Thursday, December 27, 2012

The Standardization of Knowledge in Enlightenment Hospitals


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

No comments:

Post a Comment