The Care Of Strangers: The Rise Of America’s Hospital System

by Charles E. Rosenberg; Basic Books; 437 pages.

When Thomas Jefferson was President, there were two hospitals in America, one in Philadelphia and one in New York, and to be accepted into one of them, a patient had to be judged morally worthy. A man with a venereal disease or an unwed pregnant woman need not apply. Nor did the hospitals aceept anyone with a “contagious” disease—including tuberculosis and cancer. Society leaders, esteemed for their high moral character, ran the hospitals, and no one questioned their Christian stewardship.

There wasn’t much hospitals could do for their patients anyway. They could offer food and shelter, a degree of cleanliness (high by the era’s standards, appalling by today’s), and a bed. At that time most of the sick were cared for at home, and society’s outcasts landed up in almshouses, which maintained a few beds for people to die in as well as serving as repositories for the destitute and insane.

In this important and highly readable book, Dr. Rosenberg, a prizewinning historian of medicine, traces the evolution of the American hospital from these medically primitive beginnings to the high-tech, vastly expensive system we have and complain about today. One of the most important elements in shaping the “texture of hospital life” was the professionalization of nursing. Florence Nightingale and her advocacy of cleanliness, order, and ventilation to prevent the dreaded complications then lumped together under the term hospitalism played a large part in this advance, as did hospital design as it developed during the Civil War.

Anesthesia, although accepted only slowly, relieved surgeons of the need to operate at breakneck speed while their agonized patients were forcibly restrained. And such new inventions as the stethoscope (also regarded somewhat suspiciously at first) proved useful in diagnosis.

It was not, however, until Joseph Lister in the late 1860s introduced his germ theory and his doctrine of antiseptic surgery that the possibilities of medicine exploded. Many doctors were slow to respond; as late as 1878 the editor of New York’s leading medical journal wrote that Lister “has a grasshopper in his head.” But during the half-century following Lister’s discoveries, the germ theory would “not only reshape the hospital but help transform every aspect of medicine.”

Dr. Rosenberg concludes that our present hospitals—highly and competitively technical and forbiddingly expensive—are considered unsatisfactory and inhumane by many Americans. The “discipline of the marketplace” will not necessarily protect the most vulnerable members of society, he concedes, but the problems cannot be blamed entirely on the medical system. “Health care policy will continue to reflect,” as it has since those first two hospitals at the beginning of the nineteenth century, “… our attitudes toward sickness and society.”