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How Our Hospitals Happened : THE CARE OF STRANGERS The Rise of America's Hospital System by Charles E. Rosenberg (Basic Books: $22.95; 349 pp.)

November 08, 1987|Alfred H. Katz | Katz, professor emeritus of public health & social welfare at UCLA, writes frequently on socio-medical and public health topics. and

In the late 20th Century, it's hard for us to imagine a time when the hospital was not the major center of medical diagnosis, treatment and care, as automatically accepted a part of the social landscape as public schools, freeways, and supermarkets.

Given that we have some form of insurance or funds to defray the steep costs, we expect that when we're more than mildly ill, physicians will refer us to a hospital. To aid in diagnosis, complicated machines and laboratory tests will scan our bodies and analyze their products; for treatment, a vast variety of medications can be administered, singly or in combination. Even childbirth, the most ubiquitous, medically significant human event, performed in natural settings throughout history, now occurs largely in hospitals in the "developed" world.

But it wasn't always so. Rosenberg, a prize-winning historian, has written a detailed account of what has brought about the spectacular changes through which the hospital became accepted as the repository of medical knowledge and skills. In its own field, his book is as readable and as fascinating as Barbara Tuchman's popular accounts of critical epochs in human history; with our growing self-consciousness about health, it deserves to attract as many readers as hers.

In tracing the growth of U.S. Hospitals, Rosenberg starts with and concentrates on 19th-Century America. He vividly depicts the character of the few hospitals that existed in cities from 1800 to the Civil War. They were little different in physical care from the ghastly congregate alms-houses, which lumped together the mentally ill, blind and crippled, aged, alcholic and syphilitic, children and prostitutes, and ordinary working people suffering from bouts of rheumatism, bronchitis or pleurisy. Few who entered the early hospitals did so by choice; they were last resorts for the most helpless and deprived city-dwellers.

If you were a 30-year-old of moderate means in Boston, Philadelphia or New York, ill with a high fever, severe muscular or abdominal pains, numbness or paralysis, you would not have gone to a hospital, because its staff would not have been able to diagnose your illness, or to relieve or treat it. If you had a private doctor, he would much prefer to treat you at home; hospital care was viewed as simply custodial, not curative.

Despite the good intentions of their sponsors, the early hospitals were frequently dirty and degrading; and often quite dangerous because of epidemics that spread in them. Hospital sanitation was a problem both for the inmates and for the institution's unfortunate neighbors. Even in the best-run hospitals, washing facilities and dry bedding were rare. Crowding was endemic--with many beds placed in corridors, patients often had to sleep on the floor. Supply shortages were chronic--nurses tore up threadbare sheets and blankets to make bandages. Some patients paid for their "board" in these hospitals--$3 or $4 a week usually! Those who were well enough were expected to work, including cooking, cleaning privies and wards; pregnant women often scrubbed floors until the onset of labor.

The unsanitary conditions resulted both in the frequent spread of contagious diseases and very high death rates. Therapeutic resources were minimal: a few common drugs--mercury, quinine, purgatives and emetics; "bleeding" patients, until the practice became obsolete about 1860. Even after the advent of effective anesthesia in the 1840s, surgery was mostly limited to fracture-setting and wound-dressing. Rest, nutritious food and proper thoughts--uplifting moral messages, handed down in a repressive atmosphere--were thought to maximize the patients' chances of recovery; most diseases were viewed as self-healing.

Even though they could offer little to patients, another motive for creating hospitals emerged as city populations grew before the Civil War; namely that of providing subjects medical gradutes could learn from and practice on. Hospital wards with 100 or more patients provided a far greater variety of diseases and injuries than any private physician's case-load. So the hospitals soon became as essential for clinical medical training as they are today.

Throughout most of the 19th Century, European medicine was more advanced than ours in theory, research and clinical practice; ambitious U.S. physicians flocked to France and Germany to acquire sophisticated skills. The establishment of laboratories and epidemiological monitoring in some U.S. hospitals after 1850 reflected the European models.

Just as battlefield medicine in World War II created the modern rehabilitation movement, Rosenberg shows that the Civil War tremendously advanced the organization, structure, capabilities and growth of hospitals. By the time of Lee's surrender in 1865, the Union alone had more than 200 hospitals, in which more than a million patients had been treated.

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