Hospitals and Surgeons

The American Hospital

1750-19201870 < 200 hospitals in U.S.

1927 ~ 7000 hospitals in U.S.

The Voluntary Hospital – to 1870

• “ this is city desperately needs a hospital”• New York, Philadelphia

• “ perish the thought that I or my family should ever be admitted to this place of death.”

Why not a medical hospital?

• Concepts of disease and therapy• Nature of nursing• Nature of technology

The voluntary hospital

• Purpose• The worthy poor – the Civilizing Mission of the Children’s hospital

– the alternative to the almshouse and the problem of pauperization

• No chronic disease (tb), no infectious disease (typhus, small pox), no terminal disease (cancer)

• Temporary, curable conditions (heart, respiratory, digestive)• Ornament of charity, lure for physicians• Mainly free (+ sailors, the paying mad)• The Carceratorial Hospital – Walled anarchy

Managed care in the voluntary hospital– the hospital as home

• The board of governors (churchwardens)• The privilege to recommend• Oversight of finances

• The master & matron (mom and dad)• The medical staff (friendly uncles)

• Consultants• Senior attending staff (admitting privileges)• House staff (interns, externs and later [c 1900] residents)• Students• Nurse, admitting officer, and apothecary

Varieties of Hospitals (after 1870)1 voluntary hospital (the Pennsylvania; Boston childrens)2 municipal hospital (Bellvue, epidemics, sailors, lying-in, VD)3 specialist and proprietary hospitals (c 1890-1920), including surgical

(Hertzler’shospital)4 Catholic (from 1849, St. Vincent’s), Jewish, ethnic (St. Francis’s, 1865), race-

based hospitals – Sisters of Charity5 resort hospitals -- our home on the hill6 regional – municipal gospel hospitals (1890-1920)7 almshouse8 public sanatoria9 RR and industrial (mining hospitals)

Hospitals vs dispensaries

• Hospital: inpatient, long term, high prestige, mainly male, after 1850, site of surgery – rise after 1870

• Dispensary: outpatient or in-home; oriented toward pharmacy, mainly women, children, site of social activism -- decline after 1920

• The current fate of the dispensary

The triumph of the hospital, 1870-1920

• Surgery– Anesthesia, antisepsis, asepsis

• Nursing– Civilizing Nightingale– The conquest of nurse autonomy

• Admitting privileges– Not just another form of primary care (1870 <2%; 1905 c.

10 %; 1927 52%)– You too can collect fees in the hospital

• RESULT: PEOPLE PAY

The fall of the dispensary, c 1920

• Imputations of socialism• settlement house – social worker professionalization

issues• Competition with general practice

– Irv Watters’ views• Lack of specialized services, technology• Development of other training means• Dissociation with science and control• Short life of Sheppard- Towner 1921-9

– Opposition of AMA

The issue of the Catholic Hospital

• Conversion concerns; evangelical concerns• Entrepreneurial sisters – supply side, finding

clients • Sacramental power• Ethnic identity• Middle class dignity – the paying hospital• The bargain with the surgeons

Changes in surgery

• The classic problems of surgery– Pain– Infection– Hemorrhage

• C. 1850 25% surgical mortality good• Inevitable infection – laudable pus• The problem of surgical cleanliness as a

problem of materials- steel and chemistry

From kitchen tables toOperating rooms

Both images courtesy of the National Library of Medicine, National Institutes of Health.

The Emergence of American Surgery

• Europe: surgeons, physicians, overlapping, independent (Dr. or Mr.)– The Irish case

• America: Who Gets to Cut?– The problem of fee-splitting

• From medical to surgical appendectomy

Pain• Pre 1842, pain as good; earlier use of narcotics

(opium, marijuana, henbane, wine)• 1810s -- NO, ether --

– recreational drugs• 1842 – Crawford Long, ether• 1844 – Wells/Morton NO/ ether• 1846 – John Collins Warren• 1846 – use of chloroform: problem of ethics :

suffering vs. life; pain in birth

Image courtesy of National Library of Medicine, National Institutes of Health

infection

• Healing by 1st intention – the problem of closing the wound

• Healing by 2nd intention – dressing the wound– Laudible pus– Ichorous pus

• Lister, late 1860s – antiseptic surgery• Early 1880s – germ free surgery

Crossing the membranes

• Arachnid, peritoneum, pleural • From inflammation of the bowels to appendectomy,

c. 1886 (Hall, Fitz): 1st 24 hrs. • 1900 25% of all surgeries in Atlanta• St. Mary’s Rochester

– 1900 186 appendectomies– 1905 > 1000 “

• 1890: exploratory abdominal surgery – if unsure, go in. If maybe cancer go in

Surgery and Society

• J. Marion Sims and vesicovaginal fistula, 1852; the 30th operation – silver suture– 1845: Anarcha, Betsy, and Lucy– No anesthesia, filthy rags: African-American

women bear pain better….

W. W. Mayo (1819-1911)• Chemist, Manchester England, to US• Pharmacist, Bellvue, Buffalo, late 1840s• Tailor, Lafayette, In, 1848-9• Indiana College of Medicine, 1850• To Minnesota, via Missouri, 1854,

– iron range mine claim inspector• Practice LeSueur, 1856

• Farmer, boatman, judge, editor-publisher• Draft board doctor, Rochester, MN, 1863

– Practice evolves toward surgery• Hospital founder following 1883 tornado

– St. Mary’s, 1889; leads ultimately to group practice of Mayo Clinic (run by sons Will and Charlie)

Image: http://commons.wikimedia.org/wiki/File:William_Worrall_Mayo.jpg

Surgery as the cash cow

• 1880: WW Mayo: a life in debt– No bookeeping, no fees– Sliding scale

• 1900 Halsted, Kelly, $10000/operation• C. 1916 Mayos millionaires

Gynecological surgery

• 1905 laprectomy/hysterectomy common– “they went a little wild and were inclined to find in

hysterectormy a panacea for all the ills of women” Clapesattle, 188

– “it was only a step from removing the ovaries for tumor to removing them for pain in menstruation, and then for various nervous symptoms that baffled physicians” (189)

Other Mayo surgery

• Even quiet ulcers aren’t cured– 75% require surgery

• Gastroenterostomy: bowel bypass• Abdominal surgery: ST. Mary’s hospital

– 1890-3=54, 1900=612, 1905=2157 • Adenoid-tonsil removal

– 1890 = 5, 1900=100

The anti-MayoArthur Hertzler 1870-1946

• MD Northwestern, 1894; practice Halsted KS• Interest in surgery, surgical pathology:

• 1899-1901 postgraduate study in pathology – Berlin• 1901 prof. Pathology, UMissouri, KC, 1907 prof. Surgery U of KS

med school• C. 1905 founder of Halsted hospital and Hertzler clinic

– Max operation fee $150

• 1938 The Horse and Buggy Doctor• 1942 The Doctor and his Patients