But around the time of the French Revolution, medicine, like so much else, was changing. Doctors were beginning to believe that the best way to understand the body was to correlate their treatments with what happened to their patients. They started to keep careful records and perform autopsies on patients who died. Their records and their autopsies allowed them to relate the course of a disease to the dysfunction of internal organs, and to connect their physical examination of the living body to the pathophysiology they found inside the corpse. These were powerful innovations; they would provide much of the data for our bible, DeGowin & DeGowin. And the reason that the doctors of Revolutionary France suddenly wanted control of the Hôtel-Dieu in Paris was that the best “material” for their new approach was at the Hôtel-Dieu—the most varied patients, the most multitudinous, and the most compliant.
The doctors convinced the Revolution’s administration to remove control of the Hôtel-Dieu from the nuns and give it to them.
The nuns protested. They refused to serve under the doctors. The head nun at the Hôtel-Dieu had always come before the physician, they argued. The idea of using patients—Christ’s charges—as experimental objects was a murderous, a disastrous idea, they said. They were turned down, but step by step they went up the levels of administration. Finally they were ordered to leave the Hôtel-Dieu if they remained unwilling to obey the doctors. They did remain unwilling, and they also refused to leave. They declared that should workmen attempt to enter their wards to begin any alterations of the old structure, they would stand fast and prevent them.
With this, the administration buckled and rescinded its order, returning control of the Hôtel-Dieu to the nursing nuns. And there they remained for the next one hundred and fifty years, taking care of their patients until France secularized the institution in the early 1900s. Then the nuns left.
I don’t know if Miss Lester knew this story. Perhaps they teach it in nursing school. But I do know that she embodied the stubborn and passionate caring of those nuns at the Hôtel-Dieu, and that her suspicion of the medical profession in general, and modern medicine in specific, was to some extent justified.
The main thing was that Miss Lester was certain that good nursing was crucial for the healing of the patient. And good nursing meant nurses, especially a head nurse for each ward. She’d done everything she could to get her head nurses back. She’d gone all the way up the chain of command to the director of public health and then to the board of supervisors, complaining about the cuts. The director of public health defended his decision to follow Dee and Tee’s recommendations, and when asked he reassured the board that there’d been no cutbacks in bedside nursing; the staffing patterns were still above the standards in the industry.
So perhaps it was Miss Lester who called in the DOJ. The nuns of the Hôtel-Dieu certainly would have.
If it was Miss Lester who turned the hospital in to the Department of Justice and if her intention had been to reach past the new director of public health and get her head nurses back, then her plan went completely awry.
The Department of Justice arrived, and in its wake, still a second investigative agency, the Health Care Financing Administration, and suddenly there were teams of DOJ and HCFA doctors, nurses, and lawyers poring over our patients’ records. They questioned Dr. Major, the executive administrator, and Miss Lester in detail about everything, and perhaps it was those interrogations that convinced Miss Lester to resign. Or perhaps she realized that her head nurses were never coming back. At any rate, midway during the eighteen-month investigation, Miss Lester quit—in protest, she told the newspapers. She protested the cutting of her head nurses, with the consequent decline in nursing and inevitable danger to patients.
The city’s Health Commission accepted her resignation with regret. They issued a certificate of commendation and voted that the little animal farm be named after her, and so it was. And Miss Lester left Laguna Honda, six years shy of half a century of service.
It was just as well that she resigned before the eighteen-page letter of the Department of Justice appeared. Because the report blamed her nursing department for almost everything that the DOJ didn’t like about the hospital, except for its old-fashioned wards, which they didn’t like either. Their biggest issue was the physical facility. It didn’t meet the fire codes, the ventilation codes, or the earthquake codes; worst of all were the open wards, which violated patients’ right to privacy.
Now, most of us liked the open wards. The nurses liked them because in an open ward they could see all the patients all the time. If a patient fell, if a patient was in pain, if a patient was doing something dangerous, the nurse would see it immediately. We doctors liked the open wards because they were so inviting to stroll around, and they made it easy to talk to and evaluate patients. And patients liked them because the open wards were interesting and social, especially if a patient was bedbound. There was even a 1986 study done at the hospital in which 88 percent of the patients said they preferred the open ward to a private room.
Now and then, I did have a patient who suffered from the lack of privacy. But I had many more who turned down a private room with “Doc, don’t send me there; it’s too lonely.” And it was true: On an open ward it was easy for patients to make friends. There were many people to choose from, and they saw one another every day. Patients gossiped and traded information on the open wards; cliques formed. Occasionally the visiting family of one patient would adopt an orphan patient and bring in food for him, too. The privacy so valuable to the middle-aged and stressed, to the harassed investigator and the harried doctor, was not so valuable, it turned out, and even harmful to the bedridden and disabled.
But the DOJ would have none of it. There was no way the investigators could be convinced that the open wards were not “thirty-six-bed rooms” but big, open spaces, with lots of windows, sunlight, and fresh air. Or that the community the open wards fostered was more important than the privacy they lacked. The city must do something about the old hospital, the DOJ demanded: Either rebuild it according to twenty-first-century codes or close it down.
But the building was not their only problem with us. They’d discovered patients in the hospital who didn’t have to be there, who could be managed in the community, and this violated their civil right to be cared for in the least restrictive environment. So their second demand was that Laguna Honda immediately evaluate every patient and discharge any who could be managed outside the institution, whether the patient wanted to be discharged or not.
Last, the DOJ found numerous problems with the nursing department. Even while its investigators had been on-site, patients had wandered away without their nurses realizing they were gone. Other patients had smuggled in alcohol and drugs. When the nurses became aware of such incidents, the DOJ noted, they dealt with them on an ad hoc basis; there’d been no monitoring tools, no investigations, no committees. In general, the nurses lacked training; they did not always know the side effects of the medications they gave; some did not know what to do during resuscitation attempts, and the nursing policy-and-procedure manual was more than three years old.
All these problems had to be resolved, the eighteen-page DOJ letter ended, and quickly.
The mayor read their report and passed it to Dr. Stein, our new director of public health.
Dr. Stein was from New York, and he was young, energetic, and swarthy, with a five o’clock shadow even at seven AM. He wore a suit and tie to funerals and ribbon cuttings; otherwise he wore open-collared plaid shirts and Levi’s, with one cuff rolled up because he had no car and rode a bicycle. Dr. Stein was a problem solver, an optimist, and a good listener. He listened with an open face, a curved smile, and narrowed eyes. Later in his reign he was not quite as good a listener, although he was still optimistic.
The first thing he did with the DOJ report was to have us reevaluate every one of our 1,178 patients for discharge. It took us several weeks, and the DOJ turned out to be correct: There were patients who could be dischar
ged to the community. There were sixty. Twenty-five of them refused to be discharged, and another thirty had no place to go. But five patients were agreeable to discharge and did have a place to go and were discharged.
Next, Dr. Stein began studying his options for the old hospital. Should he close it down? Rebuild it? If a rebuild was in order, how big should it be and where should he put it? On the same hill where the city almshouse had always been? Or as many smaller facilities, scattered around the city? He spent the next year evaluating the different possibilities.
Last, he appointed a replacement for Miss Lester—Ellen Mary Flanders, RN, MSN, PhD-to-be—and he bicycled over to make the announcement. Ellen Mary, he told us at the meeting, was an outstanding administrator, highly regarded for her commitment to consumer-focused care. We should all welcome her.
Scattered applause.
Ellen Mary got up for her acceptance speech. She could not have been more different from Miss Lester. She was petite and blond and dressed in a gray skirt-suit, stockings, and pumps. She wore a bouffant hairdo and expensive-looking earrings, and she smiled widely; she spoke in a warm Southern drawl. She was impressed by the hospital, she said, and excited at the prospect of bringing it into the twenty-first century. And then, perhaps to emphasize how very different her New Nursing was going to be from Miss Lester’s Old Nursing, she told us to call her Ellen Mary.
The first thing Ellen Mary did was to move the Department of Nursing out of Miss Lester’s rooms in the back of the hospital into the administration wing at the front. It was quieter there, more peaceful, and completely out of the way of ambulances, doctors, and patients. She had the old-fashioned suites redecorated in taupes, with cream carpets, blond Danish desks, and new computers, and she brought over from the County many of her coworkers, who were also pleasant and ambitious nurses. Finally she sat down to analyze the DOJ report. What was needed, she concluded, were new forms, new committees, and new training for the nurses.
So she and her new staff began devising forms, creating committees, and setting up the new Nursing Department of Training and Education. They staffed the new committees with the best nurses from the wards and required everyone to attend their newly developed PowerPoint presentations and online training sessions. Since the budget was tight, they could make little provision for substitute nurses during these forced absences, however, and patients ended up getting less nursing care.
It took the new nursing administration quite a bit of time, but eventually they had a form for just about everything and a committee, too. Now when a patient disappeared from the hospital, there was an appropriate form to fill out—the patient disappearance form—and an appropriate committee—the patient disappearance committee—to send it to. When a patient fell, there was the fall form and the fall committee; when a patient got a bedsore, or was caught using drugs, there were specific forms. If bedrails had to be pulled up to prevent a patient from falling out of bed, there was a form, and there was a form whenever a psychiatric medication was instituted or even changed. There were so many forms that the charts began to explode, and every six months all the doctors’ notes were taken out of the charts to make room for the forms.
Despite the perennial budget crisis, Ellen Mary was even able to hire enough managers to oversee her new bureaucracy. We would see them sometimes in their dark suits and shiny shoes, looking through our patients’ charts.
Unlike Miss Lester, Ellen Mary did not visit the wards daily, weekly, or even monthly. She didn’t have to. There was a form for that also—the daily report, which listed all the rapscallion activities—the drinking, falling, and wandering away—that continued, of course, to take place. Although I didn’t find the nurses any better trained or educated with all their new training and education, it didn’t seem to hurt them. Mostly they kept their common sense. They did pay more attention to whatever required a form, and what with all the forms and committees, they did spend less time with their patients. That was all I noticed, except that I kind of missed Miss Lester and her early-morning parade.
It was a time of change at the hospital, and I felt lucky to have my study of Hildegard and premodern medicine as a refuge and a bulwark.
By this time I’d finished the requirements for my PhD and condensed my master’s thesis into an article, and I was exploring new ways of thinking about Hildegard’s medicine. I spent months in libraries. Before those months, if I’d been asked how many medieval books had survived the Middle Ages, I would have guessed a few hundred. But there were thousands, I discovered.
All of them were originally published as handwritten manuscripts, the printing press not yet having been invented, and the important manuscripts were often “illuminated” with miniature paintings inside the initials that began each chapter. Despite their being painted with plant-derived inks—saffron, buckthorn, indigo—when I opened those manuscripts in the library, I was amazed to see that their thousand-year-old illuminations had not faded. The figures inside the tiny paintings were bright and lively; the red of a doctor’s hat, the blue of a pilgrim’s cloak, the yellow of a girl’s hair popped right off the page. There were thousands of such illuminations, it turned out, and they portrayed just about everything: women in their kitchens, gardeners in their gardens, doctors with their patients. They were snapshots of life in the Middle Ages, and looking at them, I felt the chasm between us, the sense of otherness, disappear.
Hildegard did not have illuminations in her medical text, but she did have them in her three most important books, which were theological texts based on complex visions that Hildegard had had since she was a girl. We don’t know what those visions were, physiologically speaking. Some physicians think they were the auras of migraines, auras being the scintillating visual images that sometimes precede the migraine headache. Other physicians speculate that her visions may have been epileptic phenomena. But whatever they were, they transformed Hildegard from a timid nun into a confident and determined woman, and in her theological books she had paintings made of each one. Copies of these illuminations still exist, and they are beautiful, complex, and odd, with the feeling tone of dreams. When I discovered them, I was amazed not only at their beauty, but at how much they could tell me about Hildegard and her world.
There was even a picture of Hildegard herself, painted while she was alive. It was not true to life, but it did reveal quite a bit about her—about how she saw herself, and wanted to be seen. Dressed in the black Benedictine habit, she was sitting inside her church at a writing table. Her feet rested on a stool, and she held a quill. Her long hair was covered; flames descended from the sky to her forehead, and her friend and secretary, the monk Volmar, looked at her in amazement.
But my favorite of her illuminations was Vision Three of her first book, Scivias, because it illustrated the System of the Fours. Painted in gold and blue, it was shaped like a pointed oval, with sun, moon, and planets all in a vertical line at the top. This signified their conjunction, and portrayed the moment that God created the world. Outside the oval were flames; inside the flames was the night sky with its stars; this illustrated the element of Fire. In the middle of the oval was the round earth, which illustrated the element of Earth. Between Fire and Earth was the element of Water, represented by wisps of rain clouds in the sky. Last was the fourth element, Air, represented by the North, South, East, and West winds at each corner of the painting. These winds were the motive power of the universe, Hildegard explained: They were how the four qualities of hot and cold and wet and dry changed into one another as the cosmos turned around the earth and created the seasons.
It was a beautiful, unifying image, and though I didn’t know it at the time, it would be my key to Hildegard’s medicine, and to premodern medicine, too.
The trove of medieval books I was discovering in the library protected me somewhat from the stress in the hospital, but outside the admitting ward it was tense; it was chaotic; I could tell by the fatigue in Dr. Major’s face. Inside the admitting ward, however, things were
going on about the same. Dr. Fintner and I continued to share patients; Dr. Romero continued to do her thorough workups; the well-tempered Dr. Jeffers continued to accept whatever happened with a smile. Not that the admitting ward was easy or peaceful, ever. What the admitting ward was, was hectic and a lot of work, but it was always interesting.
The day I met Mrs. Klara Muller, for example.
Since I’d admitted the last patient of the day before, Dr. Jeffers would be getting the first patient who came in. I’d already walked around the ward that morning and seen my patients, and I was sitting at my rickety desk when an ambulance pulled up. I watched as the drivers went round to the rear, opened up the double doors, climbed in, and wheeled out Dr. Jeffers’s next patient. He was flat on his back, strapped to the gurney. A bit later the drivers trundled past the open door of our doctors’ office with the gurney, and Dr. Jeffers unfurled his long legs, put on his white coat, and went out to greet his new patient. I went back to my work.
But a few minutes later I heard running, and then Dr. Jeffers popped his head into the office.
“Victoria! He’s escaped! My new patient! He ran outside, and he’s out in the parking lot. Help me get him back!”
I jumped up and we ran out together past Dr. Major, who joined us, and out into the parking lot. Then we stopped, and Dr. Jeffers scanned the area.
“What happened?” I asked.
“My new patient. He’s got Huntington’s disease, and his mother couldn’t handle him anymore. He’s demented, but still young and strong, and as soon as he was unstrapped from the ambulance gurney, he took off. There he is!”
And there in the trees on the forested hill across the parking lot was Mr. X.—tall and slim, trim and alert, arms flailing about, and alternating his weight from leg to leg in the characteristic dance of Huntington’s disease. He was standing in the trees and looking around for some escape like, I am sorry to say, a hunted animal. Which he was.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 12