means for study," if medicine’s most intractable problems were to be solved.” Without greater endowment, however, the hospital would never be able to take advantage of its unique research asset, its patients. The occupants of a hospital’s beds could be regarded, as one out— spoken reformer put it, as ”. . . Nature's experiments with poisons cunnineg elaborated in the tissues of the body, or with viruses coming from without, upon blood and bone, muscle and brain.”55 By the turn of the century, the stakes had risen and the demands of reformers grown more assertive. Recent findings in bacteriology and immunology had grown out of investment in laboratory re- search they contended; greater investment promised further returns to humanity and prestige for the discoverer. It also promised an improved status for the hospital that supported such work.69 Clinical research could no longer be conducted, an American Medical Association (AMA) spokesman argued in 1901, with "a few test-tubes, an alcohol lamp, and a microscope . . ." Such work required a fully equipped laboratory and "the use of exact methods and of the instruments of precision of physics, chemistry, and biol- ogy." The task of the hospital was equally to cure the sick and increase the profession’s store of knowledge; "I . . where the second duty is not or can not be performed properly, the first also suffers 1 164 A New Healing Order, 1850—1920 neglect.” Research did not conflict with the interest of individual patients; on the contrary, it helped guarantee first-rate care.” A handful of elite institutions had even begun to redefine their tradi- tional responsibilities in a new hierarchy of effort. The care of individual patients could be seen, on balance, as less important than "the science of the prevention of disease.”71 The stakes for staff members at elite hospitals were changing as well. As individuals, they also scught to do more than treat the assortment of sufferers their ward or outpatient duties brought to them. "We desire to do a great deal more in connection with our services,” Boston neurologist 1.]. Putnam explained in 1911, "than simply to attend to the most pressing needs of the patients. Investi- gations of one sort or another, or the need of a specifically prolonged and careful examination of some particular case are continually suggesting themselves to our minds. . . . we shall work with more zeal and interest,” Putnam promised, "through having the feeling that the work accomplished is of such a sort as the community expects from us scientifically as well as practically.”2 Academic physicians disagreed as to its precise content, but all could join in invoking the values of medical science. Science in fact continued to be more rhetoric than reality for the great majority of hospitals and medical men. The hospital remained, as it had been in the mid—nineteenth century, a place to earn prestige and accumulate clinical experience (some of which could be trans- lated into the unsystematic clinical reports that still made up the bulk of medical publication) while progressing securely along the track that led to a successful consulting practice and a not unrelated academic status. By the beginning of the twentieth century, how— ever, the voluntary hospital was becoming a place for surgeons and consultants to earn fees in practice as well. Despite brave words, it was in general no place for the laboratory scientist or, for the most part, the clinical investigator. It was, however, a place for the academic consultant, the special- ist, and specialist teacher. Both 5. Weir Mitchell and JJ. Putnam spoke as neurologists when they endorsed the claims of scientific medicine. And it was in this guise that most ambitious American physicians advanced their careers—and in doing so helped reshape the hospital. Unlike laboratory science, clinical eminence provided both an avenue to intellectual distinction and access to the oppor- tunities in practice that could support such ambitions. In 1910, few assays“; 4 11$; mm are ’. “was; -_ Ms. “adage. The Promise of Healing: Seizure in the Hospital 165 "laboratory men” could hope to gain hospital preferment or clinical reputation, at least while remaining in the laboratory. The leaders of American medicine were the surgeons, the prominent consultant- teachers, and the specialists who filled attending positions, became chiefs of clinical services, and taught a new generation of medical students. ...
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Week6_Rosenberg1 - THE CARE OF STRANGERS The Rise of....

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