Blocked Impulses: Myasthenia Gravis, the Prostigmin Test, and Diagnostic Legitimacy in the American Hospital

As scholars such as Charles Rosenberg and Keith Wailoo have noted, the modern American hospital functions as a space where disease categories are produced and negotiated. While the relations between disease categories and dominant power structures have received much historical attention, little research has explored how the everyday realities of hospital practice shape notions of biomedical legitimacy for both patients and practitioners, or considered the role of clinical tests in constituting diagnostic spaces, forms of practice, and patient experiences within the medicalized spaces of the American hospital. Using physician-patient correspondence, social services reports, and published medical literature, drawn primarily from the Henry Viets collection, this paper will examine the negotiation of myasthenia gravis as a legitimate disease category at the Massachusetts General Hospital’s Myasthenia Gravis Clinic from the 1930s through the 1950s and the role of the academic research clinic in relation to the space of the hospital as an institution of patient care. In the late 1930s and 1940s, myasthenia gravis was understood as a disorder of abnormal fatigability, whose characteristic neuromuscular block distinguished it from “nervous conditions.” Focusing on the adoption of the prostigmin test for defining “true cases” of myasthenia gravis, I argue that, as economic circumstances demanded that the clinic delimit its patient population to manage the costs of expensive medicine, the prostigmin test, the Myasthenia Gravis Clinic, and the identity of myasthenia gravis came to mutually constitute one another, with the test legitimizing some patient voices over others and eventually coming to stand in for the kinds of patients who would be served in the clinic space. By examining the relationships between power, diagnostic categories, and spaces of authoritative knowledge production, this paper forms an important contribution to both the history of disease and the emerging historical geography of American medicine.