– by Janet Lynne Golden, Professor Emerita at Rutgers University
I have always wanted to write about patients’ experiences of illness and ask how new diagnostic tools, treatments, and knowledge changed their daily lives. And I have always wanted to dig into the vast collection of patient records from the Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases (hereafter POH). My interest in the records began thanks to the late Larry McHenry, Jr., M.D. who had hoped to write a history of the POH, the nation’s first neurological hospital. The materials from the POH are a goldmine, and include administrative records and, more importantly, casebooks that document the experiences of patients being treated for a variety of ailments.
Founded shortly after the Civil War, the POH evolved into the workshop America’s leading neurologists. Among those affiliated with the POH were William Osler, S. Weir Mitchell, Wharton Sinkler, Charles W. Burr and W.W. Keen. They played a pivotal role in the founding and intellectual development of the field, producing a significant body of work that they shared with colleagues in the Philadelphia Neurological Society and the American Neurological Society and that they published in the leading professional publication– the Journal of Nervous and Mental Diseases–as well as in other important medical journals.
My graduate students had the opportunity to delve into the POH records decades ago, thanks to the support of then-librarian Ed Morman. I assigned them to “find a patient” and then find out everything about the individual, the disease as understood at the time, and the doctor treating the patient. The outstanding work the students produced made me want to explore into those materials myself. Now thirty-seven years after my first introduction to these archival materials, I’m finally getting to dig into them. Although COVID-19 related closures have stymied my work somewhat, I managed to collect some patient records before the shutdown.
I am studying individuals with a common bacterial infection: syphilis, from 1884 to 1917, when the United States entry into World War I changed public discussion of and responses to venereal diseases. The POH clinic records are of patients in the third stage of the disease and diagnosed with locomotor ataxia. This was not the most common diagnosis but a constant presence at the POH and other Philadelphia medical institutions.
The records provide a patient-centered account of syphilis. It is seen not through the lens of morality as late nineteenth century social hygiene activists would have wished, nor is it viewed as a sign of degeneration, as eugenicists would have proposed. It appears as a chronic, debilitating disease of the middle aged. The vast majority of patients were male, Euro-Americans, and many of them were immigrants or first generation citizens. Most held semi-skilled working class jobs and lived in Philadelphia. Charles B., a lithographer, said he had syphilis at age 20, and had taken six months of treatment at the time. At age 54 he came to the clinic having had to give up work. He had seen a number of doctors and taken medicine but his problems continued. At the clinic he was prescribed potassium iodide, and mercury, as well as special exercises. The physical symptoms that led patients to seek help included pain, difficulty walking, problems with elimination, and vision disturbances. Norman C., 55, reported having had a chancre twenty years earlier when he came to the clinic complaining of a muscular pains, stiffness in the legs, incontinence, and a loss of sexual function. Over eighteen months of visits he received prescriptions for potassium iodide and eventually Fowler’s Solution, an arsenic tonic. Individuals often came to the dispensary only a few times, but a small group came for years, had their prescriptions adjusted and continued to seek a help for a condition that could not be cured. Locomotor ataxia indicated a damaged spinal cord and nothing could be done to reverse the condition.
Diagnosis commenced with assistant physicians working in the clinic under the direction of staff physicians, most leading frequently S. Weir Mitchell, Wharton Sinkler, and Morris J. Lewis. The assistant doctors took a detailed history, including the patients’ personal and family medical history, symptoms, and the state of every organ in the body. They produced excellent records with fascinating details including reports on alcohol consumption, smoking, coffee and tea drinking, and other “habits,” such as “reading dime novels all the time.” The medical histories included lists of ailments unrelated to venereal disease such as “bullet in the head from being shot by husband.”
After taking the histories the patients were seen by the staff physician. The diagnosis of locomotor ataxia rested on three signs: Argyll-Robinson pupil, lack of a knee jerk, and motor impairments. In more than half the cases, the patients’ own recollections of earlier bouts of syphilis or the presence of a chancre offered confirmation. The case notes for the small number of female patients sometimes called it a “conjugal” infection. Contemporary social hygienists spoke of syphilis as a hidden, stigmatized condition; the patient records show many patients acknowledged their infections and recalled the year they contracted the disease. Did their acknowledgment suggest their faith in the clinicians, or was it, more likely, a sign that working class men and women did not view venereal infections the same way that middle and upper class patients and social moralists viewed them?
When the Wassermann test became available in the early twentieth century, the POH physicians used it to confirm, rather than establish, a diagnosis. After their initial visit, the patients were sent to the pathology department. The results of their initial test would be entered into the record in red ink. Returning patients would undergo periodic Wasserman or Nagouchi tests to see if they had been cured as indicated by a negative test.
Nearly all patients received prescriptions for potassium iodide drops with the dose being slowly increased over their course of their visits. Some also took mercury, either as an inunction or by mouth. Neither cured the condition, and both had serious side effects. Supportive therapies included common treatments for pain, constipation, and insomnia. When Salvarsan (arsphenamine), a medical breakthrough that became available, it would be given in the hospital. Other prescribed treatments included exercises, electricity, and, for a time, injections of Brown-Sequard fluid. New treatments did not replace old ones but were simply added to the list. Roger N, treated in 1913, had daily mercury inunctions, special exercises, and finally two treatments of neosalvarsan, which his chart noted he received “without any benefit.” Private hospital patients paid $5 for Wasserman tests, Salvarsan, and Neosalvarsan treatments. Clinic patients paid only $2.
Medical science brought syphilis patients new diagnostic tools and new treatments as well as new charges. It delivered periods of relief, although whether that resulted from the treatments or a placebo effect, is unclear and it brought them challenging side effects. It did very little to change their lives. When the United States entered World War I and venereal disease inspection of young soldiers led to cases being treated earlier in order to render individuals non-infectious. It led to an ever more aggressive conversation about and response to prostitution and to perceptions of syphilis as something that could be controlled through surveillance and treatment. However, the lives of POH patients would not change.