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Hospitals and Surgeons

Hospitals and Surgeons. The American Hospital. 1750-1920 1870 < 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

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Hospitals and Surgeons

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  1. Hospitals and Surgeons

  2. The American Hospital 1750-1920 1870 < 200 hospitals in U.S. 1927 ~ 7000 hospitals in U.S.

  3. 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.”

  4. Why not a medical hospital? • Concepts of disease and therapy • Nature of nursing • Nature of technology

  5. 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

  6. 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

  7. 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 Charity 5 resort hospitals -- our home on the hill 6 regional – municipal gospel hospitals (1890-1920) 7 almshouse 8 public sanatoria 9 RR and industrial (mining hospitals)

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. From kitchen tables to Operating rooms Both images courtesy of the National Library of Medicine, National Institutes of Health.

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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….

  19. 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

  20. 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

  21. 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)

  22. 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

  23. 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

  24. Credits Slide 13 • Surgery on a kitchen table. In the public domain. Accessed from http://www.nlm.nih.gov/exhibition/cesarean/images/abdsurgery.jpg on August 4, 2010. • Hospital operating room. In the public domain. Accessed from http://www.nlm.nih.gov/exhibition/aframsurgeons/images/douglass2.jpg on August 5, 2010. Slide 15 • Chloroform inhaler. In the public domain. Accessed from http://www.nlm.nih.gov/ on August 5, 2010. Slide 19 • Photo of W.W. Mayo. In the public domain. Accessed from http://commons.wikimedia.org/wiki/File:William_Worrall_Mayo.jpg on August 5, 2010.

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