institution’s existence, allowing one to evaluate the validity of Call’s claim. For one, hospital records regularly included the patient’s occupation and nationality. In addition, the maternity wards recorded the patient’s marital status and the number of previous pregnancies and children. In 1877, the annual reports also began to include information on the financial status of the hospital’s patients: from 1877 to 1886 they o√ered data on the number of patients who paid full board, half board, or nothing at all. Beginning in 1887, they switched to calculating the number of free days compared with paid days.≥∂ Taken together, the reports suggest that the hospital did indeed attract a ‘‘better’’ class of individuals; at least they came from a slightly higher socioeconomic class than those who received care at either Massachusetts General or the Boston Lying-In Hospital, which reopened its doors in 1872.
This is evident, for example, from the data on the hospital’s charitable work.
Table 6 covers the years 1877–86, when the New England, Massachusetts General, and the Boston Lying-In all recorded the number of patients who received free care. Table 7 covers 1887 to 1893, when the New England switched to recording the number of free days (versus paid days).
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table 7. Percentage of Free Days at the New England Compared with Percentage of Charity Cases at Massachusetts General and the Boston Lying-In, 1887–1893
1887
1888
1889
1890
1891
1892
1893
Avg
neh
45.2
n.d.
43.2
52.7
52.5
49.9
52.3
49.3
bli
80.7
77.3
76.2
84.7
79.1
77.2
69.5
77.8
mgh
83.7
81.9
83.6
76.7
79.7
77.0
n.d.
80.4
Sources: Calculated from the annual reports of the New England Hospital, the Boston Lying-In Hospital, and Massachusetts General Hospital. See also Bowditch, History of the Massachusetts General Hospital, 702, and Vogel, ‘‘Patrons, Practitioners, and Patients,’’ 290.
Notes: The data for Massachusetts General are for its female patients alone.
See Table 6 for abbreviations.
It is clear from both tables that following its move to Roxbury the New England never served quite as poor a population as Massachusetts General or the Boston Lying-In. The contrast is, in fact, quite marked. And while the data from 1887 to 1893 must be used cautiously, since we are comparing free days at the New England with the numbers of patients who received free board at the other hospitals, it may very well be that the gap was even greater than indicated: between 1897 and 1901, when the New England provided information on both free days and the number of patients receiving free board, the former indicated a higher level of charitable care than the latter.≥∑
The claim that the patient population at the New England was somewhat better o√ than the populations at other Boston hospitals is further supported by an analysis of occupational structure. Table 8, which covers the years 1873 to 1894, demonstrates that the percentage of white-collar workers at the institution was, with the exception of 1873/74, higher than at Massachusetts General or Boston City Hospital. In addition, although the percentage of blue-collar workers dropped in all three institutions, the drop at the New England was more precipitous (down 40.4 percent compared with 32.7 percent for Massachusetts General and 32.5 percent for Boston City).
The shift in the makeup of the patient population is significant for several reasons. First, scholars who have studied the New England Hospital’s patient population have claimed that it di√ered little from what one would find at other private hospitals in Boston. This has been used to argue that any di√erences in medical practices between the hospitals would most likely be attributable to the
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table 8. Percentage of White- and Blue-Collar Patients at the New England, the Boston City Hospital, and Massachusetts General, 1873–1894
1873/74
1878
1883
1888
1893/94
neh-White
7.2
10.0
8.3
10.5
9.7
mgh-White
0.9
1.6
4.2
5.0
5.6
bch-White
9.2
4.3
5.3
3.8
6.1
neh-Blue
47.5
40.6
44.0
38.6
28.3
mgh-Blue
48.5
48.0
44.3
31.8
32.6
bch-Blue
54.4
57.1
55.8
43.1
36.7
Sources: For the New England Hospital, calculated from New England Hospital for Women and Children, Maternity Case Records [b ms b19.3], Surgical Case Records [b ms b19.1], and Medical Case Records [b ms b19.2], Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Mass. For Boston City Hospital and Massachusetts General Hospital, calculated from their annual reports.
Notes: The data in the first column are drawn from 1873 for the New England Hospital. Since Massachusetts General Hospital and the Boston City Hospital lack records for that year, the data were drawn from 1874 for those two institutions.
To determine whether an occupation was white collar or blue collar, I adapted the classifica-tion scheme Stephan Thernstrom developed for male occupations (see Other Bostonians, app. B).
Under white collar, both high and low, I included teachers, nurses, physicians, asylum attendants, saleswomen, governesses, proofreaders, actresses, bookkeepers, stenographers, journalists, musicians, ministers, writers, artists, peddlers, canvassers, librarians, printers, hotel keepers, clerks, photographers, managers, and cashiers. The remainder of the patient population consisted of blue-collar workers, housewives, children, those for whom no occupation was registered (unknown), and those who fell outside these categories, such as students.
bch = Boston City Hospital. For all other abbreviations, see Table 6.
gender of the physicians, since the other Boston hospitals had all-male medical sta√s. We will explore in greater detail in the next chapter the scholarly debate over whether any significant di√erences in practice actually existed. Of importance here is the realization that since the patient population at the New England came from a higher socioeconomic bracket, any di√erences in practice could just as easily be attributable to class as to gender. The issue remains, in other words, unresolved.≥∏
None of this is to suggest that the majority of the patients at the New England came from the monied classes. Nothing could have been further from the truth.
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Despite evidence of the kinds of changes that would ultimately transform the charity hospital into a middle-class institution, the New England Hospital in the last decades of the nineteenth century continued to cater to the poor. Still, all signs indicate that however poor these women may have been, they were somewhat better o√ than the women who sought care at Massachusetts General, Boston City Hospital, or the Boston Lying-In.
More directly, the changes in the patient population also signify Zakrzewska’s loss of interest in charity work. The dispensary, for example, which she had once described as the department where ‘‘the usefulness of the whole institution is called forth,’’ became for her
‘‘not merely centres where the ailments of the indigent are attended to, but . . . sources of instruction, giving the young practitioner chances for observation and investigation of diseases and their causes.’’ It also helped ‘‘to develop the manners as well as the ingenuity of the young physician.’’ The dispensary continued, of course, to carry on charitable work, adding, for example, a ‘‘Diet Kitchen’’ that provided ‘‘wholesome and strengthening food’’ to the sick poor. But what Zakrzewska cared about most were the educational opportunities it provided her students.≥π
In addition, the radicalism of the early years, as it pertained to the poor, was gone. The scrutiny of patients, for example, which had begun in the late 1860s, was intensified in the early 1880s when the New England Hospital turned to the Associated Charities of Boston for assistance in evaluating ‘‘the worthiness of applicants for help.’’ Founded in 1879, this organization set out to coordinate the city’s poor relief by establishing a registry of those receiving aid. The New England took advantage of this by requiring all applicants to ‘‘sign a statement, giving the name and address of some responsible person as reference.’’ This the hospital filed away so that, should a question arise concerning the patient’s financial situation, it could be submitted to the Associated Charities for investigation. The hospital’s dispensary physician believed that the new practice was deterring those ‘‘who might otherwise seek free medical aid, although able to pay a small fee,’’ but it is also possible that some individuals stayed away simply because they refused to be scrutinized in this way. Whatever the reason, the numbers of individuals seeking care dropped from a high of 5,235 in 1886, when the New England began requiring the signed statement, to 3,859 the year Zakrzewska retired.≥∫
The dispensary was not the only department that evinced signs of marked change. The maternity ward, which Zakrzewska had long promoted for its radicalism, also underwent a significant transformation. Shortly after its move,
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table 9. Percentage of Single Mothers in the New England’s Maternity Wards Compared with the Boston Lying-In, 1872–1897
1872
1873
1878
1883
1888
1893
1897
neh
55.2
45.5
29.5
46.4
26.4
22.9
19.1
bli
n.d.
n.d.
54.6
46.5
53.4
38.5
35.1
Sources: Calculated from New England Hospital for Women and Children, Maternity Case Records [b ms b19.3], Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Mass., and from Annual Reports of the Boston Lying-In Hospital.
Note: n.d. = no data. For all other abbreviations, see Table 6.
the hospital established a policy refusing to admit unwed mothers ‘‘a second time,’’ unless circumstances were deemed extenuating.≥Ω That this determination was occasionally made was evident in Table 1, which showed that four multiparae were admitted in 1883. Nevertheless, it is significant that the hospital decided to go on record as formally opposing the presence of second-time unwed mothers in its wards.
At the same time, the New England Hospital also prohibited ‘‘the admission of unmarried women upon the free beds.’’ Since single mothers were least likely to be able to a√ord the twenty dollars for a confinement, this could well explain the drop in the percentage of unwed mothers in the maternity wards from 55.2 percent in the year of the hospital’s move to 19.1 percent in 1897. As Table 9
indicates, this downward trend took place at the Boston Lying-In as well, but not quite as precipitously.
In 1891, the resident physician announced in the annual report that 111 of the 161 maternity patients that year were married. She went on to describe the two populations to which they now catered: married women who, because they were boarders, lacked proper care, and women who had their own homes but were ‘‘prevented by a family of young children or moderate circumstances from enjoying the quiet and freedom from responsibility that a hospital o√ers them.’’
Although 31.1 percent of the mothers that year were single, notably absent from this report is any mention of ‘‘unmarried women’’ who, as Zakrzewska had written in 1865, needed to be ‘‘saved from moral and physical ruin.’’ Indeed, by the year of her retirement, Zakrzewska had so changed that she could write to a board member about the hospital’s maternity cases: ‘‘I don’t care for the Charity & I don’t care for working in that line any longer, than what we do.
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That kind of work brings us not a step forward in the great evolution of women’s work in the profession.’’∂≠
. . .
The New England Hospital may have started out as an institution of charity, proudly promoting an image of itself as serving the poor and needy without regard to race, class, or marital status. Several decades later, however, that was not the public face Zakrzewska wished to present. The move to Roxbury had marked the turning point. While the hospital was in central Boston, it had embraced many of the goals she had spelled out in her 1863 lecture: small and homelike, it defined its mission in terms of the care it o√ered poor, immigrant, and frequently single women and mothers. In addition, in terms of rhetoric and to some degree policy, it displayed understanding for human frailty and respect for the poor. After the move, the hospital catered to a somewhat wealthier, definitely more American patient population, and new policies reflected a desire for greater scrutiny of those seeking charity. In the hospital reports, moreover, one read more often about the institution’s ability to provide safe and comfortable accommodations to all who needed care. To be sure, this continued to include the ‘‘poor, lonely wanderer, who know not where to lay her head,’’ but increased attention was paid as well to ‘‘the woman of wealth and refinement, who finds that intelligent ready service which money cannot always provide elsewhere.’’ Money could, however, guarantee service in the hospital: thirty dollars a week secured a private room and private nurse; twenty-five dollars a week, a private room and the half-time services of a nurse; fifteen dollars a week, a room with two beds; and ten dollars a week, a room with four beds. The level of care had become dependent on one’s ability to pay.∂∞
The dominant script in the annual reports of the 1870s and 1880s was not, however, the improved accommodations available to patients seeking care. Instead, one read much more frequently about the important inroads the institution was making in advancing the cause of women’s medical education. Certainly, this had been one of the central goals of the hospital from its inception, but in most of the early annual reports it had played second fiddle to the importance of the work being carried out in the name of charity. Not so in the annual reports following the hospital’s move to Roxbury. Rather, the focus came to rest on the hospital’s objective ‘‘to aid in the medical education of women by a√ording them opportunities for thorough clinical study.’’∂≤
Zakrzewska’s reasons for gradually abandoning the radical and charitable dimension of her institution can only be surmised, since she never addressed
THE HOSPITAL IN TRANSFORMATION
198 ≤
this change directly. We have already considered her growing disillusionment with treating the poorest of the poor, especially if they were Irish. It is also possible that by the time of their move to Roxbury, Zakrzewska and her board had no longer felt a need to fill this niche. Boston City Hospital had opened its doors in 1864 with the clear intent of catering to the city’s poor, and the Boston Lying-In reopened its doors in 1873, after a sixteen-year hiatus. With other alternatives to the almshouse now available for the ‘‘worthy poor,’’ Zakrzewska may have seen an opportunity to transform her creation into the kind
of institution she had always wanted. One need only recall that her first choice had been
‘‘a college primarily for women’’ but that she had been unable to generate enough funding to bring that to fruition.∂≥ By the early 1870s, however, there were su≈cient signs that women’s medical education was becoming more desirable. Not only were the number of all-women’s medical colleges increasing, but more and more medical institutions were opening their doors to women. Most noteworthy was the University of Michigan Medical School’s decision in 1870
to accept female students. Zakrzewska may very well have decided that she could now risk refocusing the hospital’s central mission on the pedagogical role that she had originally coveted.
Scientific Medicine at the
New England Hospital
Zakrzewska may have waited until the move to Roxbury to focus attention on the New England’s role as a teaching hospital, but she had been working to advance this cause from the outset. Disturbed by the persistence of barriers blocking women’s entry into the medical profession, she had envisioned an institution that would once again do its part to level the playing field, this time by providing opportunities for women both to acquire medical knowledge at the bedside and to showcase what they had learned. Zakrzewska, who was determined that her institution not be a failure, set out to create a hospital that would meet the standards of Boston’s elite medical community.∞ This translated into an emphasis on the practice and teaching of scientific medicine. Medical educators may not have agreed precisely on what scientific medicine entailed, and divisions may have been growing between those who drew inspiration from Paris and those who had begun to favor Germany.≤ But however scientific medicine was defined in the 1860s and 1870s, no one was yet building the large laboratories and research hospitals that were becoming part of the German university landscape. Indeed, the Johns Hopkins Medical School, which was modeled on the German university, was not founded until 1893. Thus, in the immediate postbellum period, those who sought to base clinical instruction on scientific medicine usually promoted smaller-scale practices such as autopsies; the charting of a patient’s temperature, pulse rate, and rate of respiration; and the chemical and microscopic analysis of bodily fluids. Most hospitals at the time did not, however, even go this far when they instructed students in
Science Has No Sex Page 29