Lecture Eleven: Science, Medicine, and the Person

Science, Medicine and the Person:

From support to invasion

The Sources of Medical Authority:

From advice to procedures

The Control of Medical Need

1. "The real need for medical care is a medical, not an economic, concept....It can be defined only in terms of the physical conditions of the people and the capacities of science and the art of medicine to deal with them.  Thus, it is not always a conscious need, still less an active desire backed by a willingness to pay.  The ordinary layman lacks the knowledge to define his own medical needs and can rely only on the expert opinion of medical practitioners and public health authorities." -- Committee on the Costs of Medical Care, 1933

Subversive?  Public Health

1. "The science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in the principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."  -- C-E A Winslow, 1920

Medicine becomes Imperative

• I know you! - to be a diagnosis
• You Must! - instructions to housewives
• Demand driven to supply driven

Why does specificity disappear?

• Science kills it, OR...
• Society can't handle it

Changes in Disease Theory

1. From specificity to universalism
   • You are a ...
   • You are your heritage; your food
2. From symptoms presenting to causes underlying
3. From random assemblage to syndrome to single exciting cause of disease

Doctor as Commander

1. Doctor's orders vs. Doctor choosing
2. Arrowsmith: precision and exactitude vs. Tromp and Coughlin
3. The germ theory in America
   • 1895: Diptheria antitoxin, Behring
   • 1908-1910: Salvarsan (606), Ehrlich's magic bullet
   • 1890: Tuberculin, Koch
   • 1906: Wasserman, Koch
   • 1896: WIdal reaction, Pasteur Institute

How Does the Doctor Know?

1. The advance of diagnosis
   • The pulse
   • The stethescope - Lannec, 1816
2. Beyond subjectivity
   • 1896: Blood pressure
   • 1903: ECG - the discovery of heart attack
   • 1868: Thermometry, Wunderlich
   • 1895: X-rays and malpractice

The Second Generation Sects: Resistance - Health or Disease?

1. The resistance to objectification: validating one's own illness
   • Osteopathy: Still, c. 1875 - bones +
   • Chiropractic: DD Palmer (the discoverer), BJ Palmer (the developer) - spines +
   • Christian Science: God's Touch
   • Naturopathy
     1. God would not want us to be ill
     2. Lust on vaccination

The Fate of Specialization

1. Why aren't osteopathy and chiropractic and massage medical specializations?
2. Which is the most important specialty?
3. Where does medicine begin and end?
4. Contrast with law
5. Contrast with clergy

For and Against

1. Against:
   • Minimum standard as common standard
   • To know is also not to know; problem of coordination
   • Minimum client pool
   • Minimum college pool
   • Acquiescence of other specialties
2. For:
   • Greater knowledge is specialized knowledge

Specializations: What and Why

1. The usual model
   • The invisible hand of knowledge
   • The market model
     1. Protection from within
     2. Protection from below
2. Alternative models
   • General medical expansion
   • Specialization as charism

How Far Should Medicine Go?: The Limits Model

1. The problem of WWI:
   • Rehabilitation to:
     1. Physical functionality
     2. Psychological readjustment
     3. Decent employment and life

The Case of Rehabilitation:

The Medical Side, 1890

1. c. 1880: Electrotherapy as adjunct to gynecology and ...
2. 1892: Homeopathic electrotherapeutics
   • Natrional Society of Electrotherapeutics
   • Journal of Electrotherapeutics
3. 1891: Regular electrotherapeutics
   • American Electrotherapeutic Association
4. Problem:
   • Secure legitimate domain for electricity
   • Electricity associated with quackery and cure alls
   • One electrical device slims, prevents sleeplessness, cold feet, balding, and improves bust

The Medical Side, 1900

1. 25,000 American physicians using electrical cures
2. Electricity as most conspicuous of physical means; distinct from pharmacy and surgery; physical therapists
3. Journal of Advanced Therapeutics from Journal of Electrotherapeutics, 1902
4. Problem: continuing distrust of electro quacks
5. Problem: need to embrace X-ray (both therapeutic and diagnostic) vs. new Roentgenologists vs. neurologists over psychotherapy

The Medical Side, 1916-1926

1. Problem of WWI: staffing field hospitals and rehabilitation of wounded
2. 1887: American Orthopedic Association (AOA); services to Army
   • Military medicine is orthopedic medicine
3. Hostile reaction of general surgeons, medics
4. Deal: regular doctors and surgeons staff hospitals; physical therapists to offer convalescent care
5. Problem: Where does treatment end and convalescence begin?
   • Approval, but adjunct status
   • What role?  Physician in charge, consultant, supplemental department manager
6. 1923-1926: Protected by AMA to secure profession against device peddlers
7. 1936: Specialty formally recognized

Allied Professions - Physical Therapy, 1917-1933

1. Orthopedic reconstruction aides; "rubbing angels;" need for training schools
2. 1921: American Physiotherapy Association: non-nurse women's profession; masseurs, P.E. teachers vs. acute care nurses
3. Fight with doctors for title: technician or therapist?
4. 1933: AMA accreditation; self-registry
5. Protection from masseurs

Allied Professions - Occupational Therapy, 1917-1933

1. Social work + Nursing Asylum: TB + asylum
2. 1923: American Association for Occupational Therapy
3. 1935: AMA accreditation; self-registry
4. Protection from nurses, physical therapists, social workers

The Rise of Scientific Nursing: Charism + Science

1. Nursing
   • Profession
   • Servility
   • Vocation
   • Skilled labor
   • Advocate (General mother?)

Nursing Orders

1. Sisters of Charity of St. Vincent de Paul
2. 1827: Sisters of Mercy
3. 1839: Sisters of the Holy Cross
4. A response to social change: urbanization, industrialization

Florence Nightingale (1820-1910)

1. Gentlewomen's nursing societies
2. 1851: The Fliedner School for Deaconesses
3. 1854-1855: The Crimean war - the hospital at Scutari
4. The nurse as:
   • moral exemplar
   • lady
   • scientist

Nightingale's Theory of Disease

1. Disease as imbalance exacerbated by bad environment
2. Following the natural course of disease
3. Medicine = support, not cure: Nursing Rules
4. The quiet hospital of good air

The Formation of Profession

1. The imperative of nursing education
   • Nursing education as nursing staffing
2. Docility, obedience
3. Independence, professional mobility

Tuberculosis as the Exemplar:

Part One

1. Phthisis to consumption to tubercular
2. Problem of diagnosis: pulmonary consumption, scrofula, tabes mesenterica
   • Diathesis, cachexia, consumption
   • Cough, expectoration, hemmorhage, night sweats, diarrhea, bad breath, hectic fever, paleness, loss of appetite, weight loss, increased sexual desire
3. Children, young adults, the aged
4. Spes phthisica

Part Two

1. You are a walking contagion, my love - are you killing me, or the rest of us...
   • You have night sweats, bad breath, continual cough, diarrhea, no sex, no pregnancy.  And don't raise your arms too high to fix your hair
2. Why me?
   • Because surely you were bad - or your parents were - celibacy, syphillis, drink
3. What must I do?
   • Boil your bottle, your tableware, your bedclothes, handkerchief, have you sleep out the window

Part Three

1. What can we do?  Working to be healthy
   • The great west
   • The dispensary?: cod liver oil
   • The hospital?
   • The sheltered workshop?
   • The sanitorium?
   • Pneumothorax
2. After 1950 - streptomycin
3. But who is to help? Who will take care of? How can we pay? - TB and poverty: servant rate 8X masters

Medicalizing Behavior

1. Sodomy to homosexuality
2. Habitual drunkenness to alcoholism
3. Custom and religion to irrationality and feeblemindedness

In What Ways is...

Saranac Lake like the Central Valley in California?

Advantages

1. Natural explanation removes blame
2. Allows cure
3. Provides defense (medicine as Marx's outlet)

Disadvantages

1. Person as disease
2. Presumption of therapy
3. Sin with new authority: "that's sick..."

Neurasthenia:

Doctors take back the serious self

1. What makes a great diagnosis
   • A long list of variable symptoms
   • The concept of energy, from humor to solid and back to humor again
   • Beard and Mitchell: neurologists for the Main Line
2. Making hysteria attractive, providing a womb equivalent for men; reclaiming hypochondriacal territory
3. An all-class disease: students can see it too, treat and diagnose
4. A disease for the serious youth, not fun but a grown up response
5. Consider Deborah Viner Fiske meets Drs. Beard and Mitchell

Does it Belong in DSM-IV?

1. Drs. Beard and Weir Mitchell: the lush garden of neurology
2. Who or what is sick here?: The rest cure and the yellow wallpaper; the case of Charlotte Perkins Gilman
3. Who can be a neurasthenic?

Old Specializations

1. Mad midwifing
2. Mad doctoring
3. Urban
   • Eyes
   • Surgery
   • Nerves

From Magnetism to Christian Science

1. 1770: Early Mesmer; magnetic field real in magnets
2. 1790: Middle Mesmer; magnetism in everything
3. Late Mesmer; magnetism as psychic force
   • As Christian faith healing
4. 1860s: Mesmerism as charisma; P.P. Quimby
5. mid-1870s: Healing mental, disease mental, state body an act of imaginaton, faith (Christian Science); healing as the Christ within