A common perception in the history of
medicine, one that embodies the idea of ‘progressive science,’ was that until
the 1950’s hospitals were dangerous dens of death to be avoided at all costs,
where more died than were cured. A brief examination of the hospital movement
in the Enlightenment shows that this was not necessarily the case. Though
mortality rates in hospitals were not low by modern standards, during the
Enlightenment a “hospital movement” swept through Europe.[1]
These hospitals, rather than previous uses as religious institutions that
provided segregation and confinement of the chronically ill and impoverished,
were tools of both the private sector and the state to invest in the social
order and material economy of their societies. Due to rapid population growth
and urbanization, health conditions in the early eighteenth century were
extremely poor. Fitting with Enlightenment ideals, such hospitals were
developed with the premise that sickness could be controlled and even removed
from society. Hospitals soon admitted hundreds of patients with the expectation
that they could be cured as were also considered valuable tools for medical
instruction. Though presently hospitals revolved around teaching medical and
surgical students, they were organized for serve as observational tools only
which in turn, standardized treatments and behaviors of doctors in Western
Europe.
Clinical instruction in hospitals was
not unique to the eighteenth century. In the sixteenth and seventeenth
centuries a few professors of medicine brought their students to hospitals in
order to present examples of conditions on which they lectured. Surgeons,
apothecaries and midwives had long, deeply entrenched traditions of clinical training
but this was new ground for physicians. Since at this time hospitals were
places that used the skills of surgeons and physicians, these fields became
more blurred than ever before. Additionally, the demand for skilled
practitioners in the military required that some standardized venue be used to
educate military doctors. Initially at the Royal Hospital in Edinburgh,
students were allowed to freely observe the actions of surgeons and physicians
until their large numbers proved to be a distraction and inconvenience. Though
in London students were allowed free access well into the eighteenth century, since
many of their patients were non-paying, the hospital administration at
Edinburgh began to rely on revenue from admission tickets as early as 1738,
also restricting the hours and rooms that students could visit. For the most
part of the eighteenth century, clinical lectures were popular and encouraged
among medical students though they were not actually required until 1783.[2]
In many hospitals, autopsies were also used for pathological purposes in order
to instruct burgeoning students about the effects of certain conditions on
anatomy.
Given the very strict purposes of the
hospitals to be both centers of research and teaching, as well as
rehabilitating institutions to improve the social order and economic efficiency
of an area, the type of patients admitted was very specific. First, though
hospitals were working to get away from an image of havens for the poor only,
some even changing their titles to “infirmaries,” they were still mainly
populated by the poor who were more likely to get sick to begin with and could
not afford in-home care. However, these poor generally needed to be deemed
deserving by an outside sponsor; that is to say, they generally needed to be
working individuals with good character. Most hospitals would not even treat
venereal disease. Rehabilitating these figures, it was assumed, would ensure
that they could quickly return to work without becoming a permanent burden on
society. In order to meet these goals, they did not see a practical value
investing in those with chronic conditions or serious untreatable injuries.
Most patients suffered from acute injuries and potentially non-fatal diseases. Due to the teaching agenda of many hospitals,
administrators often ensured that they maintained a quota of certain types of
patients.[3]
Patients were sought who displayed an extremely rigidly typical set of symptoms
as they were the best suited for teaching purposes. This set of manner of collecting specific
types of patients in order to demonstrate specific disease or treatments meant
that for the first time, diagnosis as well as treatment became relatively standardized.
Since hospitals around Europe modeled themselves after their neighbors, this
because the case internationally. This
standardization as well as the routine nature of autopsies also made hospitals
rather than private anatomies schools the main centers for medical research.
For the first time, professionals had large collections of people with
potentially treatable problems in a single setting who could scarcely object to
experimental treatment.
However, perhaps more important than
the standardization of diagnosis and treatment, hospital served another purpose
in regimenting patient care, establishing a particular tradition of bedside
manner, just as regulated as fever treatments. Students, who generally were
required to have some knowledge of medicine before embarking on clinical lectures,
were able to do little more than observe and occasionally ask questions of
patients. Students were forced to adhere to specific types of questions and before
speaking to patients themselves, were required to observe the interactions
between patients and senior doctors.[4]
They were encouraged to be friendly and professional as well as respectful of
the patients’ privacy and failure to abide by these precepts could result in
expulsion. The development of bedside manner established a particular
relationship between doctors and patients, which was not an aspect of medical
education before this time. Additionally, since the majority of patients in
these types of hospitals were there experiencing an acute and treatable
condition, they were generally cooperative and deferential to physicians due to
the kind treatments and relative success rate of such institutions, as opposed
to the more standard view of doctors in earlier times as skilled men from whom
one could buy services.
Though in a standard narrative, the
Enlightenment was a relatively stagnant time in the history medicine,
sandwiched between the plethora of anatomical discoveries of the previous
century and the ‘scientific’ efficiency of the next, clearly this period was
important in the development of modern medicine. Not only did it begin a shift
from hospitals as religious institutions dedicated to hospice to social
institutions hoping to reform disease into submission and place hospitals at
the center of medical education and research, it saw the reconciliation of surgical
and standard medical education, previously separate fields and lead to the
standardization of medical diagnosis, treatment and behavior so that arriving
with a fever in Edinburgh, Vienna or Philadelphia would garner patients a
similar experience in regards to their health.
[1] Porter, Roy. 2004. Flesh in
the Age of Reason. New York: W.W. Norton & Co. p. 214
[2] Risse, Guenter B. 1986. Hospital
life in enlightenment Scotland: care and teaching at the Royal Infirmary of
Edinburgh. Cambridge [Cambridgeshire]: Cambridge University Press.
[3] Risse, Guenter B. 1999. Mending
bodies, saving souls: a history of hospitals. New York: Oxford University
Press. p. 236
[4] Ibid 253
