Historical Perspective

61301_CH01_5090.qxd 8/8/08 10:42 AM Page 1

1 HISTORICAL PERSPECTIVE

This chapter provides the reader with a brief pregnant women. These examples probably overview of the advance of civilization as moved Buddha’s devotees to erect similar hos- disclosed in the history of hospitals. A study pitals. Historians agree that hospitals existed of the past often reveals errors that can be in Ceylon as early as 437 BC. avoided, customs that persist only because of During his reign from 273 to 232 BC, King tradition, and practices that have been su- Asoka built hospitals that hold historical sig- perseded by others that are more effectual. nificance because of their similarities to the The past can also bring to light some long- modern hospital. Attendants gave gentle care abandoned procedures, which can be revived to the sick, provided patients with fresh fruits to some advantage. The story of the birth and and vegetables, prepared their medicines, gave evolution of the hospital portrays the triumph massages, and maintained their personal of civilization over barbarism and the progress cleanliness. Hindu physicians, adept at surgery, of civilization toward an ideal characterized by were required to take daily baths, keep their an interest in the welfare of the community. hair and nails short, wear white clothes, and promise that they would respect the confi- EARLY HINDU AND EGYPTIAN dence of their patients. Although bedside care HOSPITALS was outstanding for those times, medicine was only beginning to find its way. Two ancient civilizations, India and Egypt, had Egyptian physicians were probably the first crude hospitals. Hindu literature reveals that to use drugs such as alum, peppermint, castor in the 6th century BC, Buddha appointed a oil, and opium. In surgery, anesthesia con- physician for every 10 villages and built hospi- sisted of hitting the patient on the head with tals for the crippled and the poor. His son, a wooden mallet to render the patient uncon- Upatiso, built shelters for the diseased and for scious. Surgery was largely limited to fractures,

2 CHAPTER 1: HISTORICAL PERSPECTIVE

and medical treatment was usually given in clinical records. The columns of the temple the home. Therapy away from home was were inscribed with the names of patients, often available in temples, which functioned brief histories of their cases, and comments as hospitals. as to whether or not they were cured. The aesculapia spread rapidly throughout GREEK AND ROMAN HOSPITALS the Roman Empire as well as through the Greek world. Although some hospitals were The term “hospital” derives from the Latin simply spas, others followed the therapy out- word hospitalis, which relates to guests and lined by the leading physicians of the day. their treatment. The word reflects the early Hippocrates, for example, a physician born use of these institutions not merely as places about 460 BC, advocated medical theories, of healing but as havens for the poor and which have startling similarity to those of the weary travelers. Hospitals first appeared in present day. He employed the principles of Greece as aesculapia, named after the Greek percussion and auscultation, wrote intelligently god of medicine, Aesculapius. For many cen- on fractures, performed numerous surgical turies, hospitals developed in association with operations, and described such conditions as religious institutions, such as the Hindu hospi- epilepsy, tuberculosis, malaria, and ulcers. He tals opened in Sri Lanka in the 5th century BC also kept detailed clinical records of many of and the monastery-based European hospitals his patients. Physicians like Hippocrates not of the Middle Ages (5th century to 15th cen- only cared for patients in the temples but also tury). The Hotel-Dieu in Paris, a monastic hos- gave instruction to young medical students. pital founded in 660, is still in operation today. In early Greek and Roman civilization, HOSPITALS OF THE EARLY when medical practices were rife with mysti- CHRISTIAN ERA cism and superstitions, temples were also used as hospitals. Every sanctuary had a sa- Christianity and the doctrines preached by cred altar before which the patient, dressed in Jesus stressing the emotions of love and pity white, was required to present gifts and offer gave impetus to the establishment of hospitals, prayers. If a patient was healed, the cure was which, with the advance of Christianity, be- credited to miracles and divine visitations. came integral parts of the church institution. Greek temples provided refuge for the sick. These Christian hospitals replaced those of One of these sanctuaries, dedicated to Aescu- Greece and Rome and were devoted entirely lapius, is said to have existed as early as 1134 to care of the sick, and they accommodated BC at Titanus. Ruins attest to the existence of patients in buildings outside the church proper. another, more famous Greek temple built sev- The decree of Constantine in 335 closed the eral centuries later in the Hieron, or sacred aesculapia and stimulated the building of grove, at Epidaurius. Here physicians minis- Christian hospitals. By the year 500, most large tered to the sick holistically in body and soul. towns in the Roman empire had erected hos- They prescribed medications such as salt, pitals. Nursing, inspired by religion, was gen- honey, and water from a sacred spring. They tle and considerate. The medical precepts of gave patients hot and cold baths to promote Hippocrates, Antyllus, and other early Greek speedy cures and encouraged long hours of physicians soon began to be discarded be- sunshine and sea air, combined with pleasant cause of their pagan origins. Instead, health vistas, as an important part of treatment. The care turned toward mysticism and theurgy (the temple hospitals housed libraries and rooms working of a divine agency in human affairs) for visitors, attendants, priests, and physi- as sources of healing. cians. The temple at Epidaurius even boasted Hospitals rarely succeeded during the cen- what might be described as the site of the first turies leading to the Middle Ages; only a few

Medieval Hospitals 3

existed outside Italian cities. Occasional cians were acquainted with the possibilities of almshouses in Europe sheltered some of the inhalation anesthesia. They instituted pre- sick, while inns along the Roman roads housed cautions against adulteration of drugs and others. developed a vast number of new drugs. Mo- hammedan countries also built asylums for the MOHAMMEDAN HOSPITALS mentally ill a thousand years before such institutions appeared in Europe. The people of The followers of Mohammed were almost as Islam made a brilliant start in medicine but zealous as the Christians in caring for the sick. never fulfilled the great promise that glowed In Baghdad, Cairo, Damascus, Cordova, and in their early work in medical arts and hospi- many other cities under their control, luxuri- talization. Wars, politics, superstitions, and a ous hospital accommodations were frequently nonprogressive philosophy stunted the growth provided. Harun al-Rashid, the glamorous of a system that had influenced the develop- caliph (a title for a religious or civil ruler claim- ment of hospitals. ing succession from Muhammad) of Baghdad (786 to 809), built a system of hospitals. Med- ical care in these hospitals was free. About four EARLY MILITARY HOSPITALS centuries later, in 1160, a Jewish traveler re- Engraved on a limestone pillar dating back to ported that he had found as many as 60 dis- the Sumerians (2920 BC) are pictures, which, pensaries and infirmaries in Baghdad alone. among other military procedures, show the The Persian physician Rhazes, who lived from assemblage of the wounded. The book of about 850 to 923, was skilled in surgery. He Deuteronomy records that Moses laid down was probably the first to use the intestines of outstanding rules of military hygiene. Out of sheep for suturing and cleansing patient the urgency of care for the wounded in battle wounds with alcohol. came much of the impetus for medical Mohammedan physicians like Rhazes re- progress. Hippocrates is quoted as saying that ceived much of their medical knowledge “war is the only proper school for a surgeon.” from the persecuted Christian sect known as Under the Romans, surgery advanced largely the Nestorians. Nestorius, driven into the because of experience gained through gladia- desert with his followers after having been torial and military surgery. appointed patriarch of Constantinople, took up the study of medicine. The school at Edessa in Mesopotamia, with its two large MEDIEVAL HOSPITALS hospitals, eventually came under the control of the Nestorians in which they established a Religion continued to dominate the establish- remarkable teaching institution. Eventually ment of hospitals during the Middle Ages. Al- driven out of Mesopotamia by the orthodox though physicians cared for physical ailments bishop Cyrus, they fled to Persia, establishing to afford relief, they rarely attempted to cure the famous school at Gundishapur, which is the sick. Dissection of a human body would conceded to be the true starting point of Mo- have been sacrilege because the body was cre- hammedan medicine. Gundishapur was home ated in the image of God. to the world’s oldest known teaching hospital Religion continued to be the most important and also contained a library and a university. factor in the establishment of hospitals during It was located in the present-day province of the Middle Ages. A number of religious orders Khuzistan, in the southwest of Iran, not far created travelers’ rests and infirmaries adja- from the Karun river. cent to monasteries that provided food and Mohammedan medicine flourished up to temporary shelter for weary travelers and about the 15th century. Mohammedan physi- pilgrims.

4 CHAPTER 1: HISTORICAL PERSPECTIVE

The hospital movement grew rapidly during During the same period of hospital growth, the Crusades, which began in 1096. Military three famous London institutions were hospital orders sprang up, and accommoda- established: St. Bartholomew’s in 1137, St. tions for sick and exhausted crusaders were Thomas’s before 1207, and St. Mary of Beth- provided along all traveled roads. One body of lehem in 1247. St. Bartholomew’s cared for crusaders organized the Hospitalers of the the sick poor, but unlike like many hospitals of Order of St. John, which in 1099 established that day, it was well organized. St. Thomas’s in the Holy Land a hospital capable of caring Hospital was founded by a woman, later can- for 2000 patients. Knights of this order took onized as St. Mary Overie. It burned in 1207, personal charge of service to patients and was rebuilt six years later, and constructed often denied themselves so that the sick might again on a new site in 1228. St. Mary of Beth- have food and medical care. lehem was the first English hospital to be used Finally, an active period of hospital growth exclusively for the mentally ill. came during the late 12th and early 13th cen- The Hotel-Dieu of Paris was probably typi- turies. In 1198, Pope Innocent III urged that cal of the better hospitals of the Middle Ages. hospitals of the Holy Spirit be subscribed for Built at the beginning of the 13th century, the by the citizenry of many towns. He set an ex- hospital provided four principal rooms for pa- ample by founding a model hospital in Rome, tients in various stages of disease, as well as known as Santo Spirito in Sassia. Built in a room for convalescents and another for ma- 1204, it survived until 1922, when it was de- ternity patients. Illustrations by artists of the stroyed by fire. In Rome, nine other hospitals time show that two persons generally shared were founded shortly after completion of the one bed. Heavy curtains sometimes hung from one in Sassia. It is estimated that in Germany canopies over the bed to afford privacy, but alone 155 towns had hospitals of the Holy this advantage was more than offset by the Spirit during early medieval times. fact that the draperies, never washed, spread Although most hospitals erected during the infection and prevented free ventilation. The Middle Ages were associated with monasteries institution was self-contained, maintaining a or founded by religious groups, a few cities, bakery, herb garden, and farm. Often, patients particularly in England, built municipal insti- who had fully recovered remained at the hos- tutions. Like all hospitals of the period, the pital to work on the farm or in the garden for buildings were costly, often decorated with several days in appreciation for the care they colorful tapestries and stained glass windows, had received. but the interiors often consisted of large, drafty halls with beds lining each side. THE “DARK AGE” OF HOSPITALS With the spread of leprosy during the 12th and 13th centuries, lazar houses sprang up, Most hospitals during the Middle Ages, how- supplying additional hospital facilities. Crude ever, were not as efficiently managed as the structures, lazar houses were usually built Hotel-Dieu of Paris. Pictures and records on the outskirts of towns and maintained for prove that many hospitals commonly crowded the segregation of lepers rather than for their several patients into one bed regardless of the treatment. Special groups of attendants, in- type or seriousness of illness. A mildly ill pa- cluding members of the Order of St. Lazar, tient might be placed in the same bed as an nursed the patients. The group represented occupant suffering from a contagious disease. an important social and hygienic movement A notable exception to the general deteriora- because their actions served to check the tion in medicine during this era was the effort spread of epidemics through isolation. The of those monks who copied by hand and pre- group is credited for virtually stamping out served the writings of Hippocrates and other leprosy. ancient physicians.

Hospitals of the 18th Century 5

The great Al-Mansur Hospital, built in Cairo treatment. Both groups were regarded as infe- in 1276, struck a contrast to the European in- rior to physicians. stitutions of the Middle Ages. It was equipped In 1506, a band of long-robe surgeons orga- with separate wards for the more serious dis- nized the Royal College of Surgeons of Edin- eases and outpatient clinics. The handful of burgh. By 1540, both the long- and the hospitals like Al-Mansur would lay the ground- short-robe surgeons in England joined to form work for hospital progress to come in later the Company of Barber-Surgeons of London. centuries. In 1528, English physicians were organized by Thomas Linacre, physician to Henry VIII, as HOSPITALS OF THE RENAISSANCE the Royal College of Physicians of England. During the 16th century, Henry VIII of En- During the revival of learning around the close gland ordered that hospitals associated with of the 14th century, hundreds of medical hos- the Catholic church be given over to secular pitals in Western Europe received the new, uses or destroyed. The sick were turned into more inquiring surgeons that the Renaissance the streets. Conditions in hospitals became so produced. New drugs were developed, and intolerable that the king was petitioned to anatomy became a recognized study. Ancient return one or two buildings for the care of pa- Greek writings were printed, and dissection tients. Henry consented and restored St. was performed by such masters as Leonardo Bartholomew’s in 1544. Practically the only da Vinci, known as the originator of cross- hope for the sick poor among outlying towns sectional anatomy, and Vesalius. Hospitals also was to journey many miles to London. became more organized. Memoranda from The dearth of hospitals in England continued 1569 describe the duties of the medical staff throughout the 17th century, when the med- in the civil hospital of Padua, a city that was ical school was developed. The French and the home to the most famous medical school dur- English quickly accepted what had originated ing the 16th century. These read: in Italy: the first attempt to make medical instruction practical. St. Bartholomew’s took the There shall be a doctor of physic lead in education by establishing a medical li- upon whom rests the duty of visit- brary in 1667 and permitted apprentices to ing all the poor patients in the walk the wards for clinical teaching under ex- building, females as well as males; perienced surgeons. a doctor of surgery whose duty it is In 1634, an outstanding contribution was to apply ointments to all the poor made to nursing by the founding of the order people in the hospital who have of the Daughters of Charity of St. Vincent de wounds of any kind; and a barber Paul. Originating at the Hotel-Dieu of Paris as who is competent to do, for the a small group of village girls who were taught women as well as the men, all the nursing by the nuns, the order grew rapidly other things that a good surgeon and was transplanted to the United States by usually does. Mother Seton in 1809. The practice of surgery during the Renais- sance became more scientific. Surgery was HOSPITALS OF THE 18TH CENTURY practiced by the long-robe surgeons, a small group who were educated in the universities During the 18th century, the building of hos- and permitted to perform all types of opera- pitals revived partially. Because of poverty, at tions, and by the short-robe surgeons, the bar- first the movement made slow progress in bers who in most communities were allowed England, but a few hospitals were built and only to leech and shave the patient, unless per- supported jointly by parishes. By 1732, there mission was granted to extend the scope of were 115 such institutions in England, some

6 CHAPTER 1: HISTORICAL PERSPECTIVE

of them a combination of almshouse and the historic Old Blockley, which in turn evolved hospital. into the Philadelphia General Hospital. The Royal College of Physicians estab- Philadelphia was the site of the first incor- lished a dispensary where medical advice porated hospital in America, the Pennsylvania was given free and medicines were sold to the Hospital. Dr. Thomas Bond wanted to provide needy at cost. Controversies and lawsuits, a place where Philadelphia physicians might however, brought an untimely end to this early treat their private patients. With the aid of clinic. Not discouraged by this experience, the Benjamin Franklin, Bond sought a charter for Westminster Charitable Society created a sim- the Pennsylvania Hospital, which was granted ilar dispensary in 1715. The same organization by the crown in 1751. The first staff consisted in 1719 founded Westminster Hospital, an in- of Dr. Phineas Bond, Dr. Lloyd Zachary, and firmary built by voluntary subscription, in the founder, Dr. Thomas Bond, all of whom which the staff gave its services gratuitously. gave their services without remuneration for Ten years later, the Royal College of Physicians three years. in Edinburgh opened the Royal Infirmary. Lon- Dr. John Jones, an American, published a don Hospital, another notable, had its origin in book in 1775 charging that hospitals abroad 1740. Admission of charity patients to the were crowded far beyond capacity, that Hotel- London Hospital was apparently by ticket be- Dieu of Paris frequently placed three to five cause among its historical relics is an admis- patients in one bed—the convalescent with the sion card. dying and fracture cases with infectious cases. Antony van Leeuwenhoek (1632 to 1723) He estimated that one-fifth of the 22,000 pa- succeeded in making some of the most impor- tients cared for at Hotel-Dieu died each year. tant discoveries in the history of biology. Al- Wounds were washed daily with a sponge that though Leeuwenhoek did not invent the first was carried from patient to patient. The infec- microscope, he was able to perfect it. Many of tion rate was said to be 100%. Mortality after his discoveries included bacteria, free-living amputation was as high as 60%. Jones’s call to and parasitic microscopic protists, sperm cells, action had a positive effect on American blood cells, and microscopic nematodes. His health care. research opened up an entire world of micro- As late as 1769, New York City, with nearly scopic life. Leeuwenhoek had a pronounced 300,000 inhabitants, was without hospitals. influence on the creation of the sciences of cy- In 1771, a small group of citizens, Dr. Jones tology, bacteriology, and pathology. among them, formed the Society of the New York Hospital. The society purchased a five EARLY HOSPITALS IN THE acre site and made plans for a model hospital, UNITED STATES which fell into the hands of British troops during the Revolution. Manhattan Island claims the first account of a During postwar reconstruction, the New hospital in the New World: a hospital that York Hospital broadened its services. Under was used in 1663 for sick soldiers. Fifty years the supervision of Dr. Valentine Seaman, the later, in Philadelphia, William Penn founded hospital began providing instruction in nurs- the first almshouse established in the Ameri- ing, and in 1779 it introduced vaccination in can colonies. The Quakers supported the the United States and established an ambu- almshouse, which was open only to mem- lance service. bers of that faith. However, Philadelphia was Other early American hospitals of historic rapidly growing and also in need of a public interest include the first psychiatric hospital almshouse. Such an institution for the aged, in the New World, founded at Williamsburg, the infirm, and the mentally ill was estab- Virginia, in 1773, and a branch of federal lished in 1732. The institution later became hospitals created by passage of the US Marine

Late 19th-Century Renaissance 7

Hospital Service Act in 1798. Under this act, one person capable of improving patient care. two marine hospitals were established in Upon her arrival at the military hospital in 1802, one in Boston and another in Norfolk, Crimea with a small band of nurses whom Virginia. she had assembled, she found that the sick The Massachusetts General Hospital, which were lying on canvas sheets in the midst of pioneered many improvements in medicine, dirt and vermin. She proceeded to establish originated in Boston. Its first patient, admitted order and cleanliness. She organized diet in 1821, was a 30-year-old sailor. kitchens, a laundry service, and departments In 1832, the Boston Lying-In Hospital of supplies, often using her own funds to fi- opened its doors to women who were unable nance her projects. Ten days after her arrival, to afford in-home medical care. It was one of the newly established kitchens were feeding the nation’s first maternity hospitals, made 1000 soldiers. Within three months, 10,000 possible because of fundraising appeals to in- soldiers were receiving clothing, food, and dividuals and charitable organizations. medicine. Surgeons of the day had sufficient knowl- As the field of nursing continued to edge of anatomy to lead them to perform progress, so did medicine. Crawford Long, for many ordinary operations, and as a result example, first used ether as an anesthetic in more surgery was probably undertaken than 1842 to remove a small tumor from the neck during any previous era. While surgeons had of a patient. He did not publish any accounts sought to keep wounds clean, even using wine of his work until later, however, so the dis- in an attempt to accomplish this purpose, covery is often attributed to W. T. G. Morgan, 19th-century surgeons believed suppuration a dentist who developed sulfuric ether and (the production and discharge of pus) to be de- arranged for the first hospital operation under sirable and encouraged it. Hospital wards were anesthesia at Massachusetts General Hospital filled with discharging wounds. Nurses of that in 1846. Although not put to practical use im- period are said to have used snuff to make mediately, ether soon took away some of the conditions tolerable. Surgeons wore their op- horror that hospitals had engendered in the erating coats for months without washing. The public mind. Chloroform was first used as an same bed linens served several patients. Pain, anesthetic in 1847 for an obstetrical case in hemorrhage, infection, and gangrene infested England by Sir James Simpson. the wards. Mortality from surgical operations The year 1847 also brought about the found- rated as high as 90% to 100%. ing of the American Medical Association (AMA) under the leadership of Dr. Nathan Smith LATE 19TH-CENTURY RENAISSANCE Davis. The association, among its main objec- tives, strived to improve medical education, Florence Nightingale, the famous English nurse, but most of the organization’s tangible efforts began her career by training at Kaiserswerth in education began at the close of the century. on the Rhine in a hospital and deaconess home The AMA was a strong advocate for estab- established in 1836 by Theodor Fliedner and lishing a code of ethics, promoting public his wife. Florence Nightingale wrote disparag- health measures, and improving the status of ingly of her training there, particularly of the medicine. hygiene practiced. Returning to England, she The culmination of Florence Nightingale’s put her own ideas of nursing into effect and work came in 1860 after her return to En- rapidly acquired a reputation for efficient work. gland. There she founded the Nightingale By 1854, during the Crimean War, the En- School of Nursing at the St. Thomas Hospital. glish government, disturbed by reports of From this school, a group of 15 nurses gradu- conditions among the sick and wounded sol- ated in 1863. They later became the pioneer diers, selected Florence Nightingale as the

8 CHAPTER 1: HISTORICAL PERSPECTIVE

heads of training schools throughout the that Division 1 of the hospital was a medical world. student teaching service; Division 2 was uti- In 1886, the Royal British Nurses’ Associa- lized for midwife trainees. Maternal deaths for tion (RBNA) was formed. The RBNA worked Division 1 averaged 10%; Division 2 averaged toward establishing a standard of technical 3%. Medical students performed autopsies; excellence in nursing. A charter granted to the midwives did not. As a result of these findings, RBNA in 1893 denied nurses a register, al- an order was posted on May 15, 1847, requir- though it did agree to maintain a list of persons ing all students to scrub their hands in chlori- who could apply to have their name entered nated lime until the cadaver smell was gone. thereon as nurses. The order was later revised to include hand The first formally organized American washing between patients. nursing schools were established in 1872 at Semmelweis had the satisfaction of seeing the New England Hospital for Women and the mortality rate in his obstetrical cases drop Children in Boston (Brigham and Women’s from 9.92% to 1.27% in little more than a Hospital), and then in 1873 at Bellevue, New year as a result of an aseptic technique that Haven, and Massachusetts General Hospital. he devised. A few years later, Louis Pasteur In 1884, Alice Fisher was appointed as the demonstrated the scientific reason for Sem- first head of the nurse training at Philadel- melweis’s success when he proved that bacte- phia Hospital’s (renamed as the Philadelphia ria were produced by reproduction and not by General Hospital in 1902) nurses’ training spontaneous generation, as was then gener- school. She had the distinction of being the ally believed. From his work came the origin of first Nightingale-trained nurse recruited to modern bacteriology and clinical laboratories. Philadelphia upon recommendation by Flo- Also of great importance to hospitals and rence Nightingale. infection control was Bergmann’s introduction Mrs. Bedford Fenwick, a nurse leader in the of steam sterilization in 1886 and William English nurse registration movement, traveled Stewart Halstead’s introduction of rubber to Chicago in 1893 to arrange the English nurs- gloves in 1890. ing exhibit. As part of the Congress on Hos- By the end of the century, Lister carried pitals and Dispensaries, a nursing section Pasteur’s work a step further and showed that included papers on establishing standards in wound healing could be hastened by using hospital training schools, the establishment of antiseptics to destroy disease-bearing organ- a nurses’ association, and nurse registration. isms and by preventing contaminated air from The group formulated plans to improve nurs- coming into contact with these wounds. Lister ing curriculum and hospital administration in was not content with obtaining better results the first concerted attempt to improve hospi- in his own surgical cases; he devoted his life tals through a national organization. to proving that suppuration is dangerous and that it should be prevented or reduced by use Progress in Infection Control of antiseptics. Despite his successful work and eloquent pleas, his colleagues persisted in fol- Ignaz Philipp Semmelweis of Vienna, Austria, lowing their old methods. As time went on and unknowingly laid the foundation for Pasteur’s antiseptics and the techniques of using them later work. In 1847, at the Vienna Lying-in were improved, even the skeptical were im- Hospital, Europe’s largest teaching obstetrical pressed by the clinical results. department, he declared that the alarming number of deaths from puerperal fever was Discovery of Anesthesia due to infection transmitted by students who came directly from the dissecting room to take The discovery of anesthesia and the principle care of maternity patients. Semmelweis noted of antiseptics are to be regarded as two of the

20th-Century Progress 9

most significant influences in the development was discovered; Pasteur vaccinated against of surgical procedures and the modern hos- anthrax; Koch isolated the cholera bacillus; pital. Anesthesia improved pain control, and diphtheria was first treated with antitoxin; the hygiene practices which helped reduce the in- tetanus bacillus and the parasite of malarial cidence of surgical site infections. fever were isolated; and inoculation for rabies was successful. Treatment of patients with Modern Hospital Laboratory some of the infections necessitated isolation, and hospitals were the logical place for obser- The study of cytology originated during the vation of communicable diseases. Conse- middle of the 19th century and influenced the quently, at the end of the century, in addition development of the modern hospital clinical to their many surgical cases, hospitals were laboratory. The cell theory was first advanced crowded with large numbers of patients suf- in 1839 by the German anatomist Theodor fering from scarlet fever, diphtheria, typhoid, Schwann and was further developed by and smallpox. Jacob Henle, whose writings on microscopic anatomy appeared about 1850. Rudolph Vir- Discovery of the X-Ray chow was the most eminent proponent of the cell theory. His studies in cellular pathology Wilhelm Konrad Roentgen’s discovery of the speeded research in the etiology of disease. X-ray in 1895 was a major scientific achieve- ment. The first use of the X-ray symbolizes Changing Hospital Structure the beginning of the period that necessitated equipment so costly that the average practi- With nursing, anesthesia, infection control, tioner could not afford to install it. The natural and cytology under way, a change in hospital result was the founding of community hospi- structure began in the last quarter of the 19th tals in which physicians could jointly use such century. Buildings of the Civil War days con- equipment. Nineteenth-century inventions tinued with as many as 25 to 50 beds in a also included the clinical thermometer, the ward, with little provision for segregation of laryngoscope, the Hermann Helmholtz oph- patients. In New York City in 1871, construc- thalmoscope, and innumerable other aids to tion of Roosevelt Hospital, built on the lines of accurate diagnosis. a one-story pavilion with small wards, set the style for a new type of architecture that came to be known as the American plan. A notewor- 20TH-CENTURY PROGRESS thy feature was ventilation by means of open- ings in the roof, a definite improvement upon The treatment of metabolic diseases, nutri- earlier hospitals that were characterized by a tional deficiencies, the importance of vitamins, lack of provision for ventilation. Dr. W. G. and the therapy of glandular extracts played Wylie, writing in 1877, said he favored this an important role in the advancement of med- type of building, but he advocated that it be a icine in the 20th century. As early as 1906, temporary structure only, to be destroyed Gowland Hopkins began investigations of vit- when it became infected. amins. Two years later, Carlos Finlay produced experimental rickets by means of a vitamin- Changing Hospital Function deficient diet. This, in turn, was followed by Kurt Huldschinsky’s discovery that rickets Promoted by the wealth of bacteriological could be treated successfully with ultraviolet discoveries, hospitals began to care for pa- light. In quick succession came Casimir Funk’s tients with communicable diseases. During the work with vitamins, Elmer McCollum’s discov- decade 1880 to 1890, the tubercle bacillus ery of vitamins A and B, Joseph Goldberger’s

10 CHAPTER 1: HISTORICAL PERSPECTIVE

work in the prevention of pellagra, and Harry forts increased to train practical nurses and Steenbock’s irradiation of foods and oils. Other nurses’ aides to relieve the shortage of gradu- outstanding contributions to the science of ate nurses. nutrition include Frederick Banting’s introduc- Reform in medical education began early in tion of insulin in 1922, the studies in anemia the century and was due almost wholly to carried out by George Hoyt Whipple and the efforts of the Council on Medical Education Frieda Robscheit-Robbins, and the Minot and and Hospitals, which was established in 1905 Murphy liver extract. by the American Medical Association. Imme- Einthoven’s invention of the electrocardio- diately after its organization, this council began graph in 1903 marked the beginning of an era inspection of medical schools. The council, by of diagnostic and therapeutic aids. Shortly after establishing standards and by grading the that invention came the first basal metabolism schools, brought about gradual elimination of apparatus, then the Wassermann (August Von) most of the unethical, commercial, and un- test in 1906, followed by tests for pancreatic qualified institutions. function, and the invention of the fluoroscopic A great stimulus to the profession of hospital screen followed in 1908. Subsequently, the administration has been the work of the Amer- introduction of blood tests and examinations ican Hospital Association. Organized in 1899 of numerous body secretions required well- as the Association of Hospital Superintendents, equipped and varied laboratories. Concurrent it took its present name in 1907. Since its in- with this progress in the field of internal med- ception, the organization has concerned it- icine was the introduction of radium for the self particularly with the problems of hospital treatment of malignant growths, increasing the management. As early as 1910, the association use of the clinical laboratory for microscopic held educational programs for hospital chief examination of pathological tissue, and de- executive officers and trustees. velopments in antibiotics. The result of these The American College of Surgeons was many new aids was the conquest of diseases founded in 1913 under the leadership of Dr. formerly regarded as incurable, which in Franklin H. Martin, the first director general turn resulted in improved public confidence of the organization. One of the most dra- in hospitals. matic of the achievements of the American The 20th century is also characterized by College of Surgeons was the hospital standard- rapid growth in nursing education. The earlier ization movement begun in 1918. The founders schools were maintained almost entirely for drew up what was known as the “minimum the purpose of securing nursing service at a standard,” a veritable constitution for hospitals, low cost. The nurses’ duties were often menial, setting forth requirements for the proper care the hours long, and classroom and laboratory of the sick. An annual survey of all hospitals study almost entirely lacking. Nurses them- having 25 or more beds made the standard ef- selves had begun to organize for educational fective. In 1918, when the first survey was con- reforms. By 1910, training increasingly em- ducted, only 89 hospitals in the United States phasized theoretical studies. This movement and Canada could meet the requirements. was largely due to the work of organizations The hospital standardization movement such as the American Nurses Association and focused its efforts on the patient, with the the National League for Nursing, along with the goal of providing the patient with the best organization of the Committee on the Grading professional, scientific, and humanitarian of Nursing Schools. In 1943, the US Cadet care possible. The growth of this movement is Nurse Corps was organized to spur enrollment remarkable, especially given that participa- of student nurses in nursing schools to help tion in the hospital standardization (now re- meet the shortages due to enlistment of grad- ferred to as The Joint Commission) program is uate nurses for military service. As a result, ef- voluntary.

Just a Beginning 11

The years following 1929 will be remem- tion and medical technology; and the ever- bered as a trying period in the history of hos- increasing shortage of nurses, physicians, pitals. Due to critical economic conditions, pharmacists, physical therapists, and the like. many institutions found it difficult to keep their The ability to provide affordable access to doors open. Lowered bed occupancy and in- health care services to even the insured is an creased charity load, coupled with steadily ongoing challenge. There are nearly 47 mil- decreasing revenues from endowments and lion uninsured Americans (16% of the popu- other sources of income, worked hardships lation), and the numbers continue to on private institutions. increase. Even those with insurance are often In the later half of the 20th century, com- underinsured for catastrophic occurrences. In petition among hospitals began to grow as for- addition, with employer-based coverage de- profit hospital chains began to spring up and clining, many working families are left with compete with nonprofit organizations. Ad- decreasing health benefits. Unfortunately, vances in medical technology, such as CT, MRI, there is little evidence that the US Congress is and PET scanners and robotic surgery, as well able to reach any consensus for effectively as an ever-growing list of new medications, addressing the issue. The greatest challenge have revolutionized the practice of medicine. of the 21st century requires that each mem- Less-invasive surgical procedures and a trend ber of society assume a more proactive role toward care in outpatient settings have re- in his or her health care. duced the need for lengthy in-hospital stays. JUST A BEGINNING HEALTH CARE AND HOSPITALS IN THE 21ST CENTURY The pinnacle of hospital evolution has not been reached nor has the final page of its col- The challenges of health care are enormous orful history been written. As long as there and continue to test health care organizations. remains a humanitarian impulse, as long as a Some of today’s health care challenges include society feels compassion, love, and sympa- exorbitant malpractice awards; skyrocketing thy for its neighbors, there will be hospitals. insurance premiums; high expectations of In the past, hospitals changed as conditions society for miracle drugs and miracle cures; changed. In the future, they will continue to balancing fairly the mistakes of caregivers change to meet the needs of their communi- with the hundreds of thousands of successful ties. Health care leaders of the 21st century events that occur each year across the na- must understand their roots and the histori- tion; negative press that increases public fear; cal value of knowing the past, have the vision the ethical dilemmas of abortion and human to preserve the good, and the passion to cre- cloning; the exponential growth of informa- ate an even better health care system.