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CONSPICYO Hés, pe lp arterarn conor per corp arf eoafodearcris Nt congas delice. arsborcsanenm Inde nfl Leterme dni ge witteaea Sela ofemesalitjvrmason, fest. eran foe endemic fm rn oe onlin akan, elt for ed Sina para eer21 2.2 2.3 31 41 42 Sa 6.1 62 63 64 65 7 7.2 73 74 81 941 10.1 wa 12 113 List of illustrations The Piazza Mercatellow in Naples during the plague of 1656 A Sunderland cholera victim, 1832 Poster produced as part of the United States AIDS campaign warning about the invisible signs of HIV, 1994 Altarpiece in which Christ throws down arrows (of plague) and saints intercede, 1424 Anatomical studies of (left) a dissected pregnant woman and (right) of a female dissected woman holding a dissected baby by the anatomical illustrator Jacques Fabien Gautier d’Agoty (1717-1785) A birth scene, 1800 A quack and a barber ply their trade in an Italian market square ‘Wounded man’: Anatomical illustration from the mid fifteenth century Title page of Vesalius’s De Humani Corporis Fabrica libri septem (1555) An illustration from Vesalius’s De Humani Corporis Fabrica libri septem depicting the veins and arteries René Laennec and the use of auscultation on a patient at the Hospital Necker, Paris, 1816 Interior of a dissecting room Ambroise Paré using a ligature when amputating on the battlefield at the siege of Bramvilliers Operating theatre at St Bartholomew's Hospital, London, c.1890 Artist's impression of the first demonstration of surgical anaesthesia at the Massachusetts General Hospital, Boston, in 1846 Use of Lister’s carbolic spray Pitcairn ward at St Bartholomew's Hospital, London, c.1908 “The Doctor’ by Salles (after Luke Fildes's painting of 1891) An experiment in a chemical laboratory Florence Nightingale and her staff nursing a patient in the military hospital at Scutari, 1855 A disheveled nurse with her disgruntled patient Certificate of attendance given to Hilda Foulkes for attending 18 out of 83 classes during 1923 19 22 29 40 60 75 88 100 103 104 113 47 126 129 131 134 162 186 201 213 215 226124 12.2 14.1 15.1 UST OF ILLUSTRATIONS Responses to the plague in Rome, 1656 “The relation of eugenics to other sciences’ The ‘Hottentot venus’ Photographs illustrating shrapnel wounds to face and the treatment received between April 1916 and May 1917 232 248 281 30021 81 124 13.1 16.1 List of tables Life expectancy at birth, 1970-2000 Admissions to the principal London general hospitals, 1809-95 Infectious diseases in England and Wales, 1848-1910: Change in mean annual death rates per million for men (all ages) State expenditure on health (per cent of GDP) County asylums in England and Wales, 1850-1920 27 162, 242 270 32610 Science and the practice of medicine The drive to science-based technocratic medicine became a key feature of most societies in the second half of the twentieth century, but the place and impor- tance of science in medicine has a much longer history. Progress in medical science has traditionally been associated with key moments and discoveries, such as germ theory or penicillin, with great men Isaac Newton, René Laennec, Joseph Lister, Robert Koch, Alexander Fleming — or with the emergence of a particular style of medical science in the nineteenth century associated with physiology, the laboratory and bacteriology. Such a view has reinforced ideas of inevitable progress, the cult of personality and a technological determinism in which hospitals, universities and laboratories provided the backdrop for advances is medical science, Although historians have come to reject such a posi- tivist account of the history of medical science to examine instead how science was constructed and the values if reflected, many continue to take the rise of modern biomedicine for granted, while ideas that medicine before 1800 was somehow pre-scientific continues to find expression. However, doctors in the past have never pretended that medicine was unsci- entific and over the last five hundred years, science has come to serve a number of functions in medicine. What this science has constituted and its roles in medi- cine have changed over time and this chapter moves beyond ideas of progress and technological determinism to explore the ways in which the role of science in medicine can be seen as meaning more than the application of laboratory ‘methods or the triumph of biomedical science in the twentieth century. Ifit does not provide a chronological overview of how science influenced medicine, it does explore the contexts that shaped medical science and how practitioners used science.! The chapter also addresses ideas of revolutions in medical science to examine the nature of laboratory medicine, biomedicine and research in the nineteenth and twentieth centuries, Science and medicine Many historians agree that modem science has its origins in the Scientific Revolution of the seventeenth century, but that science in its moder sense is a nineteenth century phenomenon. They have argued that until then practitioners 189190 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE and patients were wary of science and saw medicine as an art or craft in which book learning, diagnostic skills and practical knowledge were crucial to what has been labelled bedside medicine. Although this assessment undervalues the importance of social criteria to practice [see ‘Professionalization’ it suggests that before 1800 most doctors saw a limited role for science in medicine. In this account, often a distinction is being made between medicine ~ meaning clinical or hospital practice — and science - the experimentalism of the laboratory. ‘This distinction has marginalized other varieties of scientific medicine that existed prior to 1800 to favour an essentialist view of science that identifies it with one particular historical era. If we look beyond practice and employ differ- ent terms or categories ~ for example, mechanical philosophy which sought to explain physical properties and processes through the motion of the smallest parts that composed physical bodies — it becomes possible to construct longer histories of science in medicine. Many of these modes of inquiry were initially bound up with contemporary philosophical and theological questions. Although these often had little immediate impact on medical practice, they did contribute to new ways of understanding the body and influenced how medical practitioners were trained. Historians of science have therefore looked to the natural and human sciences of the Renaissance (roughly from 1300 to the mid seventeenth century), the Scientific Revolution (seventeenth century) and the Enlightenment (eighteenth century) for comparable structures of scientific prac- tice and organization that predated the nineteenth century By thinking about the different forms science in medicine has taken, it becomes possible to see how natural philosophy (the science of nature) and moral philosophy (the science of action) offered early modem scholars and medical practitioners’ ways of understanding the natural and physical world and the body. Although historians’ views of the Scientific Revolution have under- gone considerable revision, an array of cultural and scientific practices emerged in the seventeenth century as medical practitioners and natural philosophers endeavoured to understand and explain the natural world in new ways. A grow- ing philosophical emphasis on empirical observation and experimentation encouraged investigations into how the body worked for example, how blood circulated or how respiration functioned - rather than a reliance on the author- ity of Classical texts [see ‘Anatomy’|. These investigations contributed to the emergence of new models of the body, but they also reveal how the boundaries between the natural and the material sciences in early modern Europe were hardly airtight. For example, Newtonian mathematics and Descartes’s Cartesianism (in which mind and body were separate) were incorporated into medicine. They informed iatromechanical and philosophical conceptions that represented the body as a machine (or watch) which stimulated interest in meas- uring physiological processes Nor were practices of observation and experimentation invented in the nine- teenth century. The influence of medical humanism in the Renaissance and a questioning of Classical texts in the sixteenth century along with debates inSCIENCE AND THE PRACTICE OF MEDICINE 191 natural philosophy in the seventeenth century encouraged a more experimental and observational approach in medicine [see ‘Anatomy’']. Philosophers and physicians, such as Thomas Sydenham in London or Herman Boerhaave in Leiden, emphasized the importance of observation to medicine. As practitioners sought to classify disease (or nosology) in the eighteenth century, they aimed to ground medicine in observation and experimentation. Efforts to explain the complexities of life and debate about whether or not it was purely mechanical or influenced by some vital phenomenon (known as Vitalism) encouraged phys- iological experimentation, as seen in the work of George Ernst Stahl in Germany or the experiments of the Bolognese physician Galvani with electricity. This experimental and observational approach equally influenced eighteenth century anatomists and hospital clinicians as they sought to identify and classify partic- ular disease states [see ‘Anatomy’]. Early modern medicine can therefore be represented as scientific on its own terms as natural philosophers, physicians, anatomists and other practitioners observed and experimented. Philosophical approaches and mathematical princi- ples helped define inquiry. The result was often what the historian Susan Lawrence has referred to in Charitable Knowledge (1996) as ‘safe science’ in which innovation and experimentation was judiciously balanced against patient care. As Lawrence asks, how else could medicine advance? If the use of different categories of science reveals a longer, more complex history of the relationship between science and medicine before 1800, this rela- tionship was shaped by the cultural, political and socioeconomic context in which science and medicine was constructed and practised. This connection between science, medicine and their contexts is visible in early modern Europe. As the historian Charles Webster first revealed in The Great Instauration (1975), theological ideas in the sixteenth and seventeenth centuries were important in shaping how medical knowledge was generated and received. This interaction is evident in the ideas associated with the Renaissance physician and medical reformer Paracelsus and his influence on carly modern medicine, but the reli- gious censorship associated with the Counter-Reformation also created barriers to new forms of knowledge in Italy and Spain where new ideas came to be asso- ciated with heresy. Although the effects of the Counter-Reformation and Inquisition in southern Europe were not as stark as often suggested by histori- ans, they did create a conservative intellectual culture that was to prove endur- ing in Spain. Nor did this relationship between medicine, science and theology disappear in the Enlightenment [sce ‘Religion’], while new social questions surrounding ideas of women’s place in society and notions of race also influ- enced medicine and science and vice versa in the period [see ‘Women and medi- cine’; ‘Medicine and empire’] Historians have used the social and political context of the German-speaking states in the nineteenth century to explain why Germany was at the forefront of ‘medical science after 1850. In doing so, they have pointed to the crucial role played by the high value placed on the search for knowledge or Wissenschaft,192 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE and how this combined with middle-class and national aspirations to ensure that universities were well funded to promote a competitive culture favourable to research and experimentation. Conversely, in Spain the ruling conservative élite saw science within an explicitly Catholic framework, which restricted the practice of science and the questions pursued. Political contexts were important to medical science in other ways. Science was used to assert national agendas as seen in the work of the French chemist Louis Pasteur on rabies and anthrax, Popular sciences, such as phrenology, and medical sciences, such as physiology, offered flexible resources for those who sought political or social reforms. In the twentieth century, medical research was harnessed to political and colonial agendas in new ways as industrialized states saw a connection between science, modernity and power and invested more heavily in particular styles of laboratory-based medicine. In Britain, anxiety about German competition saw state money injected into academic medicine and the laboratory sciences through the Medical Research Council (MRC), a policy that shaped interwar research and institutional provision, while in Spain the Francoist regime (1939-75) directed funding to those styles of science the regime deemed safe. If states employed medical science for political ends, the relationship was not one way. The German bacteriologists Robert Koch, for example, used rivalry between the new German state and France to argue for a research institute to match the Pasteur Institute in Paris. New funding opportunities in the twentieth century made it possible to develop research careers and develop a style of academic medicine that came to characterize how doctors were trained and how medical research was organized in universities Other sources of funding and institutional support equally fashioned medical research and the questions asked. In the nineteenth century, German chemical, dye and pharmaceutical companies started to invest in research, but in the twentieth century the connection between pharmaceutical companies, such as Burroughs Wellcome or Bayer, and research was to become essential to medical research, For example, Paul Ehrlich’s work on Salvarsan for the treatment of venereal disease or Gethard Domagk’s research that led to the identification of sulphonamide as a ‘means of treating streptococcal infection both relied on support from industry. New relationships were developed between the research laboratory, production plant and the clinic, while the association of medical researchers with commercial and pharmaceutical companies became commonplace after 1945. Philanthropy also shaped national and international scientific cultures. The best example of this is the activities of the Rockefeller Foundation. Incorporated in 1913, it launched an inter- national scientific and medical programme in the 1920s and worked to export an American model of academic medicine to Europe. Although this brought an invest- ‘ment in capacity building, as could be seen in Czechoslovakia where the Rockefeller Foundation funded laboratory equipment, the Foundation had an inflexible approach that often lacked sensitivity to national sentiments. Funding from chari- ties or industry often came with strings attached that influenced the type of medical science or research pursued.SCIENCE AND THE PRACTICE OF MEDICINE 193 Science was further made, negotiated and received in a range of sites. These multiplied from the seventeenth century onwards and were gradually institu- tionalized. Cities represented important locations and contexts for research, but, as studies in microbiology in the late nineteenth century demonstrate, the cities themselves, such as Paris and Hamburg, also influenced the form this research took. Cities were also home to a range of institutions from the hospital, labora~ tory and university to the meeting place of professional bodies, coffeehouses and public houses where medical science was formulated, observed and discussed. In the sixteenth and seventeenth centuries, anatomy theatres were central to the development of new knowledge about the body, while eighteenth century muse- ums developed a range of functions for the production, discussion and display of new knowledge. In the nineteenth century, hospital patients as sources of information and the hospital as an experimental site grew in significance [see ‘Hospitals’, while in the German-speaking states, universities were central to the growth of laboratory medicine (see below). By the start of the twentieth century, the hospital had become, along with the university, the premier site for medical research. Although it is a mistake to see hospital and university laboratories as the only spaces for medical science in the twentieth century, the emphasis placed on them as legitimate locations for research ensured that the place of ‘medical science became more strictly defined. The result was that other forms of science, such as popular sciences like mesmerism, and the amateur, were margin- alized. These experimental sites or laboratory spaces were more than just passive locations. They were spaces where observations were made and new discoveries were displayed, but they equally affected the production and transmission of knowledge. As discussed in Chapter 8, hospitals were multifaceted institutions and not merely the backdrop for medical science. Science in them was shaped by competing professional and lay concems, by internal tensions, by patient needs, and by finance. The impact of these institutions on medical science and discipline formation is evident in the different patterns of university expansion in Germany and Britain, Whereas in Germany an investment in universities facilitated the growth of a style of laboratory medicine that came to characterize late nineteenth century approaches to disease, in Britain only in those universi- ties where medicine was peripheral, for example at Cambridge, or in medical schools with a strong university connection, such as Manchester, did medical research take root before 1890. Nor were these experimental sites parochial in nature. Coffeehouses, muse- ums and anatomy theatres were all part of what Jurgen Habermass referred to as the public sphere - an area in which people can get together and freely discuss and identify problems. These sites offered places of knowledge and cultural exchange. Practitioners did travel to observe others at work, a move initially encouraged by seventeenth century ideas about the importance of demonstrat- ing knowledge as a means of asserting its validity. This was extended by the growth of published pamphlets and treatises that allowed those at a distance to194 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE observe. Scientific and medical societies, hospitals and universities, created new spaces in the eighteenth century where knowledge was displayed and ratified, Students, clinicians and researchers who travelled to foreign universities and laboratories to learn brought new practices back with them. For example, Russian physicians learnt about bacteriology in Paris having first travelled there with rabies sufferers to receive treatment from Louis Pasteur. International research networks became a feature of most institutional and commercial labo- ratories during the 1920s and by the second half of the twentieth century, few Institutions or researchers could afford to be isolated. Historians of science have argued that the shape and success of science has been further influenced by complex sets of social relations and by practitioners’ abilities to make links with different communities (both within and outside science). The growth of universities not only fashioned new experimental spaces, but also professional researchers. The creation of full-time academic posts in the late nineteenth century provided opportunities for a range of practition- ers to develop and consolidate their disciplines, as evident in the case of pathol- ogy in British provincial medical schools. These practitioners were helped by skilled technical workers, as well as by students, and this created environments that fostered the development of research schools. By the twentieth century, the existence of identifiable research disciplines was increasingly associated with such institutional and professional structures. At the same time, patronage and personal networks influenced how and what ideas were transmitted. Societies, journals and conferences not only communicated research, but also contributed to discipline formation, For example, publications in specialist journals, such as the German Zeitschrift fir Bakteriologie und Immunologie, a dense network of personal contacts, and international meetings, helped shape bacteriology in the nineteenth century, The growth of an increasingly sophisticated publishing industry in the twentieth century offered a mechanism for communicating ideas, and for ensuring that busy or isolated doctors could keep up to date. ‘This is not to ignore the role of technology in framing medical science. In their groundbreaking work Leviathan and the Air-Pump (1985), Steven Shapin and Simon Schaffer drew attention to how seventeenth century debates about the nature of air depended on access to air pumps and the practical skill to operate them. Just like science, medicine is a practical activity and different technologies gave form to research and to new disciplines. Clinical thermometers aided stud- ies of metabolism in the sixteenth century, while in the seventeenth century microscopes exposed new structures in human anatomy. In the nineteenth century, improvements in microscopes contributed to the growth of laboratory studies, while in the twentieth century the electron microscope aided advances in molecular biology, biochemistry, genetics and virology. By the 1960s, a number of medical disciplines were constructed around technological needs and their associated institutional spaces. However, the development of new technol- ogy should not be seen as sufficient in itself. For example, Julius Cohnheim’s work on inflammation in the mid nineteenth century was not merely the resultSCIENCE AND THE PRACTICE OF MEDICINE 195 of new techniques or apparatus, but was also dependent on the institutional structures fostered by Rudolf Virchow at the Berlin Pathological Institute, New ‘ways of seeing and new methods had to be institutionalized and taught, and this explains why medical schools and universities came to be central to medical science, research and discipline formation in the nineteenth and twentieth centuries. In exploring these contexts, the pace of change should not be overstated nor routine work ignored, Continuities existed. Empirical and mechanical trends in seventeenth century natural philosophy did not immediately see older ways of conceiving the body displaced. Existing ideas were often reworked within new frameworks, as demonstrated by the endurance of the ‘seed and soil’ analogy in nineteenth century explanations of infectious disease. Nor did contemporary medical practitioners always view developments with the same enthusiasm as later historians. The proponents of scientific medicine, such as those who devoted themselves to physiological research in mid nineteenth century Britain, initially found themselves in a beleaguered clique. New discoveries, techniques, procedures or models were hotly debated and resisted. European universities in the sixteenth and seventeenth centuries, for example, resisted incorporating findings from anatomy or mathematics. Nor did a single or uniform chronology ‘of medical science and research emerge. Whereas France and Germany are seen as countries that nurtured science ~ in France from the late eighteenth century to the 1830s and in Germany from the 1840s onwards ~ other countries did not embrace science in the same ways. In Spain, the socio-political structure limited the science undertaken and the questions asked, while in Britain the idea that science was a ‘gentlemanly pursuit’ was influential and the institutional support for medical science remained limited until the late nineteenth century. If simple chronologies do not work, the relationship between medicine and science was not a simple one, Not only did what this science represents change over time to produce a longer chronology of the role of science in medicine that does not over-privilege the nineteenth century, but, as we have examined in this section, it was influenced by a range of institutional settings and contexts. At the same time, it could serve political, economic or social roles. As we shall see in the next section, medical science was also employed to further professional ends. Science and status In medicine, science did not just have a practical value; it also had a rhetorical significance for practitioners in their claims to expertise. Although at times this often created the appearance of a distinction between basic and applied science that did not always exist in practice, science offered a flexible symbolic and cultural resource. Scholarship since the 1980s has pointed to how doctors used science in different ways. For the American historian Gerald Geison, late nine- teenth century clinicians were sceptical of the practical contribution of science196 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE to medicine but embraced the laboratory for its ideological value and utilized science to assert their cultural authority, a view supported by Shortt who argued that physicians used the rhetoric of science to enhance their status (see Further Reading). Although counter-arguments have been presented, such as that of Christopher Lawrence in his compelling examination of the attitudes of elite British physicians to science, the idea that medical practitioners employed the language of science to confer authority was not limited to the nineteenth century. The networks of early modern science, linked to commercialization, print culture and a growing public sphere, offered opportunities for the middling sort and the gentry to define and assert their identity and authority. Learned and scientific societies, such as the Royal Society in London, were established which offered an arena for polite conversation among the emerging professions ~ cler- ics, lawyers and doctors ~ and also conferred identity and authority on their members. Such societies established networks that legitimated new knowledge and provided members with social capital [see ‘Professionalization’|. The salon served a similar function in France. Science became a potent instrument of persuasion in the nineteenth century and assumed a key role in popular culture. In response, doctors increasingly emphasized their role as medical experts and scientific practitioners to exert their authority. One way they achieved this was by becoming involved in local and national scientific cultures and by using a range of rhetorical strategies to claim expertise, acquire cultural legitimacy, and insulate themselves from lay interference. Given that science was increasingly viewed as a force for moder- nity, medical practitioners readily incorporated a scientific culture and rhetoric Into their professional identity [see ‘Professionalization’]. This rhetoric lent support to practitioners’ claims that medicine was increasingly beyond lay comprehension, separating medicine from empiricism and defining legitimate medical knowledge. The credibility of the medical profession was further enhanced by the successes associated with laboratory medicine (see below). However, what this science was had different meanings for different groups of ‘medical practitioners at different times. Notions of science were used to support claims to identity and learning by different groups of medical practitioners as they vied for status: eighteenth century surgeons, for example, asserted the value of anatomy and a Hunterian tradition of surgery to distance themselves from craft associations and to present surgery as a learned profession [see ‘Surgery’). But it was not just licensed practitioners who exploited science to enhance their status. Alternative medical practitioners equally used science to assert their rival claims to authority. The German physician Samuel Hahnemann, the founder of homeopathy, for example, equally drew on eighteenth century medical thought that emphasized observation and experimentation to justify his ideas. New forms of scientific knowledge affected systems of alternative medicine and contemporaries did not perceive them as antiscientific. French spas and hydrol- ogists, for example, established a body of scientific literature through the creation of chairs of hydrology in medical faculties and new research institutesSCIENCE AND THE PRACTICE OF MEDICINE 197 to convince other practitioners of their legitimacy. Developments in the physi- cal sciences, such as the idea of radioactivity, were employed by naturopaths in the twentieth century to support ideas of human radiation, Nor was this language of medical science restricted to practitioners. Nineteenth century radicals used phrenology in their critiques of the structure of society, while a language of germs and viruses quickly gained currency outside ‘medicine. If the relationship between scientific developments and social views is not straightforward, as the example of eugenics reveals, by the late nineteenth century, science provided a powerful resource as enthusiasm grew that it offered a means to improve and manage society [see ‘Public health]. Science was used to challenge older social models and was incorporated into a language of moder- nity and social reform. Lay groups equally used science to promote their own agendas. For example, in efforts to secure compensation claims, South Wales’ ‘miners used scientific evidence and expert witnesses in the twentieth century to make sophisticated appeals as they attempted to secure compensation for pneu- moconiosis sufferers. By the late twentieth century, different groups were using the gene as the essence of identity and as an explanation for social difference. ‘There are problems with the above account. It presupposes that the public ~ however defined - uniformly accepted science and the authority it conferred. As already noted in Chapter 9, many contemporaries in the past remained uncer- tain of medical practitioners’ authority. Although the popular effect of critiques of science are unclear, in the eighteenth and nineteenth centuries the public questioned medical science. Gothic representations, such as Mary Shelley's Frankenstein (1818) ot H. G. Wells, The Island of Dr Moreau (1896), painted a darker picture of medical science that was influenced by concerns about anatomy, vivisection and experimentation, Such sensationalism and fears were not limited to the novel. Opposition to medical science was expressed in a number of movements, such as the protests against vaccination voiced in nine- teenth century Britain. Physiological research and cases of human experimenta- tion equally generated public and professional censure. This ethical dimension was clearly visible in nineteenth century debates about vivisection, ‘The perceived torture inflicted on animals by physiologists drew on fears of immoral behaviour and cruelty; on support from a European movement for the protec- tion of animals, and later on Charles Darwin's work on evolution, which empha- sized the connections between the condition of people and animals. Antivivisectionists equated physiology and the laboratory with contested and questionable methods of experimentation. Laws were introduced to regulate animal experimentation, for example in Britain in 1876, while in other coun- tries, such as Russia and France, antivivisectionists questioned scientific progress. If, as Shapin argues in A Social History of Truth (1996), there can be no science without a large degree of trust, notwithstanding the growing cultural authority of science this trust was by no means assured. The anti-vaccination and antivivi- section movements reveal that just as medical practitioners were at times ambivalent about the merits and benefits of science (sce below), so too were the198 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE public. Both hospital medicine and laboratory medicine were contested as doubts were voiced about the value of particular theories (anti-vaccination) or the practices associated with laboratory medicine (antivivisection). ‘Nor would it be wise to focus solely on the rhetorical value of medical science for practitioners. Accepting that the ideal of science was more important that the reality ignores the extent to which medical science informed clinical undei standing or practices. As we shall see below, for science to flourish in medicine it often had to have a practical application. Anatomical investigations were insti- tutionalized in the sixteenth and seventeenth centuries because they offered a way of understanding not only God’s work but also morbid processes [see ‘Anatomy'|. Nineteenth century pathologists regarded their field of expertise as a bridge between the clinic and the laboratory and used their diagnostic work to assert their value and position. Biochemistry and haematology in the 1920s were equally framed in terms of their contribution to diagnosis and patient manage- ment, with their utility aided by the introduction of relatively simple tests. Diagnostic machines became emblems of scientific medicine that also had a practical value, while laboratory findings that had a practical clinical application ‘were hailed as major breakthroughs. Science could therefore serve a number of functions. It offered licensed prac- titioners both a means to assert their cultural or expert authority and a practical tool. By thinking about medical science in terms of its rhetorical value and how it aided diagnosis and clinical practice, it is possible to understand the multiple roles science has had in medicine and for the medical profession, but also how this science was contested, In the next section, we will explore some of these themes as we examine the ‘Laboratory Revolution’ and the development of labo- ratory medicine in the nineteenth and twentieth centuries. A laboratory revolution Just as the ‘birth of the clinic’ in Paris has been associated with the triumph of hospital medicine and the start of modern medicine [see ‘Anatomy’, scientific medicine has been equated with the growing dominance of the laboratory and technology in the last years of the nineteenth century and the first two decades of the twentieth century. Historians have argued that this laboratory medicine represented both new knowledge and practical diagnostic work that contributed to rising life expectancy through the development of new cures and interven- tions and hence to the growing status of medicine. Whereas France had been the centre for hospital medicine, laboratory medicine was associated with the growth of universities and research schools in the German-speaking states. This laboratory medicine asserted a reductionist view that located disease at a cellu- lar or biochemical level. It required new spaces, skills and methodologies, and changes in the ways that disease was interpreted, how research was conducted, and how doctors were trainedSCIENCE AND THE PRACTICE OF MEDICINE 199 Historians have suggested that the laboratory came to replace the hospital ward or clinic as the major site for research in late nineteenth century Europe and have pointed to an associated shift in the focus of medical authority. If stud- ies have come to reveal how this was a contested process, historians have remained interested in laboratories as spaces in which scientific knowledge was produced and around which new disciplinary institutions and cultures emerged. There has been a tendency to assume that one consequence was a division between medical science and clinical practice that was only reversed after 1945 with the emergence of biomedicine. Yet, the laboratory was not a monolithic institution and significant links were fashioned between diagnostic and experi- ‘mental sites and with hospitals and public health agencies. Laboratory medicine also covered a range of disciplines from physiology and bacteriology to biochem- istry and genetics, which make generalizing difficult. Although historians are now more sanguine about the impact of laboratory medicine on clinical prac- tice, how did the laboratory influence medicine? Laboratories were being used in medicine in the sixteenth and seventeenth centuries. Under Philip II, distillation laboratories were created in Spain between 1564 and 1602 as part of Paracelsian practices, while in eighteenth century Germany apothecaries used laboratories in their research. Such laboratories had a practical purpose, but in the eighteenth century, medical science was firmly rooted in the bedside, the dissection room, and nosology. Although there was a link between the Paris Clinical School and the laboratory, it was clinical science and an interest in the structures of the body that dominated medicine in the carly nineteenth century. However, with improvements in microscopes and developments in histology attention started to shift from organs to cells as exemplified by the work in the 1850s and 1860s on cellular pathology by the German pathologist Rudolf Virchow. Virchow uncovered new histological struc- tures and encouraged research into histopathology and cellular pathology, promoting new analytical techniques that were more suited to the laboratory. Promise was also found in chemistry, especially in the work of the research school associated with Justus von Liebig’s Institute of Chemistry in Giessen. Here Liebig’s emphasis on laboratory-based experiments, accurate measurement and analysis provided a coherent approach to chemical and medical research. Following the work of the English physician Richard Bright on kidney disease in the 1820s, new chemical tests for analysing urine were introduced. If such work provided a practical focus for chemical analysis and research, it is around the development of physiology that historians have seen the emergence of a labora- tory-based approach to medicine. Notwithstanding the eighteenth century studies of the Swiss biologist von Haller and the French anatomist Xavier Bichat, it was in the mid nineteenth century that physiology moved beyond a focus on the functions of the body, such as digestion and respiration, and became a more experimental laboratory- based discipline. Although early physiological studies were initially dominated by clinicians (and in the case of France by veterinarians), they were influenced200 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE by the methods and advances in chemistry and physics and became coupled with experimentation, instrumentation and materialism, Ideas associated with the French chemist Antoine Lavoisier and Liebig’s Giessen school were applied to examine how the body’s functions were affected. The nervous system and metabolism attracted particular interest. Experimental methods were adopted as physiologists increasingly observed, measured and recorded the body's functions in a laboratory setting as evident in the work on nerves by the German physiol- ogist Bois-Reymond and the German physician von Helmholtz. Encouraged by the methods adopted by Bichat and Frangois Magendie in France, animal vivi- section became the normal experimental process adopted. Most of the early experiments ~ chiefly on cats, dogs or rabbits ~ were basic in nature and concen- trated on the functions of specific organs. After the basic functions were under- stood, physiologists turned to vivisection, chemistry and laboratory experimentation to determine the physical and chemical processes involved. In doing so, they elaborated a functional perspective on disease. Initially these laboratories were primarily private spaces: for example, the German physiologist Bois-Reymond worked in his own apartment in the 1840s, As physiology rose in status, these laboratories were institutionalized and small- scale research was replaced by more cooperative experimentation. Even though few countries matched France or Germany in terms of investment in physiolog- ical laboratories, close links between physiological laboratories and clinical issues were forged everywhere in Europe, while laboratory teaching became a routine feature of medical training as physiologists eagerly showed how their experimental work delivered clinical benefits If physiology encouraged the growth and institutionalization of laboratories in the mid nineteenth century, it is the germ theory of disease, commonly asso- ciated with the work of the French chemist Louis Pasteur and his German rival Robert Koch, which has been cast as the new paradigm for the laboratory sciences. In the 1860s and 1870s, Pasteur isolated several disease-causing microbes, while in Germany Koch made advances in techniques to identify bacteria, establishing a procedure ~ Koch’s postulates - to prove that a particular microorganism caused a disease. What was crucial was how their work gave new meanings to disease and its causes. Their research ushered in a period of rapid discoveries in which the organisms responsible for major infectious diseases were identified and new therapies were developed. New research institutes were established, with the Pasteur Institute in Paris becoming the model after it was opened in 1886. A decade later, municipal authorities, universities and medical schools could boast bacteriological laboratories for diagnosis and for the produc- tion of serums and vaccines. Historians have spoken of these changes as a ‘Bacteriological Revolution’ (or in France ‘Pasteurization’, and by the 1990s were associating this with a ‘Laboratory Revolution’. This revolution was more than the development of bacteriology as a discipline. If bacteriology demonstrated the value of laboratory knowledge to medicine and public health, the Laboratory Revolution was anSCIENCE AND THE PRACTICE OF MEDICINE 201 international movement that enabled widespread changes to medicine through the discovery of the microorganisms responsible for major infectious diseases, the development of new therapeutic agents, and a shift in authority from the ward to the laboratory. The formulation of germ theory became the icon of this revolution and has been represented as a watershed between traditional and modern scientific medicine. Examples of this process are seen in Joseph Lister's work on antiseptics [see ‘Surgery’], Koch's postulates, and the new opportunities for vaccination and immunization. Just as with physiology, integration of germ theory and bacteriology was assisted by the promotion of the laboratory as a site for training doctors and for delivering clinical benefits. New diagnostic laborato- ries were opened in hospitals and by municipal authorities. By the 1890s, sputum, blood and urine from patients were being routinely tested. University and research institutes, such as the Institute for Infectious Disease in Berlin (1891), were established and research laboratories were opened by pharmaceuti- cal companies. Research was framed as leading to new diagnostic and therapeu- tic techniques as demonstrated by the development of a diphtheria antitoxin (1894) and the production of Salvarsan for the treatment of venereal disease (1908), associating early laboratory studies with cures for dangerous infectious Figure 10.1 An experiment in a chemical laboratory. Source: Wellcome Library, London202 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE diseases. Such was the power of the laboratory that emerging specialties sought to harness laboratory experimentation to acquire legitimacy. The first three decades of the twentieth century witnessed large-scale efforts to introduce the laboratory into medical and commercial institutions, and an unprecedented rise in funding for medical research. Laboratory medicine and the search for further ‘magic bullets’ following the success with Salvarsan held out the promise of major advances. This was reflected in developments in vaccine therapy before the First World War (1914-18) and in the discovery of penicillin in 1928, Research into endocrinology and biochemistry in the 1920s and 1930s identified hormones, such as insulin, which could be used in the treatment (for example, in diabetes), while research on metabolism, digestion and deficiency diseases revealed the role of vitamins. If room remained for clin- ical experimentation, such as in cancer, new research institutes and university departments were established after 1919 that fostered an academic medical culture modelled on German universities and associated with Johns Hopkins University in Baltimore. Links with the pharmaceutical industry and with municipal authorities through public health work were consolidated. New tech- niques were introduced in the 1920s and 1930s that made serological, immuno- logical and laboratory analysis easier. A growing emphasis on metabolic concepts saw blood-testing become key to the diagnosis and management of many disor- ders. As clinical biochemistry became important to patient management, specialized laboratory facilities were required. Subtle distinctions emerged between routine testing and research as a growing institutional investment was made in research and the appointment of full-time scientists. This Laboratory Revolution in medicine was dependent on pragmatic local contexts and the perceived benefits. Where there were few direct clinical benefits ~ for example, in physiology - practitioners were more wary. Bacteriologists and pathologists were keen to show that their laboratory work had clinical relevance, reinforcing the role of clinical cases as the focus for investigation. For example, Koch’s postulates were formulated to answer clinical questions. If in the 1890s bacteriology started to modify clinical and diagnostic practices, laboratory work frequently had a service role. Laboratories carried out routine testing on patho- logical or bacteriological samples for hospital clinicians, local practitioners, and public health agencies, and had a practical use in the production of antisera and vaccines. How they were used depended on local contexts and this ensured that the relationship between the laboratory and the clinic was seldom static. Different kinds of observation were combined: clinical and laboratory observa- tions were both used to explain the particular case under investigation and to contribute to the development of new knowledge. There was often no clear demarcation between these different kinds of work. Clinical cases and routine testing were frequently the basis for research and for advancing scientific know!- edge. At the forefront was the clinician-scientist who combined laboratory science with the clinical control of practice and research. The above assessment would point to a triumph of laboratory medicineSCIENCE AND THE PRACTICE OF MEDICINE 203 However, whereas historians are in broad agreement that by the 1930s medical and hospital practice and how doctors were trained were being structured around academic medicine and the laboratory, older ideas of a revolution and the nature of the relationship between clinic and laboratory have been chal- lenged. Revisionists have encouraged historians to become more sensitive as to how ‘the ascendancy of the germ theory in etiological explanations does not provide a straightforward indicator of the rising medical esteem for the labora- tory’.? Received wisdom that germ theory was a defined entity has not held up to scrutiny. Its meanings changed over time ang its acceptance did not mean the rapid triumph of laboratory medicine. New chronologies have therefore been put forward as historians have examined how national cultures led to different bacteriologies in France, Germany and Britain. Nor did the acceptance of germ theories see a simple or sudden switch from holism to reductionism. Existing ideas about disease that favoured metaphors of ‘the seed and the soil’ persisted. Rather than a bacteriological or laboratory revolution, change was uneven, shifts in medical or preventive practice were slow to materialize, older ideas persisted, and the authority of the laboratory was questioned. ‘Tensions also existed between the laboratory and clinic. This reflected intra- professional conflicts and unease about certain types of laboratory research or disciplines. Although attitudes to laboratory medicine were not straightforward, some doctors feared that bacteriology and the laboratory would turn medicine away from clinical practice. As Christopher Lawrence revealed in his article “Incommunicable Knowledge’, the view that medicine was an intuitive, clinical art remained a potent concept among elite British physicians in the 1920s and 1930s as some worried that laboratory methods were usurping traditional clini- cal skills and devaluing bedside investigations (see Further Reading). Nor was unease limited to Britain. A significant number of physicians in interwar Germany emphasized a holistic and intuitive approach to medicine that was at odds with laboratory medicine. Although resistance declined as more practition- cers received training in laboratory methods, many remained cautious. Some sought to distance themselves from the ethical problems associated with the animal experimentation central to laboratory research. Attempts to introduce new medical practices and ideas about science into old institutions equally met with resistance. Universities and medical schools invariably recruited former graduates and suffered from inbreeding. This reinforced established practices and ensured that institutions were not always willing to invest in expensive laboratories or research activities. At its most extreme, opposition encouraged the development of alternative medical systems that emphasized the healing power of nature (naturopathy) or the individual (mesmerism) As the above section illustrates, heroic narratives of laboratory medicine should be balanced against how the laboratory and laboratory knowledge were employed. New models for understanding and classifying disease were widely discussed and gradually used, and efforts were made to institutionalize the laboratory through ‘medical education. However, changes in medicine were dependent on a wide204 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE range of factors and not just bacteriology or the laboratory. Values rooted in a clinical pathological approach and individualism remained strong, while new knowledge continued to be generated in a clinical setting that drew on practice Given the dominant enduring usefulness of the pathological anatomical approach, the benefits of mastering new and difficult diagnostic tests or knowl- edge was not at first clear. New easier methods associated with analysing blood, urine or other bodily fluids had to be devised before they became clinically prac- ticable. Clinical studies or innovations through practice, such as in surgery, remained important, as evident in the award of the Nobel Prize for Medicine in 1909 to the German surgeon Theodor Kocher for his work on the thyroid gland ‘Nor was laboratory medicine or knowledge uncritically accepted. Whereas some of the therapeutic agents associated with laboratory and pharmaceutical research, such as diphtheria antitoxin or insulin, were welcomed, others, such as organotherapy in the 1920s, which used extracts of animal glands and organs to treat disease, remained contentious. Developments in laboratory knowledge were slow to spread, especially to practitioners working away from medical schools or universities. Generation gaps existed and not all practitioners cham- pioned scientific or laboratory developments. By the 1920s, the laboratory had become a resource, but one that had an equivocal acceptance that was not always used in the ways that research papers or laboratory workers outlined. Rather than a laboratory revolution therefore, a process of accretion can be seen. Biomedical science and research: 1945-2000 After 1945, medical research came to permeate every aspect of medical practice and laboratory research and clinical medicine became inseparable. As the previ- ous section has illustrated, if this relationship between the laboratory and clini- cal medicine was being forged in the early twentieth century, biomedicine or the large-scale merger of laboratory-based and clinical activities became characteris- tic of the post-1945 period. The success of research programmes during the Second World War (1939-45) ~ for example, in the production of penicillin — encouraged a climate that favoured investment in biomedical research and academic medicine. Often labelled ‘big science’, large-scale programmes were developed as the number of researchers, university and medical school laborato- ries, and research institutes increased. Here the American biomedical model had a powerful influence. After 1945, medical research took on a transatlantic dimension as American biomedicine provided a resource and a reference point for European studies. Cancer and genetic research are ideal examples of not only big biomedicine and the development of transatlantic research programmes, but also of professional and public associations of disease with research, laboratory medicine and hopes for a cure, In the post-war years, medicine in Europe was driven by a rapid expansion of biological and biomedical research and by the political and cultural climate ofSCIENCE AND THE PRACTICE OF MEDICINE 205 the Cold War. Modes of scientific practice based around institutional coopera- tion and collaboration increasingly came to define research. This promoted new research cultures. Institutes set up before 1939 experienced a period of growth and governments, charities and pharmaceutical companies established new research institutes. In France, support favoured government agencies, such as Centre National de la Recherche Scientifique, while in Britain the MRC under- took a programme of diversification and set up 109 research units, although support continued to build on a tradition of medical school-based research. Divisions between basic and clinical research areas gradually became more pronounced as established disciplinary hierarchies were perpetuated by how medical research was funded. New specialties were developed, while emerging health problems like cardiovascular diseases or AIDS attracted considerable research investment and effort. Cancer research offers a case study of these processes. It received substantial investment not just from the state but also from charities, pharmaceutical companies and the tobacco industry. It provided the focus for the development of a number of disciplines and for biomedical science in general. Such was the scale of research investment that European collaborative partnerships were developed in the 1960s as the kind of work required was increasingly beyond the capacity of individual countries. However, despite the investment in research institutions and cancer research, Europe struggled to keep pace with the biomed- ical complex that developed around cancer research in the United States. Although doubts were to emerge in the 1970s, in the two decades following the Second World War medical research contributed to a series of advances that fuelled faith in the ongoing ability of medicine to cure many diseases. This was matched by confidence in the application of science and technology to progress and make improvements. Notwithstanding attempts to distance legitimate research from Nazi science through the Nuremberg Code (1947), ethical concerns were not always an issue. Until regulations were strengthened in the 1960s following the thalidomide tragedy, controls on experimentation were lax and regulation minimal, leading to practices that would later come to be condemned. Dramatic successes with streptomycin in the treatment of tuberculosis and with penicillin not only helped generate optimism and change patterns of treatment ~ for example, by the 1950s many tuberculosis sanatoria had closed ~ but also stimulated considerable investment in develop- ing chemotherapeutic agents. The need for a better understanding of disease mechanisms encouraged work on antibodies, enzymes, hormones and genes. Research into hormones, for example, saw the rapid introduction of fertility drugs and the contraceptive Pill in the 1960s. Virology, particularly in relation to work on live and inactivated vaccines, provided further examples of the clinical and preventive benefits medical and laboratory science offered. Following Watson and Crick’s work at Cambridge in the early 1950s on the structure of DNA, research on genetic diseases and gene therapy promised further breakthroughs.206 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE New tools and instruments fashioned not only knowledge but also new disci- plines, such as molecular biology, genetics and virology, in the second half of the twentieth century. Although institutional and professional cultures should not be undervalued, the growing automation of the laboratory contributed to its increasing importance in the diagnosis and monitoring of disease. Many of the tests developed in the 1920s and 1930s were standardized and automated. New methods were introduced. The randomized controlled trial (RCT) ~ first devel- oped in connection with a trial of streptomycin for the treatment of tuberculo- sis in 1946 ~ and the application of epidemiological methods to investigate Clinical conditions extended clinical research. Although the use of RCTs was not without opposition as they ran counter to clinician autonomy, they became the gold standard and had a particular impact on cancer research. RCTS offered an efficient tool for organizing research and evaluating therapies as biomedical research and the development of new measurement techniques continued to extend the ability of clinicians to diagnose illness and examine the disease process. Sophisticated biochemical tests, such as for enzymes and hormones, became available. Radioimmunoassay, pioneered by Sol Berson and Rosalyn Yalow in New York in the 1970s, allowed very small amounts of hormones in the blood to be measured. Biochemical tests of blood and urine became essential to hospital work and to general practice. Although European states invested increasing amounts in research in a Cold War climate that favoured scientific mobilization, the pharmaceutical industry assumed a major role in medical research. The wartime development of peni- cillin had relied on a combination of funding from governments and pharma- ceutical companies in the United States and Britain and the same pattern was repeated after 1945 for other drugs, such as the anti-viral agent Interferon. Many academics initially viewed collaboration with pharmaceutical firms as an intru- sion, but the realities of funding made such relationships increasingly impor- tant. Funding came at a price, however, as some researchers started to loose control of their work. Some commentators have suggested that the pace of change had slowed by the 1980s and 1990s; that by the late twentieth century, there were no major medical breakthroughs that could rival, for example, developments in medical genetics in the 1950s. Older technologies, such as stethoscopes and X-rays, continued to be used. From the mid 1970s, funding for research decreased following the economic downturn precipitated by the oil crisis of 1973. Many older research institutes merged or were forced to seek external funding, Private and charitable income, for example from the Nuffield Foundation or Wellcome ‘Trust in Britain, or from pharmaceutical companies, became increasingly impor- tant for universities and research institutes as countries began to re-evaluate their medical research programmes. Financial constraints stimulated debate on the value of medical research and its benefits, encouraging the growth of research programmes directed at applied work or major clinical problems, such as cancer or cardiovascular disease.SCIENCE AND THE PRACTICE OF MEDICINE 207 If new explanatory models and diagnostic tools directed therapeutic interven- tion, as exemplified in the post-war history of cancer, their direct impact was less tangible. For example, the substantial investment in cancer research did not result in the promised cures despite the advances made. Often the practical benefits of such medical research took longer to emerge, as seen in the case of Watson and Crick’s work on DNA. By thinking about the above examples, it becomes possible to come to a more critical assessment of the relationship between science and medicine in the second half of the twentieth century and how notwithstanding the successes of biomedicine, this relationship did not necessarily imply progress Conclusions As this chapter has shown, the role of science in medicine, and what this science has meant, has changed over time. Rather than an account that favours the nineteenth century and a laboratory revolution, this chapter has illustrated how it is possible to see a longer chronology and how different types of medical science existed in the past. It has shown how neither technological determinism nor inventions/discoveries adequately account for the relationships that were forged between science and medicine, and how the position and nature of medical science was often closely tied to political, theological, socioeconomic, institutional or professional contexts. In examining the nature and role of revo- lutions in medical science, the chapter has explored how change was uneven and how older ideas persisted, and, as the example of bacteriology and labora- tory medicine reveals, how medical science was contested. For licensed practi- tioners, medical science had both a practical and a rhetorical value. If in a Clinical or public health setting it was often the practical application of medical science that ensured its acceptance, science served other roles for practitioners as they used a language of science in their claims for expertise. Yet, as concerns about anti-vaccination and antivivisection reveal, it was not just Lawrence's elite British physicians who were ambivalent about medical science - contemporaries had their own ideas about progress, Further reading There is a substantial literature on science and the role of science in medicine from studies of individual disciplines to more thematic examinations, The further reading outlined here can hence only touch on the most important issues and studies. For readers interested in the history of science, Peter J. Bowler and Iwan R. Morus, Making Modern Science (Chicago, IL: University of Chicago Press, 2005) is an excellent introduction that also includes sections on biology and medicine, while Roy Porter, The Greatest Benefit for Mankind: A Medical208 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE History of Humanity from Antiquity to the Present (London: HarperCollins, 197) offers a detailed overview of medicine and science. ‘There are few up-to-date examinations of the historiography, but John Harley Warner, ‘The History of Science and the Sciences of Medicine’, Osiris 10 (1995), pp. 164-93, remains a Clear and concise assessment, while Ronald Doel and Thomas Séderqvist (eds), The Historiography of Contemporary Science, Technology, and Medicine: Writing Recent Science (London: Routledge, 2007) tackle approaches to the post-1945 period. There is a large literature on the Scientific Revolution, which is best approached through Steven Shapin, The Scientific Revolution (Chicago, IL: University of Chicago Press, 1996) and John Henry, The Scientific Revolution and the Origins of Modern Science (Basingstoke: Palgrave Macmillan, 2008). If there are few overviews of laboratory medicine, W.E. Bynum, Science and the Practice of ‘Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994) is a clear introduction to the period. John Lesch, Science and Medicine in France: ‘The Emergence of Experimental Physiology, 1790-1855 (Cambridge, MA: Harvard University Press, 1984), Gerald Geison, Michael Foster and the Cambridge School of Physiology (Princeton, NJ: Princeton University Press, 1987) and Arleen M, ‘Tuchman, Science, Medicine and the State in Germany: The Case of Baden, 1815-1871 (Oxford: Oxford University Press, 1993) provide studies of physiol- ogy and experimentation in different national contexts. Robert Kohler, From Medical Chemistry to Biochemistry: The Making of a Biomedical Discipline (Cambridge: Cambridge University Press, 1982) does the same for biochemistry, and for pathology see Russell Maulitz, Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century (Cambridge: Cambridge University Press, 1988). Although much has been written about germ theory, Bruno Latour, The Pasteurization of France tr. A. Sheridan and J. Law (Cambridge, MA: Harvard University Press, 1988) explores and questions the impact of Pasteur on France, while Michael Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865-1900 (Cambridge: Cambridge University Press, 2000) is a sophisti- cated study of how germ theories were used in practice. Stanley J. Reiser, ‘Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1982) and Stuart Blume, Insight and Industry: On the Dynamics of Technological Change in Medicine (Cambridge, MA: MIT Press, 1992) present different perspec- tives on the role of technological change in medicine, with Joel Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore, MD: Johns Hopkins University Press, 1995) offering a perceptive examination of the impact of technology on hospitals. On the role of the labo- ratory in medical education, readers should turn to Thomas N. Bonner, Becoming @ Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945 (New York and Oxford: Oxford University Press, 1995). For the twen- tieth century, the essays in Roger Cooter and John Pickstone (eds), Medicine in the ‘Twentieth Century (London: Routledge, 2000) and the chapters by Chris Lawrence, Anne Hardy and Tilly Tansey in W.F. Bynum et al, The Western Medical ‘Tradition, 1800 to 2000 (Cambridge: Cambridge University Press, 2006) are excel-SCIENCE AND THE PRACTICE OF MEDICINE 209 lent introductions, while Nikolas Rose, The Politics of Life Itself (Princeton, NJ: Princeton University Press, 2007) explores biomedicine, subjectivity and power, Harry Marks, The Progress of Experiment (Cambridge: Cambridge University Press, 1997) remains the best available account of clinical experimentation in the twentieth century, while the essays in A.H. Maehle and J. Geyer-Kordesch (eds), Historical and Philosophical Perspectives on Biomedical Ethics (Aldershot: Ashgate, 2002) address the ethical dimension. Readers interested in a sociology of science approach to twentieth century medicine should turn to Harry Collins and Trevor Pinch, Dr Golem: How to Think About Medicine (Chicago, IL: University of Chicago Press, 2005) with an introduction to this approach given by Sergio Sismondo, An Introduction to Science and Technology Studies (Oxford: Blackwell, 2004). On the pharmaceutical industry, see John Swann, Academic Scientists and the Pharmaceutical Industry (Baltimore, MD: Johns Hopkins University Press, 1988) or Miles Weatherall, In Search of a Cure: A History of Pharmaceutical Discovery (Oxford: Oxford University Press, 1990), while Robert Budd, The Uses of Life: A History of Biotechnology (Cambridge: Cambridge University Press, 1993) and Jean- Paul Gaudilliere and lana Lowy (eds), The Invisible industrialist: Manufacturers and the Construction of Scientific Knowledge (Basingstoke: Palgrave Macmillan, 1999) examine biotechnology. On the importance of cancer research, see the special issue of the Bulletin of the History of Medicine in 2007. For those interested in the opposition medical science generated, a good starting point is Nicolaas Rupke (ed.), Vivisection in Historical Perspective (London: Routledge, 1987) and Nadja Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853-1907 (Durham, NC: Duke University Press, 2005). Christopher Lawrence, in ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain, 1850-1914’, Journal of Contemporary 20 (1985), pp. 503-20, provides a standard text on British physicians’ attitudes to laboratory medicine, while Gerald Geison, “Divided We Stand” Physiologists and Clinicians in the American Context’, in Morris Vogel and Charles Rosenberg (eds), The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia, PA: University of Pennsylvania Press, 1979), pp. 67-90, and S.E.D. Shortt, ‘Physicians, Science, and Status: Issues in the Professionalization of Anglo- American Medicine in the Nineteenth Century’, Medical History 27 (1983), pp. 51-68, take a different approach to how science was. There is a large literature on popular science, but for science’s impact on popular culture and vice versa see Colin Russell, Science and Social Change, 1770-1900 (Basingstoke: Palgrave Macmillan, 1983) and Bemard Lightman, Victorian Popularizers of Science: Designing Nature for New Audiences (Chicago, IL: University of Chicago Press, 2007),11 Nursing Nursing history has often been described as the Cinderella of the history of medicine. Mostly written by nursing leaders, early nursing histories embraced an account that emphasized the importance of the nineteenth century to professionalization, tracing the perceived development from the ill-educated and drunken nurse epitomized by the comic figure of Sarah Gamp from Dickens's Martin Chuzzlewit (1843-44) to the trained, efficient nurses personi- fied by Florence Nightingale. This triumphalist approach provided an unprob- Iematic, moral tale of progress that reinforced both mid nineteenth century caricatures and the post-reform image of the professional nurse to foster a sense of identity and tradition. Although at first little influenced by the growth of women’s history in the 1970s, in the 1980s work on nursing started to be shaped by feminist critiques, the social history of medicine, and by soci- ological studies that challenged ideas of professional authority. As historians began to re-examine the history of nursing they began to emphasize the diffi- culties of developing a new profession and in changing attitudes to nursing, Nightingale’s contribution became the subject of considerable critical revision as attention turned to the work of nursing sistethoods in the early nineteenth century as providing the foundations for nursing reforms. Studies revealed how reform was an intricate process that reflected wider socioeconomic trends, such as women’s move into the public sphere, religious concerns, rising living standards, and developments in clinical medicine. Slowly the experience of ordinary nurses began to be examined and the realities of nurse training and the position of nursing in hospitals were re-evaluated as revisionists drew on feminist histories that demonstrated the inadequacies of a professional model when applied to women’s work. Studies revealed how values of obedience and discipline were important to professionalization, and how reformers used socially constructed stereotypes of women for their own ends to create work identities and shape reform, although what nursing care meant and how to interpret this care remained problematic. By the 1990s, historians of nursing were pointing to the revolution that had swept the discipline, Nurses were not a monolithic group as historians examined differences according to class, ethnicity, culture, religion and so forth nurses were no longer seen as a monolithic group. This chapter builds on this revisionist history to explore the parameters of nursing reform and Nightingale’s 210NURSING am contribution, alongside questions of class and gender to balance ideas of profes- sionalization against nurses’ experiences and the contexts that shaped reform. Nursing, religion and charity: 1500-1800 Often the problem for historians looking at the period before 1800 has been separating out what was nursing from what was not as most nursing was an extension of the care provided by women on a relatively informal basis, either within families or in communities. These arrangements were shaped by the emphasis placed on women’s role in the domestic sphere and the duties of women in caring for, and tending to the sick. Nursing care was further influ- enced by familial and community responsibilities and by an ingrained charita- ble imperative, which cast the care of the poor and the ill as a necessary part of Christian duty [see ‘Religion’]. Although early modern women were expected to practise some form of medi- cine and nursing as a domestic art, during the sixteenth and seventeenth centuries, religious orders came to play a prominent role in the care of the sick poor and in allowing women to move beyond the domestic sphere and informal nursing arrangements. The San Giovanni di Dio nursing order, which originated in Spain in the late sixteenth century, not only established hospitals but also provided nursing care for other institutions, while the Ministers to the Sick (Known as the Camillians) combined pastoral with nursing care, visiting the sick in their homes. In France, Catholic reforms stimulated changes to the structure of healthcare and emphasized the centrality of charity and spiritual mother- hood. As hospital administrators sought to improve medical provision and rationalize care [see ‘Hospitals’, they turned to nursing sisterhoods for a range of medical services. Nursing orders - the Daughters of Charity, the Sisters of St ‘Thomas of Villeneuve, and the Brothers of Charity - were established and came to provide an important component in staffing hospitals. Founded by Vincent de Paul and Louise de Marillac in 1633, the Daughters of Charity supplied a model for female pious activism and for later nursing organ- izations. Determined not to succumb to the pressures of the Counter- Reformation, de Paul saw the Daughters of Charity as not just spiritual workers but also as competent women who devoted their lives to the service of God through nursing, challenging ideas that women should lead a cloistered exis- tence. As part of their routine training, a Daughter of Charity was taught to care for the sick in the community's infirmary (for sick sisters), shown how to grow and administer medicinal herbs, and how to perform minor surgery. Rather than being attached to a specific institution, they were contracted to municipal authorities, parishes or medical institutions. Evangelicalism proved a strong ‘component of their work: a Daughter of Charity was to bring the sick poor back to God if they had strayed. However, they did take their professional duties seri- ously. This led to conflict with physicians and surgeons, and with powerful22 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE patrons, over how hospitals were administered, but at the same time, the Daughters of Charity had a significant impact on the nature of hospital services, A different situation existed in England. The dissolution of the monasteries by Henry VIII had largely ended the care of the sick by religious orders, but public outcry ensured many existing hospitals (notably in London) were re- established as secular institutions. These institutions, such as St Bartholomew's Hospital, employed a number of nursing sisters. However, the bulk of nursing care was undertaken in a non-institutional setting and was left to domestic households and communities, a situation that remained a feature of English nursing care into the nineteenth century. Studies of female depositions to the London church courts in the late seventeenth and early eighteenth centuries suggest that nursing remained a relative small area of full-time employment for ‘women. Most of those who assumed the duties of a nurse continued to be employed in domestic households as servants, cleaners or laundresses, or were themselves in receipt of poor relief who provided nursing as a form of outdoor relief. Those employed in the small number of hospitals in the period had func- tions similar to that of a domestic servant - administering food, changing linen, basic cleaning, etc. While some women gained a reputation for their nursing skill, most nursing arrangements remained informal, short-term or part-time and essentially involved often unskilled, manual labour. One set of arguments would suggest that the professionalization of medicine and the exclusion of women by male-centred medical guilds in the eighteenth and nineteenth centuries forced women out of medical practice and into nurs- ing. This influential view sees nursing only emerging as a separate female sphere asa consequence of men’s increasing control of healing. The growth of hospitals in the eighteenth century did encourage a shift in nursing into an institutional context to create clearer divisions between caring and curing [see ‘Hospitals'] However, many eighteenth century nurses remained little more than domestic servants. Nursing work had a poor and gendered image: most nurses had little formal education or training, and worked under poor conditions, These estab- lished patterns of nursing only began to be disrupted in the nineteenth century ‘when nursing moved beyond informal domestic arrangements and limited insti- tutional provision to take on new forms. Florence Nightingale has been seen as central to this reform of nursing, Repositioning Florence Nightingale ‘The image of Florence Nightingale, the American poet Longfellow’s ‘Lady with a Lamp’, has dominated popular perceptions of the history of nursing. Her contri- bution has been absorbed into a professional mythology as an icon of modern nursing. Born into a wealthy and cultured family, Nightingale sought to escape the claustrophobic nature of her background and trained as a nurse at Kaiserswerth in Prussia and in Paris. Nightingale achieved iconic status duringNURSING 23 the Crimean War (1853-56). Using her connections, she led a party of thirty. eight nurses to the English military base at Scutari. Her efforts there and her subsequent work in connection with the Nightingale Fund and St ‘Thomas's School of Nursing were hailed as a revolution in nursing. Disseminating her ideas through a large body of writings, particularly her influential Notes on ‘Nursing — What It Is and What It Is Not (1859), and through the Nightingale Fund and School, the charismatic Nightingale quickly became a central figure in nurs- ing reform, Her work with the Nightingale Fund and St Thomas's came to symbolize the triumph of a modern system of nursing through the creation of a body of disciplined and institutionally trained carers who brought ideas of order and hygiene to the wards and to the care of the sick. Just as historians of medicine have moved away from heroic narratives that stress the role of pioneers, so too has the myth surrounding Nightingale been questioned. The English writer Lytton Strachey in Eminent Victorians (1918) had already challenged the sentimental public image of the ‘Lady with a Lamp’, revealing another side to her as a woman with a harsh temper. The nursing Figure 11.1 Florence Nightingale and her staff nursing a patient in the military hospital at Scutari, 1855. Lithography by Thomas Packer. Source: Wellcome Library, London24 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE historian Monica Baly offered a less caustic but no less critical reassessment of Nightingale’s contribution. In Florence Nightingale and Nursing Legacy (1986), Baly challenged the Nightingale myth, illustrating how the founding of nursing schools was tangential to Nightingale’s interest in changing the way hospitals were constructed and to reforming the delivery of healthcare. Subsequent research revealed how Nightingale lacked any defined plans for nursing reform before she went to the Crimea; how the idea of the Nightingale Fund, its appli- cation to nursing reform, and the initial development of the St Thomas's scheme, relied on other peoples’ initiatives. Far from being meek and selfless, Nightingale was increasingly presented as a complex and talented women; a tough-minded administrator who insisted on having her authority respected. Studies have questioned not just the woman but also the nature of Nightingale’s achievements. Although historians have continued to credit Nightingale with forging nursing into a respectable occupation ~ a crucial component in professionalization — her work in the Crimean has been placed in context. For example, a system of military nursing existed before Nightingale, with wards staffed by male orderlies, while her presence in Scutari met with a mixed reception, Nightingale was neither a lonely pioneer nor responsible for coming up with the idea of sending out a female nursing expedition to the Crimea. Rather, Nightingale was an excellent self-publicist and concentration on her work has obscured the contribution of other nurses in the Crimea. Perhaps most notable was the Jamaican-born ‘doctress’ Mary Seacole. Unlike Nightingale, who oversaw nursing activities from a distance, Seacole worked at the battlefront in Balaklava. Nightingale did not approve of Seacole, her aggres- sive medical tactics, or how she got round the Nurses Enlistment Centre, the institution controlling nursing activities in the Crimea, Although her efforts were appreciated at the front, Seacole remains a secondary figure to Nightingale in part because of her mixed racial background and low economic status. Nor was Seacole alone: most of the female nursing in the Crimean was outside of Nightingale’s jurisdiction. Rather than seeing Nightingale’s activities in the Crimea as a defining moment, itis possible to push back the chronology to examine nursing reforms in the first half of the nineteenth century. Within this framework, nursing reforms can be seen in the context of changing patterns of hospital care, women’s moves into the public sphere, and of the religious revivals of the early nineteenth century. The pioneering work of earlier nursing reformers and nurs- ing sisterhoods were crucial to Nightingale’s success. Sisterhood and nursing reform: 1800-1850 In the early nineteenth century, it was difficult to distinguish nursing from other areas of female employment. No specialized training or knowledge was required, Although hospital nurses were expected to be of good character, most wereNURSING 2s Figure 11.2 A dishevelled nurse with her disgruntled patient. This caricature illus- trates early nineteenth century views of nursing and ils negative associations. Source: Wellcome Library, London, casual, lacked training and performed mainly menial tasks. Even matrons were primarily housekeepers. Although nursing care remained essentially domestic in nature, it was in the hospital that attempts were made to improve nursing. This was achieved by raising wages, improving accommodation, and by the laying down of minimum standards as part of a drive to create a more ordered and respectable (or moral) environment, At Guy's Hospital in London, for example, insubordinate and drunken nurses were dismissed, salaries were raised, and scrubbing and other work associated with servants was prohibited in the hope that a better class of woman would be attracted. Without these provisions, it was not possible to attract and keep quiet orderly women. Doctors had a crucial part in shaping these reforms, a role frequently over- looked in traditional accounts that favoured the heroic efforts of leading female reformers. In Germany, a six-month training course was established by physi- ians at the Berliner Charité hospital in 1832, while in London the medical staff of a number of general hospitals made similar moves to improve the quality of the nursing care. Conscientious doctors already offered some form of training for nurses and sisters on their wards, but changes to the nature of hospitals and216 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE clinical medicine required more far-reaching changes. A rapid growth in the number of hospitals, the influx of doctors into them with interests in research and teaching, and the changing nature of hospital medicine made the tradi- tional system of hospital nursing no longer suitable. As hospitals became centres of medical education and prestige, and as shifts in medicine placed a heavier burden on those charged with caring for patients, unreformed nursing was seen as.a hindrance to treatment [see ‘Hospitals']. This required not only more nurses, but also nurses who were trained and subordinate to the needs of the medical staff. To see medical and hospital concerns as the main drivers of nursing reform is to overlook the other factors at work. Moves to improve nursing were part of wider contemporary efforts to reform the workforce and instil character and discipline. At the same time, the early nineteenth century saw a series of reli- gious revivals and the growth of evangelicalism. The latter provided a useful ethic for the emerging middle classes that emphasized hard work and charity to raise individuals out of their suffering and to reform morals. Whereas religion offered spiritual and practical benefits, philanthropy gave respectable women an important, socially acceptable public role that built on established traditions of caring. In nursing, this religious and philanthropic role was fused to create an Ideal occupation for middle-class women to overcome their narrow social and economic roles. Early nursing reformers drew on these ideas. They saw in nurs- ing a suitable occupation for honourable, single women who would not other- wise have work outside the home. This can be seen in the Dutch Society for Sick Nursing whose founders sought to engage decent ~ preferably middle-class — ladies as nurses. In drawing on contemporary ideas of mortality, hard work, respectability and deference, reformers utilized constructions of femininity that stressed mother- hood and nurturing as moral values for women [see ‘Women and medicine’) Supporters of nursing reform argued that because middle-class women had these qualities and were used to dealing with servants they were ideally suitable for supervising nurses. They put forward a new concept of hospital nursing that involved vocation, training and a clear class hierarchy. This was a dramatic inno- vation: it recast the hospital as somewhere between a convent and an institu: tionalized version of a middle-class household. Nursing sistethoods were central in meeting this early demand for trained nurses and for respectable female employment. Although these nursing sister- hoods drew on established traditions of female religious orders, they introduced the concept of systematic hospital training for nurses. Here the Lutheran Order of the Deaconesses at Kaiserswerth (near Diisseldorf) in Prussia proved influen- tial. The Deaconesses’s Institute, established in 1836 by Pastor Theodor Fliedner for the order, not only revived a traditional church organization, but also created a hospital and nurse training school. ‘The school aimed to create a sisterhood of hospital nurses who had received three years of training in order to produce a prototype professional nurse. Kaiserswerth served as a model for other nursingNURSING 217 sistethoods, including the French Etablissement des Socurs de Charité Protestantes and St John’s House Sisterhood in Britain. Established to create a legitimate field of work for respectable women, these sistethoods turned ‘members of the order into trained head nurses or lady superintendents for hospi- tals and for domestic nursing. It was assumed that respectable women had the spiritual and social qualities necessary to provide proper nursing care and to instruct ordinary, often working-class nurses. However, it was not just a question of replacing drunken Sarah Gamps with more respectable women. ‘The sister- hoods insisted on hospital training, a division between nursing and domestic duties, and ideas of morality that drew on contemporary notions of respectabil- ity. Concerned with the spiritual salvation of the sick poor, as well as their phys- ical comfort and cure, they were successful in creating a new type of trained nurse who was efficient, respectable and moral. Hospitals bought in their serv- ices. The sisterhoods trained further women to be hospital nurses via a system of ward-based apprenticeship that was to remain a feature of nurse training throughout the nineteenth century. The religious values associated with the work of the nursing sisterhoods played a vital role in re-constructing nursing as a respectable profession. By the 1840s and 1850s, the moral qualities attributed to philanthropic women and the vocation and training of the sisterhoods had combined in a model of nursing that gained widespread support. These ideas fitted neatly with wider middle- class notions of domestic femininity and respectability. Links were established between nursing and the ideal middle-class wife: both were expected to be good tempered, compassionate and sympathetic to the sick, quiet in their manners, neat, and have a love of order and cleanliness. Knowledge of medicine was not initially important. Nursing was shown to be naturally women’s work. ‘Combined these ideas became central to the feminization of nursing and to the entry of middle-class women into the field. Although sisterhoods battled to improve patient care and ward management, they could not staff every hospital. Nor were they always welcomed. They posed a threat to medical authority while their religious credentials encouraged hostil- ity. Most nurses continued to come untrained from the ranks of the working- class, and most hospital nursing remained menial in nature, similar to domestic service. However, to overstress the rough and lowly nature of nursing would be to accept the rhetoric of early nursing reformers at face value. Often the impres- sion of early nineteenth century nursing depends on what sources are consulted. Research on English Poor Law nurses and other contemporary evidence suggests that not all nurses conformed to contemporary caricatures of them as drunken or incompetent. Many performed their duties in a competent and efficient ‘manner though for most, nursing remained an informal occupation. They could easily move from post to post, ensuring that the turnover of nurses was high. It was only after 1850 that nursing started to be transformed from casual labour into a vocation.218 AN INTRODUCTION TO THE SOCIAL HISTORY OF MEDICINE Professionalizing nursing: 1850-1914 The changes that occurred in nursing in the second half of the nineteenth century were closely tied to socioeconomic and political change and to shifting patterns of hospital care. Industrialization and urbanization contributed to rising levels of ill health and disease and disrupted domestic and family care, encouraging the development of market and institutional solutions to meet a range of social needs. Religious revivals and changes in the pattern of philan- thropy promoted ideas of active participation and reinforced the belief that social and nursing work was a Christian duty [see ‘Religion’]. The growth of hospitals and civic infirmaries created further demand for nurses as more patients needed to be cared for and supervised. Changes were also occurring with regard to the nature of hospital medicine with a shift to new supportive therapies and an extension of surgery, although it was not until the late nine- teenth century that these had an obvious impact on nursing [see ‘Hospitals'] "New social structures were emerging. For middle-class women, nursing offered a Way of entering the public sphere within socially acceptable gender norms, Because of these inter-locking forces, pressure grew for trained nurses and for nursing as a source of employment for respectable women. These two trends ~ the drive to separate nursing from domestic service and make it respectable, and the association of nursing with training and a recognized body of skills ~ marked what many nursing historians have seen as the start of professionalization As we have already seen, this drive to professionalize nursing is often associ- ated with the work of Florence Nightingale. Revisionists have not only placed Nightingale within a broader reform movement that was gaining momentum independently of her, but also shown how professionalization was a longer and often contested process. In explaining these nursing reforms, sociological models of professionalization were found wanting and nursing emerged as a paradigm of the contradictions in the gendered nature of professions [see ‘Professionalization’]. Nursing reform drew on a conflicting set of ideals that emphasized traditional, socially constructed womanly values of caring and a thetoric of training, morality, discipline and hygiene. If nursing reformers adopted a language of professionalization similar to other areas of medicine - for example, the need to protect the public through the exclusion of the untrained and shared some of the same strategies ~ the creation of nursing organizations, professional journals and state regulation - the professionalization of nursing ‘was equally shaped by gender, notions of respectability and domesticity, and by inter- and intra-professional tensions. Whereas the appointment of a trained nurse in the early nineteenth century was seen as a way of promoting order and cleanliness in hospital wards, after 1850 the need for professional clinical nurses became the primary concern. Many nursing reformers shared a common view of the unsatisfactory nature of nursing standards. Combining the model embodied in the nursing sistethoods with their values of vocation, training and class, reformers extended the ideaNURSING 29 that nursing needed to be transformed into a feminine profession for respectable women who, once trained, would impose morality, hygiene and efficiency on working-class nurses and patients. Reformers hence saw character and class as fundamental, and made ideas of order, discipline and obedience central to nurs- ing reform. Moral and technical training were interlinked. These were important ideas in differentiating the trained nurses from other areas of female employ- ment. They were also a practical response to a hospital environment in which discipline was necessary to cope with understaffing and poor educational stan- dards. Just as in the early nineteenth century, religious and charitable organizations and hospitals were central in promoting reform. Hospital administrators were keen to employ the cheapest, most efficient nursing force as pressure intensified for higher standards of patient care. Doctors continued to have a crucial role in influencing reform. In the Netherlands, for example, nursing reforms were spear- headed by doctors in Amsterdam who used training, textbooks, nursing organi- zations and journals to influence reform, As part of attempts to reform hospitals and patient care, doctors wanted trained nurses but ones that were subordinate to them. But it was not just doctors who pressed for reform. Nursing reform could also serve cultural and political ends. In France, during the Third Republic (1870-1940) nursing reform was linked to debates about the health of the nation, anticlericalism and the politics of gender. Pressure was brought to bear by the Republic on existing nursing organizations to initiate reforms which became closely tied to pressure for laicization. By mid-century, the knowledge expected of an ordinary nurse required some- thing more than picking up information by working on the wards for a few months: training was needed through hospital-based schools. These became central to the professionalizing process. Although many nursing schools were established to create both a cheap source of nursing labour and income for hospitals, they fashioned a particular type of nurse, style of training and condi- tions of work that strengthened professional identities. It was here that Nightingale had an important role. In her Notes on Nursing (1859) and through the St Thomas's School of Nursing, Nightingale outlined an influential model for the professional trained nurse, Influenced by the activities and ethos of the nurs- ing sisterhoods, and by ideas of respectable female employment, hygiene and morality, she fashioned nursing as an appropriate occupation for lay women. Nightingale did this by claiming that nursing was part of the woman’s sphere, by replicating existing class structures, and by making nursing subordinate to medicine. In doing so, Nightingale reinforced the close links between nursing, religious vocation and philanthropy. This was combined with values that stressed an unquestioning obedience to hierarchy. Nightingale’s aim was to train sisters and matrons, using a two-tiered system of paying pupils, who trained for two years, and probationers, who came from humbler backgrounds and trained for one year. The Nightingale system hence recreated the middle-class house- hold: paid, well-trained nurses worked under the supervision of ladies who acted