Dr. Sweet's memoir, like her diagnoses of some of her patients, has multiple independet but interacting parts. In part it is about her work in San Francisco's Laguna Honda Hospital, a public facility which is a direct intellectual descendent of the medieval almshouse. The second part is her study of the medical writings of Hildegard of Bingen, a 12th century Germany nun(and abbess) better known for her mystical religious writings. The third strain, which appears towards the end of the book, is about how her experiences walking the Santiago de Compestela pilgrmage in Spain, changed her thinking. As the descendent of an almshouse, Laguna Honda is now a very rare institution in the United States. Basically it has served (this may change) as a free, public hospital for those with chronic conditions. The emphasis on caring for people who aren't likely to get better distinguishes Laguna Honda from the public county hospital in San Francisco, which is supposed to treat acute conditions, after which if need be the patients will be transferred to Laguna Honda. Although Laguna Honda does have many patients with drug abuse problems and mental illnesses, it is not set up (no locked wards, etc.) to deal with violent or severely mentally ill people
The characterization of Lunga Honda as a hospital for the chronically ill may not hold true in the future. In conjunction with the completion of a new building in the last couple of years, Laguna Honda may become a facility focusing on the mentally ill and homeless, though the new building was not designed with those patients in mind. Those patients who are not mentally ill or homeless are supposed to be speedily rehabilitated (see page 325, not doubt released to the community (which may very well mean released to a Single Room Occupancy hotel on skid row). It will certainly house fewer patients. Part of the reason for this change lies in the budget problems of San Francisco, which in additon to Laguna Hospital has a public county hospital and a mental health facility to fund. The lawsuits and investigation mentioned below also played a part.
Dr. Sweet ended up at Longa Honda because at the time it was the only place she could practice medicine part-time. She wanted to work part-time in order to carry out serious academic research on Hildegard of Bingen. Her interest in Hildegard was a result of an experience in medical school, where she witnessed the autopsy of a man who had been her patient. Something seemed missing in the autopsied body; that something was a soul. The experience got her to wondering if medicine had always been the mechanistic affair it now was. It may be relevant to note that Dr. Sweet had originally intended to be a psychiatrist, but ended her psychiatry residency early once it became clear to her that mental illness was now (and often very successfully) treated with drugs rather than the talk therapy of her hero Jung. She became an internist instead.
She did discover, though, that prior to (very roughly) the 19th century, medicine had not been a mechanistic endeavor and that concepts such as the soul were part of medicine. This interest is what got her to read Hildegard's medical work. Hildegard's thinking about medicine was pretty standard for the times; it revolved around what is sometimes called the system of fours. This system appears to be (there is a helpful diagram on page 181) a set of relationships between the seasons, the cardinal directions, the (medieval) elements, bodily humors, the patient's temperament, and 4 qualities, all of whch come in groups of four. The qualities are cold or hot, wet or dry. The bodily humors are blood, melancholia, bile, and phlegm. The four elements are air, fire, earth, and water. As an example of the associations among these moieties, spring is associated with ot and wet air, the dominant humor is blood, and the associated temperament is sanguine. The medieval practitioners goal was to bring the body into accord with patient's age and the season, through appropriate drugs and appropriate behaviors, such as the correct diet. To decide on the appropriate treatment, the doctor had to consider both the personality of the patient and the patient's environment. On the whole Dr. Sweet is happier with modern medicine, but does think some things have been lost.
Dr. Sweet worked in the admitting ward (now abolished in conjunction with the move to the new building; patients will now be admitted directly to the presumably relevant ward, oops I forgot the euphemism for ward is "neighborhood"), the dementia ward, and two complex medical wards. The dementia ward is what it sounds like; one thing I learned is that a diagnosis of Alzheimer's since the 1980s is at best an elimination of other possible causes of dementia and, more often than not, is simply the default description given to those suffering from dementia but who have not really been thoroughly examined to eliminate other possible causes. Before about 1980 Alzheimer's specifically meant a kind of dementia arising before old age. The medically complex wards were for those who had major medical problems and who could not, for other reasons, take care of themselves.
One of the things I learned from reading about Dr. Sweet's medical experiences was the benefits of giving a doctor the time to make a really thorough exam. In part because many of her patients had had chronic illnesses for a long time, a two-hour physical exam could tell you quite a lot about a patient without blood tests or imaging. I also learned that many patients are taking drugs they no longer need, largely because doctors generally continue prescriptions that their patients got from previous doctors. Dr. Sweet was often able to eliminate one-third or one-half of her patient's prescriptions. Nor were these prescriptions simply unneeded; often they were actively harmful.
The fate of Laguna Honda as an institution was bound up in two lawsuits (Davis and then Chambers) by disability-rights lawyers, a multi-year federal Department of Justice investigation, and money. What the disability-rights lawyers appear to have wanted was for everyone to be let out of the hospital and receive home care. In Dr. Sweet's view, the basic problem with this option was that money was an issue, and that, contrary to the plaintiff's claims, home care costs more because the increased medical expenses. The Department of Justice's complaints to some extent overlapped the claims in the lawsuits, and an elaborate but basically unsuccessful process was put into place to review which patients could be discharged; the number was much smaller than the Department wanted. Also, the Department, like most other outside observers, hated the open wards that housed most of the patients. The Department believed that the open wards were violation of the patients' rights to privacy. The Justice Department also noticed the drinking, illegal drug use, and sex that some of the patients were enjoying. The Department was correct that all of this was going on to some extent. However, I am puzzled that the Justice Department didn't consider the possibility that the increased privacy in the new building (patients basically has their own bedrooms, sharing a bathroom with 2 or 3 others) won't increase the amount of drinking, illegal drug use, and sex. Perhaps all the cameras in the new building (which would seem to me to be a violation of the patients' right to privacy) is supposed to prevent this, in conjunction with the fewer entrances and exits in the building. My hunch is that, unless the cameras cover every corner and unless every visitor is searched, the new building will lend itself to more drugs, alcohol, and sex.
I greatly enjoyed this book, which I thought was well-written. I first posted this review at Goodreads.com
