Pacemakers, implantable, and dominance of heart surgeons:
“Thoracis surgeons devised the standard implantable procedure and held a near-monopoly on the implantation for many years. The dominance of surgeons was inevitable given the design of the pacemaker, a device that required the surgical opening of both the abdomen and the chest.” Even after cardiologists began implanting pacemakers in catheterization labs, “surgeons remained their dominant position until the 1980s.”
Palliative care, critical care nurses, surgeons and:
“Jezewski suggested that critical care nurses are ‘culture brokers,’ bridging the complex cultural environment of the critical care unit between the physicians, patients, and families” (Buchman, 667). . . . We suggest that the surgeon is ideally trained to organize and sustain the rescue attempt. We suggest that the surgeon is poorly positioned to abort the rescue attempt when it has failed. The covenant between the surgeon and the patient as social and, at the end of life, spiritual beings demands comfort and dignity. Repeated fruitless attempts at physiological rescue delay and even deny these covenantal obligations” (671).
Paracelsus, and physician as aiding body’s “internal alchemist”:
“For Paracelsus, the internal alchemist ([read: the role of DNA] also had the job of separating what was useful from what was not in the body. Since the influence of the greater world, the astra, also contained disease, the internal alchemist needed to separate what was poisonous from what was beneficial to the body. . . So the physician needed to understand the processes by which alchemists worked. He or she needed to know what calcination and sublimation were and needed to understand distillation and fermentation, because these processes were the means by which all chemical natures were completed . . . Knowing these things allowed the physician to come to the aid of the body’s ‘internal alchemist’ . . . The two, the body and the physician, then worked together, the ‘internal alchemist” receiving help from the physician-alchemist, who supplied, by laboratory means, what a specific part of the body required [i.e., by .Making medicine and applying medicines] . . .” (B. Mora, 41).
Paracelsus, chemical (nonhumoral) basis of his “new medicine”:
“Paracelsus also rejected the notion that all things in the immediate physical world were composed of earth, air, fire and water. In his view, there were some things that preceded even them: the cosmological wombs, as he called them, of Sulphur, Salt, and Mercury. These were known as the ‘first three’ . . . The knowledge of powers – or how things knew what to do, and what they could be expected to do when applied as medicine – was, therefore, chemical at its root. This is where the new medicine staked out a new frontier. The human being was a divinely created, spiritually infused, chemical apparatus. The body worked in an alchemical way. Its parts possessed their own ‘inner alchemist’ that ‘knew’ how to separate what was useful to the body from what was not” (B. Mora, 32).
Paracelsus, Luther and:
“All the same, Paracelsus’s theological philosophy, while hardly itself scientific, enables science, where Luther’s prohibits it. Indeed, it is not easy to separate Paracelsus’s ‘science’ from his theology, and to the man himself there could never by any such division: his chemical cosmos was comprehensible only within the framework of his distinctive and idiosyncratic Christianity, for God’s work was visible everywhere in nature” (P. Ball , 105). . . Luther’s notion that faith was all did not sit comfortably with Paracelsus’s practical mission of healing” (118).
Paracelsus, magical remedies of:
“Paracelsus was first of all a physician, and he regarded his own medical remedies as magical. But that was, in his view, the opposite of superstitious; the doctor systematically concentrated and manipulated the invisible, magical forces and ‘virtues’ of nature. And Paracelsus sought to embed this ‘new medicine within a comprehensive system of (devoutly Christian) natural philosophy, from which the doctor’s art emerged naturally. In this much at least, his aim was no different from that of contemporary science: it all has to fit together” (P. Ball, loc 264).
Paris School, why antebellum Americans flocked to it rather than to London:
“The single element in American accounts of Paris yet consistently missing from accounts of London was enthusiasm about free access to medical facilities and instruction.” . . . that the official course of instruction in the hospital wards and lecture halls of Paris came free of cost to foreigners was a point “that American observers made persistently and emphatically. . . . It was access more than scientific brilliance that chiefly decided Americans on the French over the British capital” re access to cadavers and “to instruction from the living body at the bedside” (Warner I, 70-71).
Pathology, in relation to bacteriology:
“The chief preoccupation of most pathologists between World Wars I and II . . . was their relationship with bacteriology. Just as more time and energy was spent working out physiology’s relationship with biochemistry than it did with pathology or other basic science disciplines, so too did pathology have to deal with the problem of its daughter science bacteriology. In fact, many investigators in the 1910s and 1920s considered bacteriology the experimental wellspring of pathology. . . By the 1930s it was clear, especially with the explosions of viral research, that microbiology was too large to be contained within pathology. In that decade, an increasing number of medical school deans engineered the two disciplines’ fission, so that bacteriology might stand on its own, with everything that implied in terms of careers and patrons” (Maulitz, 230, 231)
Patient, viewpoint of in medical history:
“Thus the patient’s point of view remains enigmatic. On the one hand, there is a call to consider the patient in history of medicine as an important partner, voice, subject, object or whatever you like to name it with the ultimate aim of rewriting the history of medicine according to the patient’s view. On the other hand, we have statements that the patient has actually disappeared from the medical narrative or is merely a by-product of medicine. A full debate between these two positions – that the patient’s view can be unearthed form the sources against the statement that the patient is a construct of the medical gaze – has, to my knowledge, never taken place” (Condrau, 529). Contra Porter, patient history as “history from below” doesn’t work because: “it over-emphasizes polarity. Porter’s patients stand against doctors – there is not much room for the social or local environment. The family or, lo and behold, other occupational groups such as nurses and midwives play only a minor role in such an account. . . . most histories from below were driven by a political interest [e.g., women’s history derived from feminist movement; black history derived from civil rights movement]. A comparable political background for patients is not easy to unearth” (533,534).
Patient-centered record, and emergence of the modern patient as Subject:
“The topic to be addressed here is the embodying of the patient: the production of a patient with a body whose characteristics are the effect of the interrelation of the patient with a growing number of professionals and investigative probes, and with a medical record which becomes more and more significant as a gravitational node in these interrelations” (Berg & Harterink, 14) . . .The patient-centered record might be seen to perform the patient as a Subject: a bounded, coherent and unified self, with a history that forms a whole, and an inner core tha t is unique to this person and constitutive of who she or he is. . . . The patient record concretely attires the patient with many of the characteristics of liberal subjectivity (Hayles, 1999): coherence, boundedness, centeredness, unique historicity, self-determination” (Berg & Harterink, 29).
Patient-centered record, and re-historicization of the patient temporally and physiologically:
“ . . . the patient-centered record became a crucial actor in the performance of a new mode of embodiment (Berg & Bowker, 1997). . . . Partly mirroring the compartmentalization of the hospital organization, a compartmentalized yet unified body emerged here, in which organs or organ functions are each allotted a separate section in the file, or a separate portion of a preformatted form. In the interrelation of proliferating techniques, patient-centered record, doctors, nurses, and the patient, a body emerged whose dimensions do not map the everyday sites and events on the ward or in the clinic. This body extends in an anatomical/pathophysiological space and time which is traveled by blood cells and growing tumors, and which is explored through urinalysis and endoscopies (Berg & Harterink, 23-24). . . . “the new space-time that emerged between the covers of the record was a novel phenomenon. The embodiment of patients was loosened from the workings of the day-to-day life networks that permeated the hospital walls; the space-times that doctors now traveled in were less and less measure by moral worth and social standing. Rather, studying the X-rays and other forms, doctors could enter the space of a tumor that grows, or a fracture that heals (24). . . [This temporality is exemplified in the graph,] transcriptions that transform events occurring in the space-time of a hospital ward or laboratory into repetitive phenomena, occurring in and linking across a linear time that is lifted out of the ward’s time zones. . . . They establish a historical continuity in a double sense. The graph’s grid, first extends reassuringly into both the past and the future: the grid’s basic structure in unbounded and completely regular. . . In addition, a historical continuity is produced because the graph is accessible at any moment. The specific tracing can be rescrutinized at any later time; it can be compared to other processes, of other physiological entities, or of the same individual later in time” (25-26). . . . Compared to the series of disjointed, brief narratives in a casebook, the patient-centered record affords a physiological historization of the body in myriad ways (27). . . . Processing the body in medical practice, [now] had also become embodying the patient-as-process. . . . The patient-centered record performs a historized body; it invests the patient’s body with a linear, accessible and continuous history. . . . Recurrent tests now subjected patients to daily routines . . . Likewise, therapies began to perform the body-as-process (28).
Peabody, Francis, appreciation of GP of:
“Dr. Peabody, unlike Dr. Cabot, felt strongly that the general practitioner was more important today than ever. “Never,” he says, “was the public in need of wise, broadly trained advisers so much as it needs them today to guide them through the complicated maze of modern medicine.” He was opposed to the kind of group practice where many different specialists see the patient but no one doctor understands or is responsible for the whole patient. . . . On every important subject on which Dr. Peabody worked – typhoid, cardiac dyspnea, etc. – he wrote at least one paper especially to present the subject to the general practitioner” (Williams, 480).
Pediatrics, historical role of women in:
“Since the late nineteenth century, women physicians had enjoyed public acceptance as physicians for children. Prior to the end of the century, most children’s hospitals were women’s and infant’s hospitals rather than centers dedicated exclusively to the care of children. Several such institutions were founded by women, including the Blackwells’ New York Infirmary for Women and Children (established in 1857), Dr. Marie Zakrezewska’s New England Hospital for Women and Children (1862), Dr. Mary Thompson’s Chicago Hospital for Women and Children (1865), the Children’s Hospital of San Francisco (1875), and the Babies Hospital of the City of NY (1887). In the early twentieth century, widespread recognition of women physicians’’ child health work in voluntary societies and municipal agencies, the still shaky status of pediatrics as an academic specialty, and the unstinting support of several well-placed male academic pediatricians helped ease the way for women to make inroads in the new field” (More, 170-71).
Penicillin, Fleming’s limited laboratory use of:
“The discovery of penicillin had provided him with a most valuable reagent in his main routine occupation, the production of vaccines [in Almroth Wright’s Inoculation Dept. at St. Mary’s Hospital], and he had been quick to apply it in this way. . . . Penicillin favoured the selective culturing of the acne, influenza, and whooping cough bacilli. Fleming directed Craddock to this work in preference to his attempts with Ridley to purify penicillin. Crude penicillin was, in fact, perfectly satisfactory for the selective culture of these three organisms in the production of vaccines, and so it was itself produced for this purpose in weekly batches. . . . When it became quite obvious that penicillin was proving itself as a systemic antibacterial agent of unparalleled power, Fleming changed his stance. He reported the results of his own in vitro tests on the Oxford material, found them superior to the sulphonamides, and began to predict that, if penicillin could be synthesized, it would supersede them. And, by quoting the two predictions he had made, on in his 1929 paper, and one in the paper for the British Dental Journal, he was able to claim that he had always been aware of the potential therapeutic value of penicillin. Though it would seem that these two predictions referred to a possible local use of penicillin, many subsequent writers have interpreted them as referring to its systemic injection. This view seems to be unsupported, not only by the actual wording of Fleming’s pronouncements, but by the course of events” (Macfarlane, 254, 255).
Penicillin, Florey’s genius in pulling together the Oxford Unit:
“Florey was not only a hard worker and a clever scientist, he was a great organizer. He had the ability to recognize and to use the relevant special talents of his colleagues and assistants, and he had a very special quality of his own, the ability to inspire the confidence and enthusiasm of a group of experts so that they became a very effective team under his leadership. In 1939, with almost no money to fund such a research and with the shadows of war darkening the whole of Europe, Florey decided to gamble all his resources and those of his department on penicillin, a dark horse at best, and quite possibly a non-starter” (Macfarlane, 170).
Penicillin, impact on medicine:
“Penicillin had a dramatic effect on infection and mortality resulting from bacterial infections, such as staphylococcal and puerperal sepsis, pneumococcal pneumonia, otitis media and bacterial meningitis. It also had a big impact on minor diseases, such as impetigo, which as a result is rarely seen nowadays. . . . Just as importantly, the advent of penicillin allowed for major advances to be made in surgery, allowing for organ transplantation, cardiac surgery and the efficient management of severe burns” (Wainwright, 87). When penicillin first became available for civilian use, “It was used for pneumonia, hemolytic streptococcal infections, and for staphylococcal infections. By late 1943, it was in general civilian use: “It was such a thrill to be able to save the life of someone with meningitis or bacterial endocarditis and to bring syphilis to a half in a few days” (Beeson, 171).
Penicillin, outcome of WWII and:
“Although the Germans were well aware that the Allies had penicillin they never succeeded in producing it on a large scale, a fact which was a major contributory factor in their final defeat. There was some debate as to the legality of preventing penicillin-producing culture from reaching the enemy since it could be argued that in International Law it was illegal to distinguish between friendly and enemy wounded Despite this, the military potential of the new drug was fully recognized and, perhaps not surprisingly, cultures of Fleming’s mould were not dispatched to Nazi scientists and doctors” (Wainwright, 65).
Pernicious anemia, fragmented identity among vying specialists, 1900-1925:
The period was marked by “professional tensions and commitments concerning the hierarchy among specialties [abdominal surgeons, hematologists, gastroenterologists, neurologists] . . . The disease possessed a clinically fragmented organic identity that reinforced specialization and the search for organic causation . . . specialists brought their preferred order to a fragmented organic and therapeutic situation. How they thought about disease depended upon technologies deployed within the hospital and on the social relations of hospital practice )Wailoo I, 161).
Pernicious anemia, liver extract (Eli Lilly), and corporate pharma in 1930s:
“A key development during this era was the way the patient’s response to Eli Lilly’s liver extract was interpreted as a kind of bioassay, a diagnostic technology in its own right retrospectively constituting ‘the disease.’ Rather than curing all of the patient ordinarily diagnosed with pernicious anemia, this disease became, by definition, that entity which was cured by a new consumable and de facto diagnostic technology – liver extract. . . . [In his 1956 autobiography, Boston hematologist Roger Lee] “reflected on how academic medicine’s commercial ties had transformed medical writers into spokesmen for the drug industry” (Wailoo I, 141).
Personality, early twentieth century psychiatric focus on:
“Around psychopathy, then, psychiatrists began to constitute ‘personality’ in its modern form, as at once a possession, something a person ‘has’ or displays, and object of analysis. . . . Early-twentieth-century psychiatry’s focus on the personality, adumbrated first around psychopathy, was an important means by which the discipline effected the shift from the necessarily limited psychiatry of the abnormal to a psychiatry of normality. . . The term’s turn-of-the-century usage anticipated and facilitated the discipline’s adoption of the psychiatry of adjustment, a psychiatry applicable to everyone.(Lunbeck, 68, 69).
Philadelphia, Antebellum Southern Medical Students in:
“ . . . leading figures of the southern medical establishment . . . most of whom had been trained in Philadelphia, were not threatened by that city’s preeminence – quite the contrary” (Kilbride, 707) . . . “Philadelphia’s schools [Jefferson & Penn] were respected as the finest the nation could offer. . . . William Penn’s city . . . initiated students into a genteel culture, where they absorbed the elements of medical thought and practice and became part of a national community of professional gentlemen” (708) . . . “most informed medical men considered the city’s greatest advantage to be the availability of hands-on instruction in clinics and hospitals” (709) . . . Philadelphians aversion to radical reform “was rooted in the close ties between Phila. bluebloods and their southern peers, a relationship that gave the city a decidedly southern and conservative cast that reinforced its allure in the eyes of prospective southern physicians” (710. 714-15) . . . The city was not a center of abolitionist sedition. In fact southern men were heartened by the obvious disdain with which Philadelphians viewed antislavery activists” (711, 712-13 ) . . . 244 southern students left Penn and Jefferson after execution of John Brown (717); in 1858-60, 60% of Jefferson students was from the South; “Despite the vituperation of southern medical educators, the young men returned and were not alone in choosing a Philadelphia medical school: the next year 34% of the University of Pennsylvania’s class was southern, and 48 percent of Jefferson’s. Though the latter signaled a significant decrease from 69 percent the year before – the high point for southerners in Phila. schools – their numbers were remarkably strong given the publicity generated by their withdrawal. Phila’s conservatives had good cause to feel they had preserved the trust of the South” (719).
Physiological therapy, gap between experience of, and intended effects of, ca 1900:
“But a gap opened toward the end of the nineteenth century between a patient’s experience of medical treatment and the treatment’s intended effects. The targets sought out by newer twentieth-century therapeutics often had little connection to their immediately perceptible effects (Crenner II, 102). . . . What changed late in the nineteenth century was the availability of routine methods for extracting information about physiological effects: with blood counts and homoglobinometry, chemical urinalysis, microscopy, serology, and x-rays. . . . Drug therapy increasingly sought to produce interior changes in a patient’s body that were as concrete as surgical effects (103). . . . Feeling better was not accurate evidence of therapeutic effect. . . . [Whereas] A blood test, like an appendix on a napkin, showed both the hidden target of the treatment and its demonstrable therapeutic effects” (105). . . . Physiological therapeutics picked out interior targets for medical therapy in a manner that made a previously reliance on the patient’s perception of therapy seem less legitimate” (109).
Physiological therapy, patient’s attitudes toward:
“For the patients who accepted the premises, physiological treatments did offer a proof of control that could be perceived as a service in its own right. . . . Some patients not only identified an independent value in the doctor’s control over disease, but seemed capable of sharing it vicariously” (Crenner II, 118) . . . The concrete facts of physiologic monitoring offered a shared territory lying between the patient’s unimpeachable, if inaccessible, claims about symptoms and the physician’s assumed expertise” (123).
Physiology (experimental) and medicine, relationship of:
“By the end of the [19th] century, as physiologists and physicians had developed distinct goals, their instruments reflected different requirements. This conflict over purpose had been evident to those who attempted to apply the new instrumentation to medicine even in the 1870s. In the 1880s and 1890s, physiologists had become increasingly concerned with their own questions, and the disjunction between pure and applied experimental medicine had become more apparent. By the time of [William] Porter’s push for experimental physiology, physiology had become a discipline to train the mind in exact reasoning rather than the royal road to either diagnostic precision or effective therapy. By 1900, physiology as a discipline had become removed from clinical medicine, even though physiology as an intellectual pursuit was becoming intimately tied to clinical concerns [Borell, 310-11] . . . the eventually successful campaign for the separation of physiology from anatomy and medicine in the nineteenth century was being followed by a reconsideration at the turn of the twentieth century of the mutual benefits enjoyed to each intersecting discipline. Physiology itself was about to be threatened by the separation from its domain of fields like biochemistry and endocrinology. Moreover, physiologists were beginning to discover that the more interesting problems yet to be solved lay in the common ground between clinical medicine, experimental physiology, and physiological chemistry” [313].
Physiology (experimental) and medicine, relationship of, in Britain re vivisection:
“Opposition to the practices of medical science reached far outside of the clinical sphere. It was also a result of the application of methods of animal experimentation that proved inseparable from laboratory research. Strong feelings toward these procedures existed both among members of the general public and within sections of the medical profession in Britain. . . . The inclusion of scientific principles into medicine was also problematic because concern existed that clinicians would begin to see their responsibility as normalizing a deviant physiological process rather than caring for a sick human being (I. Miller, 346) . . . Experimental physiology was therefore inherently wrought with problems of internal ethics and public accountability. . . . Accordingly, antivivisection sentiment, including that from within the medical profession, exerted a powerful inhibitory influence on the adoption of the ideals and technologies of physiological exploration, more so in the British clinic than in other countries” (347). . . . Fears of human experimentation were certainly deeply immersed within vivisection controversies. It appeared perfectly plausible to many contemporaries that the human patient might eventually fall victim to the cruel, experimental urges of the modern medical man, particularly if the ethos of laboratory science was allowed to intrude too far into the British clinical experience (353, cites Lederer, Subjected to Science). . . . [-Re gastric analysis] Modern procedures were there not altogether rejected either as an over-simplistic science versus intuition dichotomy might suggest. It was not uncommon for British practitioners to argue that modern forms of gastric analysis should be restricted until a later date when their accuracy and usefulness was more certain. . . a postponement of the introduction of medical science until question related to clinical value were firmly settled (354-55). . . . patient discomfort seems to have been the leading factor in reducing the British physician’s motivation to abandon familiar methods. It was an aspect that held the strongest cultural resonance due to its potential association with apparently needless exercises in medical experimentation and brutality” (356). . . . enthusiasm of those who were initially eager to use gastroscopic methods was often dampened by accidental, and sometimes fatal, perforations of the gullet or stomach” (357). . . . “Fears of the cruelty and pain of the laboratory being directly transferred into the clinical setting appeared to be turning into reality within the controversy surrounding the suffragette hunger strike, which took place in British prisons from July 1909, and is likely to have contributed toward the wariness of both doctor and patient to engage with laboratory technologies” (359). . . . [Re its use in force-feeding of suffragettes], “Representations of the stomach tube as instrument of human torture therefore constituted a climax in debates regarding the extent to which technologies accrued from scientific medicine might be utilized for scientific purposes, or for torture, at the expense of questions related to the patient’s health (371).
Placebo:
“Placebos may also be procedures, diagnostic or therapeutic endeavors that the physician ‘knows’ bring no pharmacological benefit. By most definitions a placebo must be given by a physician who believes that the drug prescribed is ‘inactive’ by pharmacologic standards. This leaves us in the awkward position of claiming that a drug which is a placebo for one physician may not be for another. . . . One person’s placebo is another’s active agent (Spiro, 44). . . . The physician may give a placebo as (1) a gift to relieve pain or to treat a complaint that seems to have no objective explanation; (2) a challenge to prove that the patient is wrong (‘See, if a sugar pill has helped you, it is all in your mind!’); and finally (3) ransom to get rid of a demanding patient too difficult to deal with. Placebos benefit patients, regardless of the mood in which the doctor prescribes them – and that benefit is one of their wonders” (46).
Placebo, physician as:
When physicians listen to their patients as carefully as they now look at them, placebos will prove unnecessary because physicians will have learned again that they can help many patients through themselves. The placebo is powerless without the physician” (Spiro, 52). . . . But words from the physician can be placebos. If words can exult the health, reassurance and comfort may mobilized ‘healing’ in the sick, even if the process cannot be measured” (53).
Placebo, psychiatry, alternative medicine, and:
“Psychiatrists vigorously deny any resemblance of their craft to alternative medicine, yet sometimes the doctors who give placebos live in the same world as psychiatrists, with the same respect for the mind and its power over the body, the same respect for listening” (Spiro, 51). . . . Suggestion should come out of the therapeutic alliance of patient and physician.
Placebos, Richard Cabot on:
“The placebo, Cabot claimed, was nothing more than a lie about therapy, and it was thus unacceptable in practice. As a treatment devoid of specific effects, the placebo placed the doctor’s control over treatment at stake without its usual justification in technical knowledge about the diseased body (Crenner II, 127). . . . the use of placebos would risk separating individual therapeutic influence over patients from its material justification. If therapeutic authority was grounded in special technical knowledge about the diseased body, then the use of placebos seemed a willful misrepresentation of this authority” (128). . . . for Cabot, it [placebo] was nothing but a deception. But placebos were more potent and complex mixtures than was allowed in these critiques, as the psychodynamic interpretations of Houston and others would suggest. Isolating the placebo so cleanly from its manifold meanings and associations was not easy” (133).
Plastic Surgery, late eighteenth century advances:
use of skin flap (free flap) described; Chopart performed lip reconstruction using a neck flap (1791) In 1818, J.C. Carpue (Britain) reconstructs nose of an army officer using a flap of skin from the forehead (the “Indian Rhinoplasty” based on 1794 account Carpue read in Gentleman’s Magazine (Bennett, 152-3).
Plastic Surgery, Mid-nineteenth century advances = use of rotation and pedicled flaps and free skin grafts. 1860s:
Baronio (Italian) experiment of free grafts from one site another on flank of sheep; American Civil War: more than 30 reconstructive procedures on eyelids, nose, cheek, lips & palate, using rotational flaps, oral prostheses and intermaxillary wiring; Gordon Buck, at NY Hospital during Civil War, reconstructed faces of patients with war injuries, incl. Carlton Burgan, who lost his nose, cheek, and orbital floor to an overdose of calomel (Crumley, 9-10); 1869: Reverdin (Paris) reports taking small piece of epidermis (“free skin graft”) to heal patient with traumatic skin loss of forearm (Bennett, 154); also develops, via experiments with subperiosteal [beneath dense fibrous membrane covering the surface of bones] resection, his eponymous cleft palate repair (Chambers & Ray, 473) 1874: Thiersch described the split-skin graft, taken with a razor, of the type currently used today” (Rowe, 344) Rene Le Fort’s reports his research (via cadaver heads) on bony displacements and patterns of fracture following injuries to middle third of facial skeleton (345-46)
Pneumonia, private physicians’ opposition to serum for:
“Despite laboratory advances in the 1930s that made pneumonia serum technically easier to use, physicians remained skeptical about the wisdom of using serum therapy in community practice. . . . Practitioners’ fears of serum therapy were ultimately rooted in the economics of medical practice. Using serum remained a tricky business not only because of the potential danger to the patient, but because of the potential injury to the physician’s reputation, should the patient react badly to serum or the expensive treatment fail.. Serum therapy for pneumonia might be rational therapeutics but the prudent physician might do best to avoid it” (Marks, 67).
Polio and the “New Public Health”:
“ . . . polio epidemics appeared during an era of transition in the American public health movement. Promoters of the New Public Health urged the public to accept the germ theory, but the popular and professional association between dirt and disease lingered. . . . In their anti-polio campaigns American health officials and private physicians turned to the laboratory for therapeutic and diagnostic help. But at the peak of public hysteria they also relied on tried and true methods of disinfection and fumigation. Despite the measures’ contradictions to tenets of the New Public Health, relying on sanitary regulation was partly the result of the laboratory’s impotence in dealing with and explaining polio” (Rogers, 18, 19). “The emphasis on sanitation, then, offered both the public and the medical profession a way to define and explain the epidemic. Polio conceived as a dirt disease could resolve questions of responsibility for the spread of polio; sanitation became a means of protection and prediction. . . . Germs might be everywhere, but public health work tended to divide cases into guilty carriers [i.e., Eastern European immigrant families] and innocent victims” (46-47).
Polio vaccine, ideological divide between proponents of live and killed vaccine:
“The majority of virologists favored the live-vaccine option and regarded killed vaccine as, at best, a stopgap. The most obvious advantage of live over killed vaccine was that it was administered orally, whereas killed vaccine had to be injected, not just once but three times, at intervals, to protect against all three types of poliovirus; mass immunization would be much simpler if the necessity – and fear – of the needle could be removed. Then there was the question of the length of immunity conferred by the killed vaccine, which had yet to be established; if it lasted only one to three years before a booster injection was required, that would create problems for public health authorities. Live vaccine, by contrast, should provide long-term, if not lifelong, immunity, just as the disease did – since the whole point of it was to infect with the disease but in such a mild form as to render it harmless (Gould, 134). “With live vaccine, not only was distribution far simpler . . . but incomplete coverage mattered less, since the vaccine-induced polio would spread of its own accord, and that would be beneficial so long as there was no danger of a reversion to virulence (181).
Politics of Pain, 1945-1960:
From 1945 to 1960, number of veterans receiving disability payments and pensions climbed from just over half a million in 1945 to three million in 1960. “Here was the crux of the politics of pain. For liberals looking to the New Deal as a continuing model of governance, the veteran’s complaints could become a platform on which broader commitments could be built. But the topic split the Right, with the doctors and veterans squared off for an ideological fight” (Wailoo II, ).
Polygraph, MacKenzie’s:
“Mackenzie . . . indicated in 1909 that he never wanted his name to be linked with the polygraph . . . [which] in Mackenzie’s opinion, was a research tool, not designed to be of use to the general practitioner, who was expected to understand the significance of the heart sounds and changes in rhythm without applying the polygraph to all of his patients. . . . The polygraph provided a diagrammatic representation of the variations of the simultaneous pulsing cycle in the arteries, veins, and heart. The instrument became a symbol for twentieth-century American and European heart specialists, thus realize Mackenzie’s worst fears for its impact on medical practice” (Davis II, 129).
Professionalism, in late nineteenth and early twentieth centuries:
complexions of professions as a status category changed from “status professionalism” (i.e., “gentlemanly professionalism”) to “occupational professionalism.” “For the first time in the latter half of the nineteenth century, the professional stratum became definable by the now-familiar matrix of tasks involving specialized knowledge, requirements of high levels of formal training, tests for competent performance, regulation by professional associations, and licensing by the state. At the same time, many of the precapitalist legitimations of the professions continue, in a transformed way, during this period of capitalist expansion” (Brint, 30-31).
Professionalism, role of universities in:
“In America, the universities became the central arbiters of professional status during the era of collective mobility [late 19th- and early 20th-century]. Aspiring occupations acquired professional status primarily by gaining a place in the regular curricular offerings of universities. They did so by persuading the universities that the tasks involved in their work required training in a formal body of knowledge, knowledge that was, furthermore, relevant to the performance of important services for individual clients or organizational employers. . . . The key to acceptance as a profession during the period of ‘collective mobility’ was a successful claim to testable expertise on the basis of formal knowledge, combined with the successful claim to social status arising from the conviction of an occupation’s ‘respectability’ and social importance. These are rather vague criteria, and therefore it is not surprising that formal university-level training became the authoritative guide to the boundaries of the professional world. For all intents and purposes, it is the universities that define the professions” (Brint, 34, 35).
Professionalism, shift from social trustee to expert professionalism beginning in the 1960s:
“In particular the last three decades show a double movement – away from antimarket elements in professional organization and ideology, and toward a more exclusive emphasis on bonafide formal knowledge as the critical element in the constitution of professions. In so far as this is true, the professions show signs of consolidating around a narrower and more exclusive base.
“Beginning in the 1960s, social trustee professionalism fell under increasing attack for its apparent lack of correspondence to the organizational realties of professional life. At the same time, a variety of forces – from the increasing importance of income as a status element in the general population to the population explosion within the professions – favored the rise of expert professionalism to a position of greater significance” (Brint, 39).
Professionalization, 19th c., in relation to biomedical innovation/science:
“. . . attempting to gauge with exactitude the extent to which nineteenth-century physicians were, by present standards, scientific, proves an unproductive task. Patients judged the profession by the criteria of their age, an authority which was incapable of distinguishing in any absolute sense the relative scientific merit of, for example, a phrenologist or his opponent. Given this limitation, ‘valid’ science becomes irrelevant to the attainment of status, while to pursue diligently its antecedents adds little to an understanding of the past. What is of paramount importance, however, is the manner in which physicians used, not the content, but the rhetoric of science. In an analysis of the deployment of science of physicians it will become apparent that the nineteenth-century profession, though outwardly demonstrating increasing homogeneity, must be resolved into a series of distinct and frequently competing subgroups. Each of these fragments invoked a definition of biomedical knowledge designed to accord with its particular aspirations. In effect, science, mirroring the profession itself, must be seen not as a fixed entity but as a collage of discrete and malleable constituents. (Shortt, 60) . . . The terminology of science, then, had entered the substratum of nineteenth-century British thought at a level quite divorced from its practical achievements. This subtle invasion made a significant contribution to medical professionalization: physicians portrayed themselves as exemplars of science to a public receptive to the idiom in which these claims were phrased. Under the guise of an objective explanation of natural phenomena, science became a code-word for a methodology, a designation for specialized expertise, and a vehicle for social mobility. . . . [sufficient evidence suggests that] American physicians were not unlike their British counterparts: specific subgroups within the profession fashioned their own definitions of science in their search for acceptable socioeconomic stature” (63-64).
Professionalization of psychiatry:
“Between approximately 1880 and 1917 psychiatry shed its former status as a beleaguered specialty isolated from the rest of the medical profession. The rise of medical interest in psychotherapy, the founding of the mental hygiene movement in 1908, the creation of new psychiatric societies and journals, the rapid expansion of a body of abstract knowledge – all developments in which [Adolf] Meyer was intimately involved – testify to the increasing professionalization of psychiatry during those years. The integration of psychiatry into the medical curriculum was a crucial step in this process. Thus the founding in 1908 of the Department of Psychiatry at Johns Hopkins was a decisive event, signaling as it did the recognition by the outstanding medical school of the day of the importance of psychiatry as an academic specialty” (Leys, 453).
Psychiatric disorders, and single neurotransmitters systems and DSM III:
“During the 1970s the major psychiatric disorders became defined as disorders of single neurotransmitter systems and their receptors, with depression being a catecholamine disorder, anxiety a 5HT disorder, dementia a cholinergic disorder, and schizophrenia a dopamine disorder. The evidence to support any of these proposals was never there, but this language powerfully supported psychiatry’s transition from a discipline that understood itself in dimensional terms to one that concerned itself with categorical ones. This legitimized the rise of biological psychiatry, which in turn fostered a neo-Kraepelinian approach to diagnosis and classification, as embodied in DSM-III (Healy, 163).
Psychiatric Nursing, pre-1940s:
“Nurses in psychiatric services prior to 1940 must have been greatly confused about their roles. Were they custodians? Were they surrogate mothers? Were they informers conveying descriptions of ‘bad’ behavior to physicians? Were they companions and/or friends of patients? Were they mother-like housekeepers keeping the wards clean and in order for Daddy (the physician)? Were they jailors preventing escapes, restraining patients, punishing misdeeds? Were they habit trainers? Were they protectors of the public, family, other patients? Were they occupational therapists or hydrotherapists? The nurse role was diffuse and the phenomenological focus for practice was unclear if not elusive” (Paplau, 22).
Psychiatric Nursing, role of Norristown in promoting:
“One of the great friends and promoters of psychiatric nursing was Dr. Noyes, superintendent at Norristown State Hospital in Pennsylvania. In 1930, when I was a senior student nurse, my classmates and I spent four half-days, over a period of four weeks, at Norristown. . . . In 1962, when I gave a clinical workshop at Norristown, Dr. Noyes, then retired and in a wheelchair, attended some of the classes” (Paplau, 22).
Psychodynamic Psychiatry, dominance from 40s through the 60s:
“Psychodynamic psychiatry from the 1940s to the 1960s was virtually synonymous with the psychotherapies and, to a lesser extent, milieu and other psychosocial therapies. . . . Yet within the psychodynamic synthesis lay elements that would hasten its eventual decline. Whereas most medical specialties had committed themselves to biological and physiological research that would illuminate organ function and pathology, to the eventual development of therapies that might be evaluated by randomized clinical trials, and to an emerging hospital-based technology, psychiatrists all but abandoned research into brain pathology. Consequently, the gap between psychiatry and medicine widened precipitously. . . That psychotherapy could not be defended in strictly medical terms meant that psychiatry was vulnerable to challenges from other professional groups, particularly clinical psychology. By the close of the decade of the 1960s, psychodynamic and psychoanalytic psychiatry had begun to lose the paramount position it had enjoyed since World War II” (Grob, 213).
Psychopharmacology, criticism of benzodiazepines beginning in late 60s:
“Because the chemical properties of benzodiazepines remain unchanged, this shift can be explained only by understanding these drugs as historical artifacts whose political viability tells us much about the world that determines their worth. . . . The diethylstilbestrol (synthetic estrogen) scandal, the thalidomide tragedy, and nagging doubts about the safety of oral contraceptives had burst the bubble of confidence in pharmaceutical panacea. There were also the illicit drugs, such as marijuana and LSD, that were being widely used a rebellious youth” (Tone, 378).
Psychopharmacology, discovery of chemical transmission and:
“The third area of scientific development that contributed to the advent of modern psychopharmacology was the discovery of chemical transmission at neural junctions in the central nervous system. . . . These [1904-1914] observations suggested a possible physiological significance of acetylcholine, particularly as a parasympathetic neurotransmitter. At the time, however, acetylcholine had not been shown to be normally present in animal tissue. Conclusive evidence that the effects of parasympathetic nerve stimulation are mediated by liberation of a chemical transmitter that resembled acetylcholine in all respects examined was provided in the early 1920s by Loewi, who showed that after simulating the vagus nerve [which slows heart rate] to the frog heart, fluid from the heart inhibited a test heart. In 1929 the presence of naturally occurring acetylcholine in animal tissue was first reported. Conclusive evidence that sympathetic nerves released a chemical transmitter having the properties of adrenaline was provided by Cannon and Bacq in 1931. . . . By the end of the 1950s the weight of evidence in support of chemical transmission in the CNS was sufficient to convince even strong early advocates of the electrical hypothesis (Eccles, 1959). With the discovery of chemical transmission in the CNS, identification of the central neurotransmitters became a major focus of research. By 1960 numerous substances, including acetylcholine, norepinephrine, dopamine, and serotonin, were considered likely brain neurotransmitters” (Baumeister & Hawkins, 205). . . . “in each case, the development in understanding the mechanisms of action of psychotropic drugs depended critically on the discovery of central neurotransmitters. At the same time, the evolving understanding of drug mechanisms of action helped to clarify the physiological significance of neurotransmitters. For example, reserpine depletes monoamines and produces immobility in animals. This immobility is reversed by L-dopa, suggesting a physiologic function for dopamine in movement. . . . The discovery of chemical transmission at neuronal junctions in the CNS was a foundational event in the rise of psychopharmacology. . . . Without the knowledge that junctional transmission in the brain was chemical, along with the corollary idea that disturbances in neurotransmission underlie mental illness, psychopharmacology would have remained purely empirical” (206).
Psychopharmacology, marketing and creation of psychiatric disorder:
“Although there are clearly psychobiological inputs to many psychiatric disorders, we are at present in a state where companies can not only seek to find the key to the lock but can dictate a great deal of the shape of the lock to which a key must fit. . . . In purist circles there will be great resistance to the idea that one can create reality by marketing efforts. It can be argued, however, that it was ever thus. . . . Indeed in psychiatry, at least, a good case can be made that astute marketing extends right into the heart of academe itself. In psychopharmacology, the ideas that have caught on have done so because their originators have had a talent for coining a pithy title to describe a phenomenon – such as Type I and Type II schizophrenia or the amine hypothesis of depression. . . any consideration of the development of psychopharmacology makes it quite clear that good marketing of such ideas can capture a field, either before the evidence is in on an issue or even in the face of considerable contradictory evidence” (Healy, 212, 213).
Psychopharmacology, not paradigm-shift from psychoanalysis:
“Not only did the somatogenic perspective have many strong adherents during the zenith of the psychoanalytic movement, it predated the psychogenic perspective by more than a century (Baumeister & Hawkins, 201) . . . . the paradigmatic status of the psychoanalytic perspective is questionable. . . . Although the psychoanalytic perspective [1950-1970] was certainly a powerful force, it was by no means universally accepted. . . . scientific research in psychiatry, even during the heyday of psychoanalysis, was overwhelmingly somatic in nature. . . In the middle of the twentieth century two clearly defined competing schools existed in psychiatry: psychogenic and somatogenic. In the 1970s and 1980s the somatogenic perspective rose to a level of dominance indicative of a true paradigm (Healy, 1987). However, the advent of psychopharmacology was not a revolution in the Kuhnian sense. Rather it was a normal science outgrowth of the somatogenic school” (207).
Psychosomatic sensibility, demise of beginning in the 1970s:
“As the seventies unfolded, however, the ground under [George] Engel began to shift. . . Most significantly, psychiatry and internal medicine underwent dizzying and dramatic shifts. In psychiatry, the seventies were marked by the rapid decline of psychoanalysis, the rise of the neurosciences, and the general advance of an aggressive new ‘biological psychiatry.’ . . . Departments of medicine felt themselves reeling in ‘future shock’ as they struggled with unsettling changes in size, subspecialty fragmentation, geographic dispersion, and administrative balkanization. Tied up with these changes were further transformations: the displacement of physician-investigators by Ph.D.-trained biomedical scientists, the refocusing of research from human subjects and disease processes to ‘basic’ and increasingly molecular events, the alteration of study designs from selected patient cases to biostatistically rigorous clinical trials” (T. Brown II, 28). . . . Engel was also denied the opportunity to retreat to the ‘safe haven’ of psychosomatic medicine, because that field, took was undergoing disconcerting changes. From Engel’s point of view, the problems of psychosomatic research – already evident in the sixties – deepened in the seventies as animal ‘models,’ ‘stress’ studies, and psychoendocrine bench research took over a larger and larger portion of the field and tended to displace earlier, psychoanalytically grounded clinical studies” (29). In 1979, Engel stepped down from leadership of Rochester Liaison program which “had been a bridge connecting dynamic psychiatry to patient-centered internal medicine via extensive teaching and respected research. Now both fields pulled apart in their own, rapidly changing directions, and Engel was left without the scientific research legitimacy that had been crucial to his mainstream success. What primarily remained was teaching and the attempt to assure succession” (31-32).
Psychosomatic trend in Internal Medicine after WWI:
“ . . . by 1919 many American physicians had joined the ‘Barker line’ in Internal Medicine, that is, they had become interested in the role of emotion in the etiology and treatment of physical illness. The intensifying buzz from psychiatrists, plus experience with soldiers during World War I and with veterans in the immediate postwar period, served to underscore the role of emotional factors. The full extent of psychogenic disorder, already suspected by some before the war, was brought vividly home, and its occurrence was generalized to the entire civilian population.
What happened after 1919? The simply answer is that interest in the relationship between emotions and disease markedly increased in the twenties and thirties” (T. Brown, 14). The psychosomatic turn came to fruition when psychoanalysis and “American corporate philanthropy” were added to this development in the 1930s.
Psychotherapeutic Approach, after WWII:
“The psychotherapeutic approach became dominant in American psychiatry after World War II. Up until then American psychiatry, in broad orientation, had been more community oriented than European psychiatry. It was more prepared to see disorders such as neurasthenia, alcoholism, and substance abuse as being within the psychiatric remit. In terms of theoretical models it was poised between the disease model of Emil Kraepelin and the psychosocial model of Adolf Meyer. World War II led to an influx of clinicians into psychiatry, whose experience in the management of combat reactions led to a decisive switch in orientation from a disease model to Meyer-ian and analytic approaches. This coincided with an expansion in the number of psychiatric departments, professorships, and residency programs. These positions all went to analysts. The expansion happened at just the time that effective somatic treatments were about to appear, setting the state for a series of conflicts between an analytic establishment and a new breed of somaticists, conflicts that have spanned thirty years” (Healy, 222-223).
Psychotropic advertising, and male anxiety:
“When read psychoanalytically, their ‘success’ depends on a troubling slippage between transference and countertransference, conscious and unconscious. . . . beneath the surface, the message of the advertisements has little to do with women at all. Instead, a discourse insisting to be about women is instead an oversimplified discussion of the anxiety of men as doctors and doctors as men looking at women. . . . Anxiety is also the inquietude in the doctor, made uneasy by the threat that these symptoms [re women/marriage] come to represent. . . . psychotropic advertisements thus promote the message that male doctors – so construed by looking at the ads – can react to various forms of anxiety by the act of writing a prescription. Prescription writing is, in this system of not entirely chemical imbalance and rebalance, presented as a relationally gendered, if not entirely stable, form of power” (Metzl, 158,159).
Psychotropics, popular negative images of after 1980:
“ . . . popular assessment of tranquilizers came to focus on these negative images partly because these were key elements in other contemporary cultural currents: growing reaction against the ‘medicalization’ of society, growing distrust of big business and big science, and concern for the rights of women, consumers, and patients. Minor tranquilizers, with their hidden dangers, their widespread prescription (especially to women), and enormous sales figures, seemed to epitomize many painful defects in American society. . . . Much public discourse pushed aside the positive (or even neutral) assessments of tranquilizers between 1960 and 1980 simply because the dark side of prescription drugs was so much more useful rhetorically” (Speaker, 361-362; 371-372. 376). . . . two-thirds of prescriptions written for mood-modifying drugs were for female patients. For many feminists, as for consumer advocates, tranquilizer prescription was a prime example of economic and social exploitation” (373).
Psychotropics, shift in advertising from mid-70s:
“Beginning in the mid-1970s, science replaces sentiments as the principal means by which effective treatment is applied. . . . Gone is any reference to the collaboration or alliance with the patient, the facilitation of psychotherapy, and so on. . . . Stressing the power and potency of psychotropic drugs is accompanied by a change in the psychiatrist’s image of himself, via-a-vis his patient. Earlier advertisements suggested medication increased the potency of the personality of the psychiatrist, his own ability, his therapeutic qualities. During this period there is a dislocation of potency to the drugs themselves, which can then be prescribed by the knowledgeable psychiatrist” (Neill, 337).
PTSD, as following neither explicitly monothetic nor polythetic diagnostic rules:
“Like the polythetic classifications described in DSM-III-R, they include members that share no single overt feature, but unlike these classifications, their unity is not imposed by convention, from the outside. Rather, cases are connected by something that is intrinsic to the classification but that does not appear on the official symptom list: a submerged feature . . . In the case of PTSD, the submerged is the traumatic memory. The traumatic memory is not merely hidden below the surface of the DSM text; it is also polymorphous, showing itself in diverse presences (creating an equivalence between outbursts of anger and sleeplessness) and signifying absences (products of symptomatic avoidances). It is the traumatic memory’s protean character that gives cases the appearance, on the surface, of sharing only a family resemblance. This is what Ribot, Charcot, Janet, and Freud wanted to call attention to when they compared the traumatic memory to a mental parasite. Lawrence Kolb evokes a similar image when he suggests that PTSD ‘is to psychiatry as syphilis was to medicine,’ that is, that both maladies mimic other disorders through their heterogenous symptomatology (Kolb 1989:811)” (A. Young, 119).
PTSD, difference from traumatic neurosis:
“From the discovery of traumatic neurosis at the end of the nineteenth century to the 1960s, the psychological reaction was not explained solely as the consequence of the event. The personality of the victims themselves was always questioned. During World War I, especially in the German and Austrian armies, soldiers with traumatic neurosis were systematically suspected of simulation or of weakness and lack of moral fiber (Brunner 200). . . . The pathology was not considered to be the consequence of an event outside the range of human experience, because war experiences were supposed to be part of human experience in general. Even within psychoanalysis, traumatic neurosis was viewed with what I call a ‘clinical practice of suspicion’” (Rechtman, 914). . . . [Introduction of PTSD in 1980 in DSM-III was a consequence] less of a clinical discovery than of a kind of revolution in the American mentality. In fact, the battle for women’s rights in the 1960s, and the return of thousands of Vietnam veterans, created a very specific socio-political context where the evidence of trauma became a way to access a new political condition” (914).
PTSD, invention in nineteenth century:
Conventional genealogy of traumatic memory “represent[s] the traumatic memory as a found object, a thing indifferent to history. Research into this memory and the associated pathogenic secret is portrayed as a process of discovery. I have argued for something else: the traumatic memory is a man-made object. It originates in the scientific and clinical discourse of the nineteenth century; before that time, there is unhappiness, despair, and disturbing recollections, but no traumatic memory, in the sense that we know it today” (A. Young, 141).
PTSD, second [i.e., softer, more variable] conception of from mid-1990s:
“The surveys in the mid-1990s did not support the initial assumption that ‘almost anyone’ exposed to an event outside the range of human experience developed PTSD. Some do, many others do not. The specificity of traumatic responses was also addressed. . . . In spite of empirical findings, it seems a new way has been found to preserve both PTSD and the prominent influence of the external event. . . Such notions like risk factors, vulnerability or resilience belong to the second concept of PTSD; they could not fit the first version. . . . Issues like comorbidity, degrees of exposure, protective factors and recovery are logical consequences of this later concept of PTSD, they are not relevant in the original” (Rechtman, 915).
Public Health, persistence of environmental focus in age of bacteriology re healthy typhoid carriers:
“Health officers, because of growing numbers of healthy carriers among them, developed guidelines that encompassed both particular and general factors. Health officials needed to control disease and found ways to do this without isolating all who tested positive in the laboratory. Toward this end they judged housing conditions, sanitary facilities, and the individual’s tractability as they determined the proper handling of typhoid bacilli-carrying healthy people” (Leavitt III, 625) . . . . According to Rosenau, “The sick [with typhoid] should be isolated in homes or hospitals; the healthy carriers could be allowed to walk about on the city streets. The laboratory thus did not define the full scope of the public health problem or its solution” (626). . . . Chapin, Rosenau, and other public health officials advocated and practiced differential treatment. Public health workers sought control of carriers in ways that acknowledged their health, their place in the community, and the near impossibility of constraining them all, considerations well beyond the laboratory findings (627). . . . Early twentieth-century proponents of bacteriology could no more isolate disease from its environmental and social context than could their predecessors who were driven by the filth theory of disease. . . . But the laboratory could not provide all the answers to health officers trying to protect the public from contagious diseases. The real world impinged on their deliberations, and of necessity the health officers in the field adopted a broad approach to disease control, one that in many respects resembled earlier practices. . . . Science, when applied on the streets and in the tenements of urban America, became tainted by the values, limitations, and commitments of that world” (629).
Public Health, schism between public & private doctors in early 20th c:
“Especially significant was the break, in the early twentieth century, between doctors in private or hospital practice and those working in government. The former, represented by . . . the American Medical Association, claimed authority over the domain of patient care and vehemently opposed any initiative to provide clinical services in the public section. The notable exception was care for expectant mothers and their infants . . . Local health department were also left with responsibility for a few necessary but unglamorous categories of care that the medical profession disdained to provide: services for the indigent, treatment of sexually transmitted diseases, and control of once-epidemic but rapidly dwindling contagions such as tuberculosis and smallpox. . . . the growth of local public health was halting and uneven: as late as World War II, one-third of the U.S. population lived in an area that was not served by a full-time health official” (Colgrove, III, Intro).
Public Health Nursing, prestige of in late nineteenth and early twentieth centuries:
“Ironically, at a time when public-health medicine was increasingly seen as the backwater of the medical profession, public-health nurses, because their practice involved autonomy from medical and hospital control and the provision of cross-class care and education, were perceived as the elite in nursing. At the same time, public health remained the smallest of nursing’s practice fields” (Reverby, 110). This kind of nursing grew slowly because it required an endowed charity large enough to support the nurse’s entire salary, but after 1900, with increased immigration and government concern with health, “both voluntary and government-supported public-health agencies began to grow” (109).
Puerperal Insanity, late nineteenth century:
“Whether on a conscious or unconscious level, women who suffered from puerperal insanity were rebelling against the constraints of gender. The symptoms clearly indicate that rebellion. . . . women suffering from puerperal insanity were not acting like women at all. . . . Rebelling against cultural notions of ‘true womanhood’ was the one thing tying together the various symptoms of puerperal insanity. Physicians . . . made these rebellious symptoms legitimate by defining them within a medical framework . . . with a name: puerperal insanity. That naming was the result not only of the general ideas of the culture and the specific professionalization struggles of physicians, but also was related to doctors’ new relationship with women patients: as birth attendants. . . . The medicalization of pregnancy, birth and lactation provided a kind of permission for women to express rebellion and desperation in the particular symptoms of puerperal insanity. . . . Women played out their rebellion against the male physician, and doctors translated that rebellion into an acceptable medical category. But doctors also ‘cured’ the rebellion with their treatment and systematically silenced women in their case study reporting. In both cases, women were unequal partners in the construction of the disease” (Theriot III, 81-82).