Diagnosis and authority in the early twentieth-century medical practice of Richard C. Cabot

Bulletin of the History of Medicine

Volumn 76, Issue 1, 2002, Pages 30-35

  Crenner, Christopher ^a  

^a NONE

Author keywords

Alfred Worcester; Diagnosis; Doctor patient relationship; Francis W. Peabody; Medical authority; Medical practice; Medical technology; Richard C. Cabot; Twentieth century Boston

Indexed keywords

ARTICLE; CLINICAL COMPETENCE; DIAGNOSIS; DOCTOR PATIENT RELATION; HISTORY; HUMAN; MEDICAL RECORD; UNITED STATES;

CLINICAL COMPETENCE; DIAGNOSIS; HISTORY, 20TH CENTURY; HUMANS; MEDICAL RECORDS; PHYSICIAN-PATIENT RELATIONS; UNITED STATES;

EID: 0036518598     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (137)

1. JDS to Richard Clarke Cabot (RCC), 23 February 1939, tipped into vol. 34, p. 70, Patient Records, Richard Clarke Cabot Papers, Harvard University Archives, Cambridge, Massachusetts (hereafter cited as PR 34:70). In accordance with the restrictions placed on this collection, individual patients will remain anonymous.
2. Roger Lee, Report, 29 May 1919, tipped into PR 34:70.
3. See examples relevant to diagnosis in an earlier period in Malcolm Nicolson, "The Art of Diagnosis and the Five Senses," in Companion Encyclopedia of the History of Medicine, William F. Dynum and Roy Porter (London: Routledge, 1993), 2: 801-25.
4. James B. Herrick, "Modern Diagnosis: The Second Alpha Omega Alpha Annual Lecture," JAMA, 1929, 92 (7): 518-22 (address given 14June 1928), quotation on p. 518.
5. See Stanley Joel Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978);
6. Joel Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995);
7. both examine principally diagnostic technology, documenting its spreading use and contested acceptance by physicians. Focused on blood disease, Keith Wailoo examines interactions between new diagnostic technology and disease definition in Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997).
8. For the general historical problems of disease definition see the essays in Framing Disease: Studies in Cultural History, ed. Charles E. Rosenberg and Janet Golden (New Brunswick: Rutgers University Press, 1992).
9. For a fascinating contrast in the deployment of diagnostic technologies within professional nursing see Margarete Sandelowski, Devices and Desires: Gender, Technology, and American Nursing (Chapel Hill, NC: University of North Carolina Press, 2000).
10. The significance of diagnosis as an organizing element of medical knowledge in the period is evident in Knud Faber, Nosography in Modern Internal Medicine (NewYork: P. B. Hoeber, 1923).
11. Compare Henry L. Eisner, "On the Value to the Physician of Modern Methods of Diagnosis," Boston Med. Surg. J., 1902, 146:101-8;
12. and editorial, "Laboratory Investigation and Its Effects on Clinical Diagnosis," JAMA, 1900, 35: 1679.
13. On the need for practical experience with diagnosis to balance textbook theories sec S. C. Gordon, "Common Sense in Medicine," Boston Med. Surg. J., 1891, 125: 233-36, 261-63.
14. On the need of scientific training in diagnostic methods for the practicing physician sec Victor C. Vaughan, "The Kind and Amount of Laboratory Work which Shall be Required in Our Medical Schools," Boston Med. Surg. J., 1892, 127: 212-14.
15. For several important issues in the meaning of diagnosis in medical practice see Barbara Sicherman, "The Uses of a Diagnosis: Doctors, Patients, and Neurasthenia," in Sickness and Health in America: Readings in the History of Medicine and Public Health, ed. Judith Walzer Leavitt and Ronald Numbers, 2d ed. (Madison: University of Wisconsin Press, 1985), pp. 22-35
16. (originally pub. in J. Hist. Med. & Allied So., 1977, 32: 33-54).
17. For the relation between expertise and authority in twentieth-century medicine I have found helpful Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and The Making of a Vast Industry (New York: Basic Books, 1982), pp. 134-44;
18. and Anthony Giddens, The Consequences of Modernity (Stanford: Stanford University Press, 1990), on expertise and trust, pp. 79-111.
19. For the changing significance of professional authority it is interesting to compare Eliot Freidson's two works, Professionalism: The Third Logic (Chicago: University of Chicago Press, 2001)
20. and Profession of Medicine: A Study of the Sociology of Applied Knowledge (New York: Dodd, Mead, 1970).
21. Thirty-six bound folio volumes and one folder of unbound leaves of Cabot's manuscript, private clinic records, 1896-1926, are set aside in a separate, restricted collection in Patient Records, Cabot Papers (PR).
22. Basic biographical information on Richard Cabot appears in Paul Dudley White, "Obituary, Richard Clarke Cabot, 1868-1939," New England J. Med., 1939, 220: 1049-52;
23. Robert Schuyler, ed., "Richard Clarke Cabot," Diet, of Amer. Biog, suppl. 2, pp. 83-85;
24. Ian S. Evison provides a valuable intellectual biography of Cabot focusing on his social reforms and including a thorough annotated bibliography, in "Pragmatism and Idealism in the Professions: The Case of Richard Clarke Cabot, 1869-1939" (Ph.D. diss., University of Chicago, 1995).
25. Cabot's founding role in the Clinicopathological Conference carried enough symbolic weight to bear celebrating in the pages of the New England Journal of Medicine in editor Robert E. Scully's
26. preface to the first Clinicopathological Conference of the new millennium: "Case Records of the Massachusetts General Hospital. Weekly Clinicopathological Exercises. Case 1-2000, A 27-year-old Man with a Painful Retroperitoneal Mass," New England J. Med., 2000, 342 (2): 115-22.
27. In 1903 Cabot sent out a form letter requesting that patients who had seen him previously report back about their health. An example of the letter asking for information "on the outcome of the illness for which I saw you" is found tipped in PR 2:58.
28. "Obituary: Alfred Worcester," JAMA, 1951, 147: 1292.
29. See the extended remarks on doctoring in Alfred Worcester, The Care of the Aged, the Dying, and the Dead (Baltimore: C. G. Thomas, 1935).
30. Worcester characterized his own private practice in Waltham, Mass., in a lengthy letter to Cabot when he was a medical student: A. Worcester to RCC, 23 November 1895, folder "Psychotherapy," box 71, Correspondence, Cabot Papers.
31. Alfred Worcester, "Past and Present Methods in the Practice of Medicine," Boston Med. Surg. J., 1912, 166:159-64; quotation on p. 162.
32. For a similarly spirited critique of the disease-model compare James Jackson Putnam, "Not the Disease Only Rut Also the Man," Boston Med. Surg. J., 1899, 141:53-57.
33. Worcester, "Past and Present Methods" (n. 12), p. 162.
34. Worcester, "Past and Present Methods", Ibid., p. 159.
35. Worcester, "Past and Present Methods", Ibid., p. 163.
36. Worcester, "Past and Present Methods", Ibid., p. 163.
37. Worcester, "Past and Present Methods", Ibid., p. 163.
38. Worcester, "Past and Present Methods" (n. 12), p. 163. Ibid.
39. Francis Weld Peabody, Doctor and Patient: Papers on the Relationship of the Physician to Men and Institutions (New York: Macmillan, 1930), pp. 27-57
40. (originally pub. as "The Care of the Patient," JAMA, March 1927, 55:877-82).
41. JAMA, Ibid., p. 23.
42. JAMA, Ibid., p. 36.
43. JAMA, Ibid., p. 52.
44. Cabot's recollections of the origins of the conferences appeared quoted in Frederic Washburn, The Massachusetts General Hospital: Its Development, 1900-1935 (Boston: Houghton Mifflin, 1939), pp. 115-17.
45. See an account of an earlier teaching version of the exercise in Richard Cabot, "A Case-History Clinic," Detroit Med. J., 1905, 5:6-13.
46. Later accounts of the conferences when they included the use of hidden autopsy results appeared in Richard C. Cabot and Russell L. Dicks, eds., The Art of Ministering to the Sick (New York: Macmillan, 1936), pp. 323-24.
47. See also Richard Cabot, "A Study of Mistaken Diagnoses Based on the Analysis of 1,000 Autopsies and a Comparison with the Clinical Findings," JAMA, 1910, 55 (16): 1343-50.
48. RCC to Frederic Washburn, 19 March 1915, Correspondence, box 16, folder "Letters from Cabot, 1908-1929," Cabot Papers.
49. Richard C. Cabot and Hugh Cabot, eds., "Ante-mortem and Post-mortem Records as Used in the Weekly Clinico-pathological Exercises. Case 10271," Boston Med. Surg. J., 1924, 191 (4): 30-34.
50. Manuscript Collection, Rare Books, Countway Medical Library, Boston, Mass. Cabot himself mentioned Shattuck's course in one account of the origins of the Clinicopathological Conference: Washburn, Massachusetts General Hospital (n. 23), pp. 115-17.
51. Cabot and Cabot, "Ante-mortem Records" (n. 25), p. 33.
52. Cabot and Cabot, "Ante-mortem Records" (n. 25), p. 33. Ibid.
53. On differential diagnosis see the examples in Richard Cabot, Case Teaching in Medicine: A Series of Graduated Exercises in the Differential Diagnosis, Prognosis and Treatment of Actual Cases of Disease (Boston: D. C. Heath, 1906).
54. For an independent contemporary discussion of differential diagnosis see, e.g., Glenworth Reeve Butler, The Diagnostics of Internal Medicine: A Clinical Treatise upon the Recognised Principles of Medical Diagnosis, 1st ed. (New York: Appleton, 1901).
55. The general endorsement of the value of differential diagnosis had a long tradition in American medicine: sec Austin Flint, A Practical Treatise on the Physical Exploration of the Chest, and the Diagnosis of Diseases Affecting the Respiratoty Organs, 2d ed., rev. (Philadelphia: H. C. Lea, 1866), p. 321, and example of the differential diagnosis of bronchitis on pp. 327-31.
56. Cabot, "Mistaken Diagnoses" (n. 23);
57. Cabot and Dicks, Art of Ministering (n. 23).
58. Remarks of Ida M. Cannon speaking at Memorial Seminar, transcript, 18 January 1958, folder "Cabot Seminar Papers," box "Memorial Seminar," Cabot Papers.
59. The bottom line of each record for a new patient's visit ended with an entry of the diagnosis. The last pages of each volume of records contained an index to the diagnoses on all new patients in that volume.
60. AW to RCC, June 1908, tipped into PR 2:58.
61. SFK to RCC, June 1008, tipped into PR I:149. The similar dates of this and the previous letter resulted from a general mailing that Cabot made to his patients in 1908. See n. 10.
62. AW to RCC, June 1908 (n. 33).
63. For considerations of Cabot's controversial role in debates over the disclosure of life-threatening diagnoses to patients, see Stanley Joel Reiser, "Words as Scalpels: Transmitting Evidence in the Clinical Dialogue," Ann. Intern. Med., 1980, 92 (6): 837-42;
64. Chester R. Burns, "Richard Clarke Cabot (1868-1939) and Reformation in American Medical Ethics," Bull. Hist. Med., 1977, 51: 353-68.
65. AMB to RCC, 24 May 1913, tipped into PR 25:40.
66. Ibid.
67. Ibid.
68. Department of Medical Records, Massachusetts General Hospital, Patient Records, selected volumes 1901 to 1920; examples are cited, alongside similar records from Hospital of the University of Pennsylvania and Johns Hopkins Hospital, in Christopher Crenner, "Professional Measurement: Quantifying Health and Disease in American Medical Practice, 1880-1920" (Ph.D. diss., Harvard University, 1993).
69. Entry of 5 September 1903, PR 2:268.
70. William Osier, The Principles and Practice of Medicine: Designed for the Use of Practitioners and Students of Medicine, 4th ed. (New York: D. Appleton, 1002), pp. 761-65.
71. Entry of 5 September 1903 (n. 41).
72. Entry of 15 May 1900, PR I:101.
73. Entry of 27 May 1900, ibid.
74. Entry of 1 August 1900, ibid.
75. FFP to RCC, June 1008, tipped into PR 2:79; AJP to RCC, 7 May 1902, tipped into PR 1:168.
76. LJF to RCC, June 1908, tipped into PR 2:209.
77. GHH to RCC, 20 January 1903, tipped into PR 2:163.
78. IRD to RCC, 31 December 1914, tipped into PR 1:65.
79. A more detailed discussion of classifying the occupational status of Cabot's patients may be found in Crenner, "Professional Measurement" (n. 40), pp. 138-39.
80. MHB to RCC, 8 April 1908, tipped into PR 9:157; cf. a similar request, CK to RCC, 2 January 1912, tipped into PR 15:23.
81. Notations of charges and payments appeared in the margins of the charts in many volumes: e.g., high fee of S200 in entry of 6 January 1908, PR 8:153.
82. Cabot also excused any charge to people in a small number of cases, noting "free" in the margin of the case: e.g., entry of 9 February 1910, PR 15:61.
83. Entries of 20 August 20 1897 and 25 February 1897, with unbound records, PR.
84. For example, entry of 21 August 1897, loose pages with unbound records, PR.
85. Cabot reflected on his own self-conscious anti-Semitism and its negative effects on his practice in foregrounds and Backgrounds in Work with the Sick (Boston: New England Hospital for Women and Children, 1906), unpaginated [pp. 1-3].
86. For contemporary observations on Boston's racial and ethnic categories, sec Willard De Lue, "The Contribution of the Newer Races," in Fifty Years of Boston: A Memorial Volume, ed. Elizabeth Herly (Boston: Tercentenary Committee, 1932);
87. and see a valuable interpretation of classification in Matthew Frye Jacobson, Whiteness of a Different Color: European Immigrants and the Alchemy of Race (Cambridge: Harvard University Press, 1998).
88. The examination of racial categories in clinical notes of the period is carefully considered in Elizabeth Limbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Princeton: Princeton University Press, 1994), pp. 98-99, 122-23.
89. Observations on Cabot's hierarchical social realm appear in Arthur Mann, Yankee Reformers in an Urban Age: Social Reform in Boston, 1880-1900 (Cambridge: Harvard University Press, 1954);
90. Frederic Cople Jaher, The Urban Establishment: Upper Strata in Boston, New York, Charleston, Chicago, and Los Angeles (Urbana: University of Illinois Press, 1982).
91. Cabot recalled that his first patients came from other physicians for whom he did blood testing: "Autobiographical Notes," p. 8,
92. Biographical Material, box 109, folder "Autobiographical Notes," Cabot Papers.
93. These texts proved popular, going through many editions over Cabot's career: Richard Cabot, Physical Diagnosis of Diseases of the Chest (New York: William Wood, 1900); 11th ed., 1934.
94. Richard Cabot, Idem, Differential Diagnosis, vol. 1 (Philadelphia: W. B. Saunders, 1911); vol. 2, 1914; 4th rev. ed., 1919.
95. For further analysis of referrals in Cabot's practice, see Crenner, "Professional Measurement" (n. 40), pp. 160-70.
96. See, for example, a case where other physicians "could not make a very definite diagnosis": Dr. P. A. Adamian to RCC, 17 February 1913, PR 24:61.
97. JJD to RCC, 10 March 1907, tipped into PR 6:37.
98. ALM to RCC, 15 December 1903, tipped into PR 2:249.
99. FEC to RCC, 23 June 1909, tipped into PR 11:5.
100. Entry of 23 April 1912, PR 18:20.
101. Entry of [August 1899], PR 1:47.
102. WBK to RCC, June 1908, tipped into PR 2:158.
103. Entry of September 1900, PR 1:150.
104. The woman died two years later carrying Cabot's diagnosis of breast cancer; Cabot saw her regularly over several years through the long illness: entry of January 1902, PR 1:219.
105. AW to RCC, June 1908 (n. 33); SFK to RCC, June 1908 (n. 34); AB to RCC, n.d., tipped into PR 1:114;JRM to RCC.,June 1908, tipped into PR 2:261; NLS to RCC, 25 January 1912, tipped into PR 18:82; NWL to RCC, 13 June 1908, tipped into PR 3:74; SHB to RCC, June 1908, tipped into PR 3:74.
106. MS to RCC, 28 June 1913, tipped into PR 18:92.
107. AW to RCC, June 1908 (n. 33); JRM to RCC, June 1908 (n. 69); AB to RCC, n.d. (n. 69).
108. NWL to RCC, 13 June 1908 (n. 69).
109. This distinction was not one named by patients, but draws on a valuable analysis articulated well in Owsei Temkin, "The Scientific Approach to Disease: Specific Entity and Individual Sickness," in idem, The Double Face of Janus and Other Essays in the History of Medicine (Baltimore:Johns Hopkins University Press, 1977), pp. 441-55.
110. ET to RCC, 21 October 1913, tipped into PR 26:37.
111. FJS to RCC, 27 October 1916, tipped into PR 32:96.
112. ET to RCC, 21 October 1913 (n. 74).
113. AMB to RCC, 1 February 1914, tipped into PR 25:40.
114. Richard Cabot, "Better Doctoring for Less Money," Amer. Mag., April 1916, 81:7-9, 77-78;
115. Richard Cabot, "Better Doctoring for Less Money," Amer. Mag., May 1916, 81:43-14, 76-79; quotation from May issue, pp. 77-78.
116. Cabot attracted the spirited support of many, both at the lime and subsequently, who have also seen this as a crucial, neglected problem for twentieth-century American medical practice; sec, e.g., unsigned letter to RCC, n.d., Falls River, Mass., Correspondence, box 35, folder A, Cabot Papers.
117. Sec the Preface on Doctors in George Bernard Shaw, The Doctor's Dilemma, Getting Married, and The Shewing Up of Blanco Posnet (New York: Brentano's, 1911);
118. Richard Cabot, "Doctor's Dilemma in Bernard Shaw and in Fact," Survey, 1911, 26:381-83.
119. See also R. C. Cabot, Letter to the Editor, JAMA, 1915, 64 (9): 762-63.
120. Richard Cabot, Social Work: Essays on the Meeting Ground of Doctor and Social Worker (Boston: Houghton, 1919), p. 98.
121. Entry of 6 January 1909, PR 11:105.
122. All first diagnoses for each volume of records appear indexed by page number at the end of the volume. I have examined the indexes for all volumes for each year from 1900 to 1915. A tabulation of all new-patient diagnoses by Cabot in 1915 showed approximately 7 percent with the notation "not ill"; the rate was about 6 percent of new cases for 1912-14.
123. See, for example, records for patients diagnosed as not ill in PR 16:71, 77, 89, 92, 101, 123, 149. Cabot generally included future visits with the same patient on the same page with the original visit. A notable exception was a man who had two completely negative evaluations separated by fifteen years: sec entries of 24 October 1899 and 7 October 1914, PR 1:65.
124. An exception can be found, for example, in the unusual case of a twenty-one-year-old woman who felt perfectly well but who was sent to Cabot by her physician under the pretext of getting a routine blood exam; her physician suspected that she had a serious heart condition, which she [sic] wanted Cabot to confirm without disclosing it: sec entry of 24 June 1912, PR 23:12; MWB to RCC, 23 June 1912, tipped into ibid.
125. Sec above, n. 82.
126. Readers familiar with Cabot's reform efforts in medical social work and counseling may find puzzling his strict disease-model of practice. He argued, for example, that the social and spiritual elements of the sick person's troubles were becoming too easily overlooked in the conventional medical practice of his time. He did not, however, lobby to extend directly the physician's influence over these elements; instead, his efforts to involve social workers, counselors, and clergy with medical care were premised on the understanding that physicians, in general, would restrict their attentions to the realm of disease.
127. Sec Cabot, Foregrounds and Backgrounds (n. 55);
128. Richard Cabot, "Social Work: The Diagnosis and Treatment of Character in Difficulty," Charities & Commons, 1902, 19:1001-10.
129. LMH to RCC, 1 August 1899, tipped into PR 1:31.
130. SAD to RCC, 14 January 1912, tipped into PR 15:18.
131. LL to RCC, 11 February 1913, tipped into PR 18:99.
132. Entry of 7 October 1914, PR 1:65; this later entry was added to the page from the initial visit of the same patient in 1900, as was Cabot's practice when his earlier notes were accessible at the lime of a later visit. A related account is in Patricia Spain Ward, "The Medical Brothers Cabot: Of Truth and Consequence," Harvard Med. Alum. Rev., 1982, 56 (4): 30-34.
133. Report, Massachusetts General Hospital, October 1914, tipped into PR 1:65.
134. IRD to RCC, 31 December 1914, ibid.
135. For an interesting survey of changing fortunes of twentieth-century medical authority, sec Allan M. Brandt and Martha Gardner, "The Golden Age of Medicine?" in Mediant in the Twentieth Century, ed. Roger Cooler and John Pickstone (Amsterdam: Harwood, 2000), pp. 21-37.
136. The general verdict of Cabot's peers might be summarized in the first line of Cabot's obituary by Paul Dudley White in the New England Journal of Mediane: "In every generation there are restless souls, who cannot be made to fit the common mold . . . keeping their communities and professions in a ferment by their constant challenge to the existing order" (White, "Obituary" [n. 9], p. 1019).
137. The obituary largely maintained the expected positive tone, though going so far at one point as to note Cabot's "militant bluntness and precipitate desire to correct the errors of the practice of medicine" (Paul Dudley White in the New England Journal of Mediane, ibid., p. 1051).