ISSUES FROM THE CHAIR

Why Historical Study Belongs in Medical Education

The consequences of medicine's turn to experimental knowledge for history of medicine were profound. Reliance on texts that emphasized collective clinical experience gave way to knowledge derived from experimental methodologies based on laboratories, and, slightly later, routine diagnostic tests. Study of medical history simultaneously underwent a transition from being an activity valued for its recovery of practical clinical knowledge to one that celebrated medicine's past for its own sake. Medical students were no longer directed to the writings of deceased medical authorities to gain useful knowledge, but rather to scientific journals, hospital bedsides, and laboratories. History and medicine had split, and historical knowledge moved to the margins.

For several decades, medical education has presented itself almost exclusively as a process of acquiring scientific and technical competence. Students are selected largely on the basis of their performance in undergraduate science courses, and medical schools train them to be scientifically and technically competent. Their teachers hope that medical students emerge as caring physicians, but many schools operate as though non-technical aspects of physicianhood exist outside their pedagogical charge. Two enduring assumptions about medicine and science that took form in the Progressive Era have shaped this outlook. The first is that science concerns itself only with facts, which are value-free and universally true. The second is that, insofar as medicine draws upon the basic sciences, it is a science, but that medical practice is an art.² In other words, a dichotomy between scientific facts and values mirrors a similar split between medicine as science and art. This way of thinking has long-standing roots in classical distinctions between scientia and ars, theory and practice, mind and hand. However, prior to the middle decades of the 19th century, medicine had not experienced the distinction as a radical bifurcation.

In the late 20th century, we, our students, and our patients hardly need to be convinced of the power of scientific medicine. The question is, do medical students and physicians need history any longer? In the early part of the century, medical leaders who bemoaned the emergence of medical specialization, which they characterized as "over-specialization," thought that the study of medical history would simultaneously inculcate respect for medicine's interdisciplinary aspects as it re-humanized the physician. More recently, apologists for inclusion of "medical humanities" and/or "medical ethics" in medical curricula have made their case on similar grounds.

While these sentiments are laudable, I fear they place the study of history in the same relation to medical school curricula as the study of art and music have been placed in elementary education. Inclusion of such pursuits is "nice," but, according to the prevailing logic, they are frills and ornaments. Medical education is really about the acquision of scientific and technical competence. And, like the inclusion of art and music courses in elementary school, study of "frills" may be expendable if there is fiscal constraint.

For two main reasons that relate to the shape of 20th century medicine and science, I think history of medicine can make a stronger case. The first is that scientific medicine is a profoundly social enterprise. Laboratory science, and the lessons and pharmaceuticals that have flowed from its operations, have ameliorated numerous disease experiences, but they have not "solved" many problems of either acute or chronic diseases as early 20th century visionaries had hoped. The shape of disease, the medical profession and its institutions, and of suffering, are profoundly influenced by historical factors and social values and practices. However, "nowhere else in the medical curriculum save in history can students learn how the medical system as a whole has been put together. Nowhere else can students develop the kinds of critical perspective and vision necessary to assume, one day, a role as effective leaders within the medical community and larger society. And nowhere else in the typical medical school curriculum is there room for guided reflection about what it means to be a practicing physician."³

As the medical school curriculum over the past half-century increasingly emphasized experimental science alone, the profession gradually turned away from an interest in how the world works. If a medical school simply left its students to fend for themselves in the study of physiology, it would scandalize the profession. Yet, when it comes to the equally vital subject of how the medical system itself has been put together, in either its internal structure or its functioning within society, students are abandoned by many medical schools. What students need is a basic understanding of the overall social anatomy and physiology of medicine. History provides an awareness as well as knowledge of the kinds of factors that have driven medicine's evolution. Leading medical journals today publish articles bemoaning the profession's loss of autonomy and the erosion of medical standards in the era of market-driven health care. The study of history is useful for engaging those students who wish to have a significant impact on the future shape and structure of U.S. medicine as well as their personal careers.³

The second main argument for history in medical education relates to 20th century work in the history and philosophy of science. Logical positivism, by which I mean cognitive philosophies that assume the objective neutrality of facts, no longer enjoys the intellectual security it did in the Progressive Era. Scientific facts may be "just the facts," as Sergeant Friday said in the 1950s on TV's 'Dragnet,' but they also exist in frameworks that imbue them with moral, social, and political dimensions.⁴ As Ludwig Fleck, M.D., observed in 1935, "In science, just as in art and in life, only that which is true to culture is true to nature."⁵

Consider, for example, an important recent topic in feminist critiques of science: the biology of reproduction and development. Nancy Tuana has pointed out that "scientific" accounts of reproduction from Aristotle to the preformationists of the 18th century impose "prevailing views of women (i.e., as passive, weak, and generally inferior) onto their roles in reproduction."^6,7 Twentieth century literature on fertilization routinely depicts sperm cells as "active," "forceful," and "self-propelled," while egg cells merely "drift" along the fallopian tubes until they are "penetrated" by the sperm. As Evelyn Fox Keller observes: "Only recently has this picture shifted, and with that shift, so too has shifted our technical understanding of the molecular dynamics of fertilization."³ Current research, instead, has elucidated that proteins produced by the egg cell permit the sperm cell to adhere and enter. The new model of fertilization, according to the authoritative text, Molecular Biology of the Cell, involves a process in which the egg and sperm "find each other and fuse."⁸

I include the anecdote about fertilization theory not to belabor a specific topic, but rather to illustrate a broad change in attitude toward scientific knowledge that has emerged in recent decades in analyzes of scientific epistemology conducted by philosophers and social scientists. Historical analysis can provide an awareness of many of the values and social factors that shape both the medical profession and its knowledge. As two of my collegues, Guenter Risse and Jack Pressman, have noted:

"The choice is clear: physicians can strive to refind their voice, or retain an inward vision and have the future shape of the profession determined by others. It should be noted that the same fate awaits the bench scientists who see no reason to step outside the walls of the laboratory."²

Fortunately, the curriculum of the University of Kansas has included a required introductory course in history and philosophy of medicine for first-year students. Divided into four broad sections of four weeks each, the course examines the art of medicine, medical ethics, medicine in society, and medicine and humanity. Additionally, students experience four half-days observing emergency and ambulatory practices. Through lectures and discussions led by a broad range of clinicians, medical educators, ethicists, a cleric, and a historian, the course seeks to improve student's abilities according to five criteria:

1. Sensitivity: an awareness of what is "at stake" in each subject area on cultural, social, and ethical terms.
2. Reasoning and reflective skills: acquisition of basic skills and methods of historical, ethical, and social analysis.
3. Implementation skills: methods and tactics that promote acquisition of agency as an interpreter and healer of illness and disease.
4. Articulateness: the verbal and written ability to frame health care issues in ethical and historical terms.
5. Motivation to practice an ethically and socially informed medicine.

In some ways our course goals are not far removed from those of 17th and 18th century historians who shaped historiography in the European Enlightenment. Perhaps this is because like them, we, too, want advances in scientific knowledge to serve humanity. Experience of a century of scientific hegemony in medicine, however, has taught us that both the medical profession and medical knowledge are complicated social constructions. Perhaps this is why, at times, current historical work in medicine tends to raise more questions than provide answers. But that very quality of openness, I would argue, is what can help the medical profession re-engage with the world.

Robert L. Martensen, M.D., Ph.D.Associate Professor and Chair
Department of History and Philosophy of Medicine

¹ Dewey J. The School and Society. Chicago: U. of Chicago Press;1899.
² Warner JH. The history of science and the sciences of medicine. Osiris. 1995;10:164-193.
³ Pressman J. Risse G. Is history relevant to medical education today? UCFS History of Health Sciences Newsletter. 1995;6:1:
⁴ Daston L. The moral economy of science. Osiris. 1995;10:3-24.
⁵ Fleck L. Genesis and Development of a Scientific Fact. Chicago: U. of Chicago Press;1979.
⁶ Fox Keller E. Gender and science: origin, history, and politics. Osiris. 1995;10:27-38.
⁷ Tuana N. (ed) Feminism and Science. Bloomington: Indiana U. Press;1989.
⁸ Alberts B. et al. Molecular Biology of the Cell. New York: Garland Press;1994.

As part of the course requirements Dr. Martensen also requires the students to submit written work. Once again, I’m the lucky one who gets to see them. Each visit by a student involves a little casual chat that gives me a clue about themselves, their class as a whole, and their goals. I am finding that we have a diverse group of students. We have a mix of gender, cultural backgrounds, nontraditional students, and second careers.

Interacting with the students has been further facilitated because of our email system. All of the students are on email and, being children of the technology age, communicate with ease using the computer. It is an easy, convenient and efficient way to get messages delivered, but we still have those student mailboxes too!

I am not a doctor, librarian, or historian; however, my degree in education has prepared me to deal with the academic side of our department. I am the person many students come to with questions, problems, and to just chat. I spend much of my time attending to routine tasks that must be done for the department and the classes to run efficiently, therefore, those student interactions really make my day.

Susan Brock
Administrative Assistant

The Medical Library Association (MLA) will hold its national meeting and conference at Crown Center, June 1-5, 1996. On Wednesday, June 5, Susan Case, rare books librarian and MLA member, will host a tour of the Clendening Library for conference participants.

The Harrington Archives

Upon graduation from Wyandotte High School in Kansas City, Kansas, in 1930, Harrington, an excellent athlete, matriculated at the University of Kansas on a basketball scholarship. While at K.U., he co-captained the team that won the 1933-34 Big Six Basketball Championship. Also a member of the track team, he once held the conference record for the javelin throw. Eventually, Harrington developed an interest in medicine. After graduating from K.U. in 1934, he entered the University of Kansas School of Medicine, and received his M.D. degree in 1938.

Dr. Harrington then interned at Roper General Hospital in Charleston, South Carolina. He returned to the Kansas City area in 1940, and completed additional internships at St. Luke’s Hospital and General Hospital under Doctors Frank Dickson and Rex Dively.

During World War II, Dr. Harrington served as head of the Orthopedic Unit of the 77th Evacuation Hospital. The 77th, formed largely from doctors and nurses from the University of Kansas Schools of Medicine and Nursing, participated in campaigns in Europe and Africa.

Following his military discharge in 1945, Dr. Harrington entered private practice in Houston, Texas. There he donated time caring for patients in the National Foundation Polio Section of Jefferson Davis City/County Hospital. As a result of spiraling numbers of patients due to the post-World War II polio epidemics, Dr. Harrington became immersed in the problem of post-polio scoliosis. Through his work with the Baylor College of Medicine, the Southwest Respiratory Foundation of the National Infantile Paralysis Association was established.

In the decade from 1950 to 1960, Dr. Harrington conceived and engineered the spinal instruments that bear his name. Once the basic designs were developed, the instruments were then tested extensively by the Engineering Department of Rice University in Houston.

Over the years, Dr. Harrington became internationally recognized as an authority on scoliosis, and for his development of spinal instrumentation. A founding member of the Scoliosis Research Society, he served as its president from 1972 to 1973. Dr. Harrington also functioned as Orthopedic Consultant to both the United States Air Force and Army in San Antonio, Texas, and served as Professor, Division of Orthopedic Surgery, and Professor, Department of Rehabilitation, at Baylor College of Medicine in Houston.

In 1973, Dr. Harrington was awarded the Cora and Webb Mading Medal from the Texas Institute for Rehabilitation and Research and Baylor College of Medicine, and the Nicholas Andry Award from the Association of Bone and Joint Surgeons. The Medical School Alumni Association of the University of Kansas named him Medical School Alumnus of the Year in 1975, and awarded him a Distinguished Service Citation.

Paul Randall Harrington died on November 29, 1980, in Houston, where he had labored throughout his remarkable career. Before his death, he requested that his papers be permanently preserved at the University of Kansas Medical Center. Dr. Harrington’s wish was facilitated by Marc A. Asher, M.D., Professor of Orthopedics, whose efforts brought the collection to the Medical Center in 1981.

In the Department of History and Philosophy of Medicine, a small, attractive archives facility contains Dr. Harrington’s professional papers, photographs, publications, manuscripts, blueprints, drawings, and examples of the revolutionary spinal instrumentation he developed during his career. The Harrington Archives also includes biographical information, presentations, professional correspondence files, personal correspondence, personal photographs, movies, and videotapes. Display cases in the archives exhibit photographs, documents, and artifacts that depict the history of Dr. Harrington’s life and career.

The archives continues to accept donations of materials pertaining to the life and work of Dr. Harrington, and is in the process of launching an oral history project to interview his surviving family and professional associates.

The Harrington Archives is open by appointment.

Nancy J. Hulston,
University of Kansas Medical Center Archivist
Marc A. Asher, M.D.,
Professor of Orthopedic Surgery

The library’s foyer is the site of changing exhibits which highlight various aspects of the Clendening Library and Museum’s collections. The current exhibit, "Feminist Perspectives in the History and Philosophy of Medicine," displays recent book acquisitions for the Clendening Library and is composed of books which are available for checkout to faculty, students, and staff of the University of Kansas Medical Center. The exhibited books are available to all other readers via interlibrary loan.

"Feminist Perspectives..." is illustrated by enlarged reproductions from the work of artist Charles Le Brun [1619-1690]. Le Brun, appointed by Louis XIV, became France’s Minister of Cultural Affairs, and exercised almost dictatorial power over the artistic production of his country. From 1661 to 1683, all items of decoration for all royal dwellings in France were conceived by Le Brun, and no painting was regarded as "official" without his sanction. Le Brun’s illustrations of women’s faces in the exhibit are examples of physiognomic studies. Physiognomy, in the 17th century, was a formal discipline in which the face or countenance was viewed as an index to mind and character. Physiognomic studies were related to earlier 16th century medical studies of the proportions of the human body which attempted to correlate physical and constitutional characteristics to an individual’s susceptibility to disease.

Feminist Iris Marion Young [In: Justice and the Politics of Difference. Princeton, N.J.: Princeton University Press, 1990] identified five "faces" of the oppression of women: exploitation, marginalization, powerlessness, cultural imperialism, and violence. The theme of "faces" and the feminist interpretation of "faces" is illustrated in the Clendening Library’s current exhibit and in the collection development activities of the library.

Ideally, library collection development seeks to create collections which reflect a fair and balanced representation of all points of view on a subject. The nemesis of library collection development is censorship. The codes of ethics of Librarianship oppose censorship; therefore, the Clendening Library also collects materials which reflect criticism of feminist philosophies.

The term "feminism" was coined in France and became widely used by the late 19th century, although concern for women’s rights dates from the Enlightenment, and was articulated in Mary Wollstonecraft’s, A Vindication of the Rights of Woman, published in England in 1792. Early feminists engaged in various activities characterized as "civil disobedience" and "social action." By the end of the 19th century, the feminist movement focused on the issue of woman suffrage. Women in America achieved the right to vote in the first half of the 20th century.

La Joye Tranquille
by Charles Le Brun, 1619-1690

The modern era of feminism began with the publication of a landmark book: Simone de Beauvoir’s, Le Deuxieme Sexe (1949). Beauvoir’s statement that "One is not born, but rather becomes a woman," defined one of the central themes of feminism: the social construction of women’s reality. Modern feminist philosophical inquiry challenges the contention that "women’s destiny" is biological, and attempts to identify socially imposed conditions and definitions which contribute to the oppression of women. Feminist scholarship is now engaged in the task of "deconstructing" oppressive theories, methods, stereotypes, and cultural beliefs, and is beginning to "reconstruct" alternative viewpoints.

The new feminist theories challenge various traditional scientific and philosophical assumptions. Of particular importance to collection development at the Clendening Library is the current expansive period of feminist publication which expresses significant criticism of the medical profession. The "information explosion" is nowhere more evident than in the field of feminist bioethics. As feminism is composed of diverse voices, publication in the area of feminist bioethics reflects that diversity. The current exhibit displays books which cover a wide range of feminist perspectives in the subject areas of religion, literature, abortion and reproductive issues, sexuality, biography, psychiatry, motherhood, and history.

Susan B. Case, Rare Books Librarian

The following are examples of books in the exhibit:
Denise Wear and Lois LaCivita Nixon, Literary Anatomies: Women’s Bodies in Health and in Literature (1994).
Alice E. Adams, Reproducing the Womb: Images of Childbirth in Science, Feminist Theory and Literature (1994).
Joan I. Roberts, Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession (1995).
Barbara Hillyer, Feminism and Disability (1993).

The Founding and History of Douglass Hospital, Kansas City, Kansas.

Dr. Thompson served a brief internship in Freedmen’s Hospital, which was affiliated with Howard University. He then traveled west and practiced for a short time in Atchison, Kansas. Finally settling in Wyandotte, now Kansas City, Kansas, in 1898 he married Belle Armstrong of St. Louis, set up practice, opened his own pharmacy, and co-founded, with T.C. Unthank, M.D., Douglass Hospital and Training School for Nurses (a busy year, indeed!). As a result of fundraising drives, a building was subsequently rented and equipped at 312 Washington Boulevard. The charter for the new hospital was filed on December 5, 1899.

Named for Reverend Calvin Douglass, this was the first hospital for African-American citizens west of the Mississippi. Paragraph two of the charter read:

The purpose for which this corporation is formed, is the establishment of a Hospital and Training School for Nurses, on a charitable basis, to care for the unfortunate sick and wounded without regard to race, creed, color, or previous condition.

African-American citizens in the Kansas city area in the late nineteenth century had virtually no access to white physicians and hospitals. Essentially, home remedies and treatments served as fundamental health care for most African-American families. The "Black Hospital and Nurses Training School Movement," as written by Darlene Clark Hine in Black Women in White (Indiana University Press, 1989), began to address that issue. Finally, competent institutions were developed, such as Douglass Hospital, where young black men and women could receive skilled and professional training to qualify them for medical and nursing careers.

Douglass Hospital fell under the authority of the African Methodist Episcopal Church (AME) in 1905, lead by Bishop Abraham Grant, and retained that affiliation throughout the years. A fund raising drive in 1924 enabled the hospital to purchase a new and larger site at 336 Quindaro Boulevard. This move resulted in an expansion from ten to twenty-five beds.

Although the nurses training school closed in 1937, Douglass Hospital continued to expand. Through the assistance of a federal grant and donations from area citizens, civic groups, and churches, the Douglass Hospital again relocated, this time to a fifty bed facility at 3700 North 27th Street, on the campus of Western University.

As the segregation of area medical facilities declined during the post-World War II era, Douglass Hospital experienced a gradual decrease in patients and income. Through the 1950s and 1960s, a growing financial loss, combined with rapid and expensive advancements in technology, resulted in Douglass Hospital falling behind the development of other area medical facilities.

In 1975, the board of directors unveiled plans for a new $6.5 million hospital. This drew little community enthusiasm or support, however, and the plan was finally shelved. Douglass Hospital closed its doors permanently in 1977, and was razed in June of 1980.

Dr. Thompson, a true "horse and buggy doctor" in his early career, remained affiliated with Douglass Hospital for over fifty years. He died December 11, 1950. A memorial plaque in his honor placed in the hospital lobby described Dr. Thompson as, “An eminent pioneer physician of Kansas City, Kansas. First Chief of the Staff of Douglass Hospital, and a continuous and generous supporter of the Hospital throughout his life. An outstanding citizen and a Christian gentleman.

Douglass Hospital Kansas Collection University of Kansas Libraries

Nancy J. Hulston, University of Kansas Medical Center Archivist

The internship began with a tour of Clendening Library and its spectacular collection. Susan Case, Rare Books Librarian at Clendening, described the acquisition process required for many of the materials, including the Nightingale letters. Since a few of the Nightingale letters required conservation and preservation efforts prior to human handling, Ms. Case made an appointment with Nancy Hulston, University of Kansas Medical Center Archivist, to assess the documents for conservation needs.

Ms. Hulston provided a step-by-step overview of the preservation process required for the Nightingale letters, and demonstrated the conservation activities of cleaning, mending, and deacidifying the documents. The final step in the preservation process involved encapsulating each page in Melinex 516, a chemically inert polyester plastic. Each page was placed between two melinex sheets before being ultrasonically sealed around the edges.

Much to my surprise, after demonstrating this process on two of the letters, Ms. Hulston allowed me to preserve the remaining three letters under her supervision. I have never handled a spray bottle more carefully or a cotton swab so delicately!

With the letters protected from human handling, the next step was to scan the letters. A Umax 1600 three-pass scanner and Adobe Photoshop software were used to create jpeg images at 72 dots per inch (dpi). These images became the centerpieces of the HTML (hypertext markup language) documents which comprise the World Wide Web exhibit of the Nightingale letters.

Each Web page displays the image beside the transcription of the letter. Every attempt was made to align each line in the transcription to each line in the letter, thereby allowing the viewer an uninterrupted look at the letter. Many of the pages also include footnotes to provide supplemental information to the viewer. The outstanding resources of the Clendening Library were consulted for the majority of the footnote information. A new home page (http://www.kumc.edu/service/clendening/florence/florence.html) was created for the exhibit after the completion of several letters. The new page includes links to alphabetical and chronological listings of the letters. These lists include the name of the recipient, date of the letter, a brief summary of the letter’s content, and links to the first page of each letter. The new home page also offers links to resources by or about Miss Nightingale held by the Clendening Library. There is also a link to other Nightingale resources (sound file, portraits, letters) on the Web. The internship is formally over, but work continues on the exhibit and it expands weekly. The richness of this experience fulfilled this amateur historian’s dream of working with primary documents, and brought to life a complex woman whose contributions to nursing are well known. Perhaps not as well known are her contributions to public health, education, and statistics. These less documented, wide ranging areas of Miss Nightingale’s life provide a glimpse of a rare woman who defied her prescribed role in Victorian England. The world is surely a better place for this act of defiance which Miss Nightingale simply referred to as her "calling".

Kelly Brown Reference Librarian-Dykes Library

SUMMER FELLOWSHIPS AWARDED

Kris Canfield
History and Ethics of Medicine: What were the principles medical conduct for Puritan physicians and what were the responsibilities of their patients?

C.W. David Chang
Chinese traditional medicine, medical philosophy, coexistence of traditional and modern medicine.

Gloria Cheng
Directions of Health Care in a Biracial Community, coexistence of Eastern and Western Medicine.

Matthew Flaherty
Evolution of the curriculum of the University of Kansas School of Medicine and its relation to current medical practices.

Matthew Joslyn
Quality Control in the Medical Industry: With Special Interest in Medical School’s Evaluation of Students.

William Park
Ethics and Transplantation.

Christina Stephan
Ethical and economic considerations for "covered life" physician compensation plans.

Michael Stevenson
Use of urine as a diagnostic tool in the Middle Ages and early Renaissance.

Stephen Thies
Ethical role of family practitioners, specifically dealing with patients suffering from anxiety and depression.

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