Transcript The American Hospital

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)
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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
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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
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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)
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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