3120-06_ON2405-Kahn.qxd 9/16/05 2:38 PM Page 343 The Evolution of Orthopaedic Nursing at the Hospital for Special Surgery The First Orthopaedic Institution in the United States Barbara A. Kahn The history of nursing began in London in the late 1800s with Orthopaedic nursing continues to evolve in a professional the reform of unsanitary conditions by Florence Nightingale. partnership with the Hospital for Special Surgery, a pre- During the same period, the United States was bitterly fighting mier orthopaedic institution in New York City, which was the Civil War. Nursing had not developed as a profession, the first orthopaedic hospital founded in the United States. and most of the duties performed by nurses were conducted by men. Casualties of war required rehabilitation and care. The Beginning of the Modern Crippled children were left to die because they were considered Nursing Movement a burden to society. Dr. James Knight founded the Hospital for In 1860, Florence Nightingale (1820–1910) established the the Ruptured and Crippled in his home on Second Avenue. This first school of nursing at St. Thomas Hospital in London. would later become a world-renowned orthopaedic institution Nightingale was considered the pioneer of the nursing with exceptional nursing care. A historical analysis of nursing profession because she brought unsanitary conditions to education and practice are reviewed, along with the evolution the forefront while trying to reform the British military of the first orthopaedic hospital in the United States. healthcare system (Audain, 2004). For her time, she was educated because her family believed that all their children, including their daughters, should study history, mathemat- he history of nursing and orthopaedic surgery dates ics, and multiple languages. She used her knowledge of Tback to the late 1800s. Both developed out of societal mathematics to interpret data collected during her serv- need, advances in medical science, and a will to help those ice in the Crimean War. Through statistical analysis she afflicted with disease. Crippling disorders have plagued proved that the incidence of preventable deaths was caused mankind since the beginning of time. These unfortunate by unsanitary conditions and that with improvement in people had no recourse except begging for survival. The sanitary methods, the death rate would decrease. As an same premise exists today in all disciplines of medicine. innovator of data collection, statistical analysis, and sani- Nursing has played an integral part in caring for those tary reform, Nightingale founded the nursing profession in need and affording patients, physicians, and hospi- and started what has become known as the Modern tals the ability to function dynamically and superiorly. Nursing Movement (Audain). Agnes Hunt was born in England in 1867. She devoted her life to the care of crippled children by opening the first open-air orthopaedic hospital. She knew too well the fate of those with chronic infirmity because she developed Orthopaedic nursing continues to evolve osteomyelitis of her hip at the age of 9 after a bout of sep- in a professional partnership with the ticemia (Shropshire routes to roots, 2005). Tuberculosis of Hospital for Special Surgery, a premier the joints and osteomyelitis were common untreatable ill- ness during this time. Ms. Hunt believed that continuous orthopaedic institution in New York City exposure to fresh air would help eradicate the transmission that was the first orthopaedic hospital of airborne diseases. Florence House, an outpost of the founded in the United States. ▼ Barbara A. Kahn, BS, RN, ONC, Nurse Clinician, The Hospital for Special Surgery, New York, NY. Orthopaedic Nursing September/October 2005 Volume 24 Number 5 343 3120-06_ON2405-Kahn.qxd 9/16/05 2:38 PM Page 344 Salop Infirmary in Shrewsbury, opened in 1900 with open- the tenement houses. Lillian Wald would not begin her mis- air sheds that served as patient wards. Hunt developed a sion at the Henry Street Settlement until 1893. During this friendship and professional partnership with Dr. Robert period, 20–30% of reported deaths resulted from tuberculo- Jones, an orthopaedic surgeon in Liverpool. Florence sis. As a result of these communicable diseases, there was House became the Shropshire Orthopaedic Hospital lo- an increase in bone and joint infirmity. The treatment of cated in Oswego. Long after their deaths, the hospital was these bone and joint diseases formed a large portion of renamed the Robert Jones and Agnes Hunt Orthopaedic orthopaedic practice during this period (Rang, 2000). Hospital and remains in Oswego servicing the commu- Only 150 hospitals were in existence in the 1860s, most nity (Carter, 2001). of which did not accept disabled or crippled individuals be- cause they were considered incurable. Dr. Knight, a physi- cian practicing in New York City, was compelled to rehabil- Only 150 hospitals were in existence in itate these unfortunate souls, mostly youngsters, and in 1863, he welcomed 28 children into his Manhattan home. the 1860s, most of which did not accept Ninety-Seven Second Avenue within the Lower East Side of disabled or crippled individuals because Manhattan would, from that time on, be known as the they were considered incurable. Hospital for the Ruptured and Crippled (Figure 1). Dr. Knight believed that bracing, exercising, and prayer would heal those afflicted because surgery had a high mortality The United States was also involved in conflict as the rate (Time and effort, skill and gifts, vision and faith, n.d.) Civil War began in 1861 and continued until 1865. There (Figure 2). Mrs. Knight, family members, and hired domes- were more than 600,000 casualties and an insurmountable tics provided the necessary care for patients because there number of wounded. Nursing was dominated by males be- was still no formal nursing school in the United States. cause society and military protocols mandated that women were too frail to cope with the demands of caring for the sick and injured (Stein, 2004). As a profession, nursing was still in its infancy because no formal nursing schools had yet been established. Casualties continued to increase, forc- ing the demise of gender restrictions. Seizing this opportu- nity, women immediately sprung into action. Dorothea Dix was named Superintendent of the Women Nurses of the U.S. Army by the Secretary of War. Dix had no formal train- ing as a nurse, yet she set the standards for nursing appli- cants. Nurses were paid 40 cents per day and given food, housing, and transportation. Their male counterparts re- ceived $20.50 per month with superior benefits. In 1862, Clara Barton, who would become the founder of the American Red Cross, brought food, clothing, and medical supplies to the battlefields of the Union Army (Stein). Although the Civil War ended in 1865, it was not until 1892 that the U.S. Congress recognized how valuable nurses were to the war effort. This prompted the passing of a bill that provided a $12 per month pension to military nurses (Archer & Goehner, 1982). Even with these acknowledgments, nursing was still considered a matronly profession based on moral charac- ter, virtue, and discipline rather than education and skill. It was becoming more socially acceptable to be a nurse, de- spite the intensity of the work load combined with the in- decent wages. Still, it did not attract aristocratic women to the profession, and the role of the nurse remained oppres- sive and subservient (Archer & Goehner, 1982). The First American Orthopaedic Institution Infection from tuberculosis and polio spread rampantly through the community because the industrial revolution led to overcrowding and unsanitary conditions in New York City. Although tuberculosis had first been described by Hippocrates in 300 BC, it became known as the “White FIGURE 1. Dr. Knight’s home at 97 Second Avenue was the first Plague,” and those who contracted it rarely survived. home of the Hospital for Special Surgery, known then as the Pasteur discovered the germ theory of disease in 1861, and Hospital for the Ruptured and Crippled. Reprinted with permis- yet only a few blocks away from Dr. Knight’s home stood sion from the Hospital for Special Surgery. 344 Orthopaedic Nursing September/October 2005 Volume 24 Number 5 3120-06_ON2405-Kahn.qxd 9/16/05 2:38 PM Page 345 FIGURE 2. Children with crooked spines are shown using an FIGURE 3. A nursery school tailored to the physical limitations exercise apparatus. Dr. Knight believed that bracing, exercise, of patients with cerebral palsy. Reprinted with permission from and prayer would heal the afflicted. Reprinted with permission the Hospital for Special Surgery. from the Hospital for Special Surgery. pling diseases and long recoveries. To accommodate these children, the Hospital for the Ruptured and Crippled estab- Nursing Education lished classrooms so the children could continue their ed- Bellevue Hospital School of Nursing, the first Nightingale- ucation while hospitalized. Manhattan Public School 401 influenced nursing school in the United States opened its was established on the children’s ward with special desks doors in 1873 (Christy, 1970). Nursing duties in 1887 con- and equipment enabling the patients to do homework, sisted of sweeping, mopping, cleaning windows, dusting take tests, and return to school on discharge (Time and the wards, bringing coal to the furnaces, filling lanterns effort, skill and gifts, vision and faith, n.d.) (Figure 3). with kerosene to supply light for assessments, and writing nurse’s notes to assist the physicians. Nurses were expected Orthopaedic Nursing to work 7 days per week. Graduate nurses were given one evening off per week, two if you went to church regularly. From 1929 to 1960 Any nurse who smoked, drank, or frequented a beauty The depression during the 1930s brought on a rapid shop or dance hall had her professional intentions scruti- change in the nursing profession.