Post on 04-Jan-2016
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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