Lecture Eight: Hospitals and Surgeons

 The American Hospital (1750-1920)

1. 1870: < 200 hospitals
2. 1927: ~7,000 hospitals

The Voluntary Hospital to 1870

1. "this city desperately needs a hospital"
   • New York, Philadelphia
2. "perish the thought that I or my family should ever be admitted to this place of death"

Why not a medical hospital?

1. Concepts of disease and therapy
2. Nature of nursing
3. Nature of technology

The Voluntary Hospital - Purpose

1. The worthy poor; the Civilizing Mission of the Children's hospital; the alternative to the almshouse and the problem of pauperization
2. No chronic disease (tuberculosis), no infectious disease (typhus, smallpox), no terminal disease (cancer)
3. Temporary, curable conditions (heart, respiratory, digestive)
4. Ornament of charity, lure for physicians
5. Mainly free (+ sailors, the paying mad)
6. The Carceratorial Hospital - walled anarchy

Managed Care in the Voluntary Hospital: the hospital as home

1. The board of governors (churchwardens)
   • The privilege to recommend
   • Oversight of finances
2. The master and matron (mom and dad)
3. The medical staff (friendly uncles)
   • Consultants
   • Senior attending staff (admitting privileges)
   • House staff (interns, extern, and later [c. 1900] residents)
   • Students
   • Nurse, admitting officer, and apothecary

Varieties of Hospitals after 1870

1. Voluntary hospital (the Pennsylvania; Boston Children's)
2. Municipal hospital (Bellevue, epidemics, sailors, lying-in, VD)
3. Specialist and proprietary hospitals (c. 1890-1920), including surgical (Hertzler's hospital)
4. Catholic (from 1849, St. Vincent's), Jewish, ethnic (St. Francis', 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)

Hospitals vs. Dispensaries

1. Hospital: inpatient, long-term, high prestige, mainly male, after 1850, site of surgery -- rise after 1870
2. Dispensary: outpatient or in-home, oriented toward pharmacy, mainly women, children, site of social activism -- decline after 1920
3. The current fate of the dispensary

The Triumph of the Hospital, 1870-1920

1. Surgery
   • Anesthesia, antisepsis, asepsis
2. Nursing
   • Civilizing Nightingale
   • The conquest of nurse autonomy
3. Admitting privileges
   • Not just another form of primary care (1870: <2%; 1905: ~10%; 1927: 52%)
   • You too can collect fees in the hospital
4. Result: People pay

The Fall of the Dispensary, ~1920

1. Imputations of socialism
2. Settlement house - social worker, professionalization issues
3. Competition with general practice - Irv Watters' views
4. Lack of specialized services, technology
5. Development of other training means
6. Dissociation with science and control
7. Short life of Sheppard-Towner 1921-1929; Opposition of AMA

The Issue of the Catholic Hospital

1. Conversion concers; evangelical concerns
2. Entrepreneurial sisters - supply side, finding clients
3. Sacramental power
4. Ethnic identity
5. Middle-class dignity - the paying hospital
6. The bargain with the surgeons

Changes in Surgery

1. The classic problems of surgery
   • Pain
   • Infection
   • Hemorrhage
2. ~1850: 25% surgical mortality good
3. Inevitable infection - laudable pus
4. The problem of surgical cleanliness as a problem of materials - steel and chemistry

The Emergence of American surgery

1. Europe: surgeons, physicians, overlapping, independent (Dr. or Mr.)
   • The Irish case
2. America: Who gets to cut?
   • The problem of fee-splitting
3. From medical to surgical appendectomy

Pain

1. Pre-1842: pain as good; earlier use of narcotics (opium, marijuana, henbane, wine)
2. 1810s: NO, ether
   • recreational drugs
3. 1842: Crawford Long, ether
4. 1844: Wells/Morton, NO/ether
5. 1846: John Collins Warren
6. 1846: use of chloroform, problem of ethics, suffering vs. life; pain in birth

Infection

1. Healing by first intention: the problem of closing the wound
2. Healing by second intention: dressing the wound
   • Laudible pus
   • Ichorous pus
3. Late 1860s, Lister: antiseptic surgery
4. Early 1880s: germ-free surgery

Crossing the Membranes

1. Arachnid, peritoneum, pleural
2. From inflammation of the bowels to appendectomy, c. 1886 (Hall, Fitz): First 24 hours
3. 1900: 25% of all surgeries in Atlanta
4. St. Mary's Rochester
   • 1900: 186 appendectomies
   • 1905: >1000 appendectomies
5. 1890: Exploratory abdominal surgery - If unsure, go in; If maybe cancer, go in

Surgery and Society

1. 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)

1. Chemist, Manchester, England, to U.S.A.
2. Late 1840s: Pharmacist, Bellevue, Buffalo
3. 1848-1849: Tailor, Lafayette, Indiana
4. 1850: Indiana College of Medicine
5. 1854: To Minnesota, via Missouri as iron range mine claim inspector
6. 1856: Practice, LeSueur, farmer, boatman, judge, editor-publisher
7. 1863: Draft board doctor, Rochester, Minnesota
   • Practice evolves toward surgery
8. Hospital founder following 1883 tornado
   • St. Mary's, 1889; leads ultimately to group practice of Mayo Clinic (run by sons Will and Charlie)

Surgery as the Cash Cow

1. 1880: W.W. Mayo, a life in debt
   • No bookkeeping, no fees
   • Sliding scale
2. 1900: Halsted, Kelly, $10,000 per operation
3. ~1916: Mayos are millionaires

Gynecological Surgery

1. 1905: Laparectomy/Hysterectomy common
   • "they went a little wild and were inclined to find in hysterectomy 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" - Clapesattle, 189

Other Mayo Surgery

1. Even quiet ulcers aren't cured
   • 75% require surgery
2. Gastroenterostomy: bowel bypass
3. Abdominal surgery: St. Mary's hospital
   • 1890-1893: 54
   • 1900: 612
   • 1905: 2,157
4. Adenoid-tonsil removal
   • 1890: 5
   • 1900: 100

The Anti-Mayo

1. Arthur Hertzler (1870-1946)
2. 1894: earned M.D. at Northwestern
3. Practiced in Halsted, Kansas
4. Interest in surgery, surgical pathology:
   • 1899-1901: postgraduate study in pathology, in Berlin
   • 1901: professor of Pathology at University of Missouri, Kansas City
   • 1907: professor of Surgery at University of Kansas Medical School
   • c. 1905: founder of Halsted hospital and Hertzler clinic
     1. Maximum operation fee: $150
5. 1938: The Horse and Buggy Doctor
6. 1942: The Doctor and his Patients