Monthly Archives: December 2013

Nurses in the modern hospital

The modern nurse emerged from the church and the military. Religious sisters served in almshouses, caring for the poor and sick as part of their religious service. Military nurses came from two classes, patriotic women who wanted to serve their country, and servants and camp followers who knew how to provide hands on care. Florence Nightingale was very clear about the two classes of nurses. The patriotic women were the managers and Florence required them to have little direct contact with patients; their job was to direct the work of the floor nurses. The direct care nurses came from the large service class who understood how to be of service in any way necessary.
Florence Nightingale
In the modern hospital, the head nurse or matron had similar authority over nurses as the medical superintendent had over the entire hospital. She was in charge of training and supervising a nursing staff that was made up largely of trainees who usually lived in the nursing school and served for long hours in the hospital. The nurses were being trained in the ways of the modern hospital and their schools were modelled after the medical schools in many ways. As trainees, student nurses were given many of the more menial tasks in the teaching environment that had been the responsibility of apprentice doctors before medical schools became professionalized. The political friction that characterizes the relationship between doctors and nurses was present as far back as 1914.

In The Modern Hospital, we read:

There seems to be something radically wrong with the trained nurse of today – the medical profession says there is something wrong; the thinking women at the head of training-schools say there is something wrong; and the lay public finds something radically wrong. Not all these elements agree as to just what the trouble is, in fact, they all seem to differ. The doctors say the nurses who are being graduated from the training-schools are not efficient, and a great many thinking members of the medical profession say that the nurses are being trained to too fine a point, but not in the right direction . The heads of training-schools think the nurses are not being sufficiently trained. The public does not seem to care to analyze the situation, but merely finds fault with the nurse as an individual (pg. 34).

The author goes on to present the medical side of the argument –  doctors, now scientifically trained, have begun to assume the clinical authority that nurses used to have, and nurses have been left behind and resent their supportive role. One can see that the hospital has already become the battleground between doctors and nurses over the division of clinical labour. Today, nurses continue to struggle to work to “their full scope of practice.” Since early on nurse have been trained to assume far more clinical responsibility than they are actually given. For many years they were considered to be the aides and supporting staff for doctors: their role was to carry out orders of the doctors with no independent practice. From the beginning of nursing some nurses went on to become doctors in order to expand their role and authority. Some have accepted that their role is a ‘pink collar’ occupation, and see themselves as the health care equivalent of police and firemen. And yet others have taken on the political burden of making nursing a health profession fully on a par with medicine and with its own knowledge and philosophy of practice.

An excellent history of the development of nursing and its politics is presented in An introduction to the Social History of Nursing by Robert Dingwall, Anne Marie Rafferty, and Charles Webster. There are many good biographies of Florence Nightingale.

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The role of medical superintendent

The modern hospital was very hierarchical, like many institutions of the day. The medical superintendent had absolute authority over every aspect of the hospital; the matron was his subordinate helpmate, and the administrator, if there was one, worked as his aide.

There were no strong internal boundaries between the various people who worked in the hospital; the boundaries were to the outside. Upon entering the hospital, every patient came under the authority of the medical superintendent, much as pupils were under the authority of the principal of the school of that time. The values of the organization were clear to everyone and not questioned – they derived from the central overarching authority of the medical superintendent.

Some of his authority came from the knowledge and wisdom attributed to him, and his knowledge was based on extended and intelligent clinical experience. Medical education came from a lengthy clinical apprenticeship. The medical superintendent embodied the sum of this kind of knowledge through experience. He kept up with the major advances of medical science and his authority reached all the operations of the hospital. He was not merely the final arbiter of decisions, he made them all. There was no long-term planning, nor any need for it: he just did whatever he felt was necessary. If there were any plans, they were in his head.

Because the hospital was usually built and funded by the community, it was a major social institution. Many communities identified themselves through the creation of their hospital. Its independence from external authority and its special place in the community allowed it to remain relatively stable for a long time. The importance of the hospital gave the medical superintendent status and prominence in the community which enlarged his authority even more. The board which appointed him would for the most part bend to his will.

The early modern hospital was in many ways related to the much earlier self contained church communities in which a chief cleric had absolute authority over all aspects of its activity. And many of these institutions functioned as villages or small towns. Early hospitals had not only wards, patients and operating rooms; they were full service organization with their own stables, farms, kitchens and laundries. When I worked at the Royal Victoria Hospital in Montreal in the 1980s, it retained some of these features. There were roofers who were constantly replacing fallen tiles from the huge slate roofs, an upholstery shop that made sure that the furniture in the head nurse’s public rooms were in tip top shape, and a full service laundry.

There was widespread agreement on the authority of the role of doctors and hospitals, and this occurred without a formal healthcare system. Everyone seemed to agree on the values associated with healthcare and healthcare professionals.

William Osler, Canadian born physicianA Canadian born doctor, William Osler, personified this kind of doctor. You might want to read about him and his struggles to understand the role of doctors in the modern healthcare system. Writer Michael Bliss recently published a biography of him, William Osler: A Life in Medicine.

More to follow on William Osler and his impact on modern healthcare.

The patron saint of hand washing

Ignaz Semmelweis was a young Hungarian obstetrician who began teaching in the Vienna Maternity Hospital in 1846. The hospital had been founded in the late 18th century, and it contained two free Maternity Clinics. Women received free medical and nursing care in the clinics in exchange for taking part in the training program for obstetricians and midwives. When Semmelweis arrived he found that the death rate for mothers was very high due to a disease called “childbed fever.” No one knew why the incidence of this disease was so high, but there were many speculations. Most believed that is was an epidemic disease caused by everything from the weather to problems with the birthing process. Semmelweis was concerned by the high death rate, and along with everyone else, had no idea about the cause. He did find one notable fact – the death rate in one of the two clinics was higher than in the other. He learned that after 1840, the First Clinic was accessible only to male medical students and the Second Clinic was visited only by young women studying to become midwives.  Table 1, taken from Semmelweis’ article, The Etiology, Concept and Prophylaxis of Childbed Fever, shows this difference over a period of five years.

Semmelweis data on death rates

His first conclusion was that the cause of the disease was not the result of an epidemic because epidemics would not occur in only one of the wards over such a prolonged period of time. He then tried changing various procedures in the First Clinic to make it more like the Second Clinic, and nothing worked. On March 2, 1847, he travelled to Venice with some friends, as he described, “I hoped that Venetian art treasures would revive my mind and spirits which had been so seriously affected by my experiences in the maternity hospital.”

When he returned to Vienna he learned that Jakob Kolletschka, the professor of Forensic Medicine, had become ill and died after pricking his finger with a knife while performing an autopsy. The results of the autopsy convinced Semmelweis that Kolletschka had died of the same disease as the women in the maternity ward. He remembered that infants who died along with their mothers had similar symptoms thus leading him to believe that they also died of the same disease. He concluded that “cadaverous particles” contaminated Kolletschka’s wound and that cadaverous particles on the hands of medical students were the cause of childbed fever.

He instituted the requirement that medical students wash their hands in a chlorine solution before visiting maternity patients and the result was a precipitous drop in mortality in the First Clinic. Once he instituted it in the Second Clinic, the mortality dropped there as well. He published a paper with his results and gained some followers across Europe.

But the medical establishment, led by people like Rudolph Virchow, did not support his views which were considered to be unscientific. They were taken to derive from Galen’s discredited humoral theory of medicine. At a medical conference in Speyer in 1861, Virchow – who was by then extraordinarily influential – attacked Semmelweis’ views. He said that local infection of the type Semmelweis described was only one type of childbed fever, and that it did not exclude the existence of the epidemic that most scientists believed existed. Virchow declared that the disease could be caused by atmospheric conditions, disturbances in milk secretion, excited state of the nervous system, and other possible causes. He also had some incentive to argue against the causal relationship between autopsies followed by obstetrical examinations and childbed fever. He was a pathologist deeply committed to the value of autopsies and the notion that one of the iatrogenic consequences of autopsies was the unnecessary death of thousands of women was unthinkable. Semmelweis published a book The Etiology, Concept and Prophylaxis of Childbed Fever soon after the congress in which he pointed out the fallacies in Virchow’s criticisms, but to no avail. There is no doubt that Virchow’s authority in medical circles prevented the recognition of the Semmelweis’ doctrine until Lister showed the importance of antisepsis, and until Pasteur and Koch established the germ theory.

Several years after that publication, Semmelweis became mentally ill and was confined to a Psychiatric Hospital where he died of gangrene after being beaten by a guard. Ignaz Semmelweis is the patron saint of hand washing and his story, like the account of the modern hospital, has relevance today.

The modern hospital and laboratory

I have been talking about critical changes that made the modern hospital central to health care in the early 20th century, such as the new operating rooms that enabled sterile pain-free surgery, and the nightingale wards that allowed modern nurses and hospitals to care for a broader population. Modern laboratory medicine is the next contributor to this change. According to the authors of The Modern Hospital, the modern laboratory has four functions: as an aid to diagnosis, as part of treatment, as an educational aid and as a contributor to scientific research. No longer is a hospital complete without laboratory capacity.

The modern physician is never content in this day to rest a diagnosis of even the simplest case upon his bedside observations, and requires the aid of the laboratory of pathology… In very modern, efficient institutions there is a routine laboratory practice that includes at least a complete examination of the urine, and a complete examination of the blood as a part of the routine of the admission of the patient, and in these institutions there is also a routine examination of the blood-pressure, the hemoglobin content, and a white and red and differential blood-count (The Modern Hospital, page 453).

These examinations were not by themselves new. Urine testing dates back to ancient times. The foul smell of the urine of a sick person has been an indication of illness as far back as we can look. Similarly, urine that is red with blood or dark brown with contaminants are obvious signs of illness. In the seventeenth century doctors who took urine samples were called “piss tasters” and could identify various conditions based on the smell and taste of urine. With the invention of the microscope, urine could be inspected more closely, and by the second half of the 19th century different types of kidney disease could be identified by the microscopic examination of urine.

Rudolph Virchow was a larger than life German doctor who made important advances in the microscopic examination of blood cells by showing that diseases like leukemia could be identified at the cellular level. He is celebrated as the founder of modern cellular pathology among many other accomplishments. He made a major contribution to the transformation of medicine from a home based service industry into a modern scientific profession. Rudolph Virchow Virchow was an accomplished microscopist. (The adept use of the microscope in his day could be compared to the skill of accomplished computer programmers today.) This helped him make major contributions to our understanding of cell division and modern pathology. He was also active in politics and was one of the founders of a liberal political party during the 1848 political turmoil.  (He was well-known enough to be challenged to a duel by Otto von Bismarck.) He was very active and competed vigorously in the scientific life of his day: he was accused of stealing some peoples’ ideas and of dismissing the important ideas of others. In retrospect, one of his most indefensible acts was his reaction to the work of Ignaz Semelweiss. But more of this in my next blog.

The photograph below is from the archives of the Haslar Naval Hospital in the UK. Its first Medical Superintendent was James Lind (See my article on the history of scurvy and James Lind).Image is from the archives of the Haslar Naval Hospital in the UK. Its first Medical Superintendent was James Lind.