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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 • “ 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), racebased 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) 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, 18701920 • 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 to Operating 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-Mayo Arthur 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