Surgery was in large part what tipped the balance in people’s attitudes towards hospitals. Until the late 1800s hospitals were largely places where the poor and indigent went to die from lingering diseases, at least in the public mind. And surgery was limited to treating a narrow range of conditions that could be fixed with minimally invasive techniques; there was no reason not to perform it in the home or at a doctor’s office:
Like nursing, but even more so, surgery enjoyed a spectacular rise in prestige and accomplishment in the late 1800s. Before anesthesia, surgery was brutal work; physical strength and speed were at a premium, so important was it to get in and out of the body as fast as possible. After Morton’s demonstration of ether at the Massachusetts General Hospital in 1846, anesthesia came quickly into use, and slower and more careful operations became possible.
But the range and volume of surgery remained extremely limited. Infections took a heavy toll in all “capital operations,” as major surgery was so justly called: the mortality rate for amputations was about 40 percent. Very rarely did the surgeons penetrate the major body cavities, and then only in desperation, when every other hope had been exhausted. Operations were so infrequent that a surgeon’s colleagues considered it a privilege to be brought along to help out even in the minor chores. Surgery had a small repertoire and it stood far behind medicine in the therapeutic arsenal.
Change came slowly after Lister’s work on antisepsis was published in 1867 because it was inherently difficult to reproduce. Many surgeons tested out his carbolic acid spray but found they were still plagued by fatal infections; carrying out antiseptic procedures demanded a strictness—an “antiseptic conscience” it would later be called—they could not at first appreciate. Lister’s method was not generally adopted until around 1880, soon after which it was superseded by aseptic techniques. (While antisepsis called for use of disinfectants during surgery to kill microorganisms, asepsis relied on sterile procedure to exclude them from the field of operation.)
With control over infection, surgeons could begin to explore the abdomen, chest, and skull, but before they could do much good a variety of new techniques had to be developed and mastered by the profession. It was not actually until the 1890s and early 1900s that surgery began to take off. Then, in a burst of creative excitement, the amount, scope, and daring of surgery enormously increased.
Now the stage was set for the shift:
Growth in the volume of surgical work provided the basis for expansion and profit in hospital care. But first certain impediments to the use of hospitals had to be removed. Before 1900 the hospital had no special advantages over the home, and the infections that periodically swept through hospital wards made physicians cautious about sending patients there. Even after the dangers of cross-infection had been reduced, the lingering image of the hospital as a house of death and its status as a charity interfered with its growth. Both patients and physicians had grounds to be wary of hospitals. Many people objected to losing the privacy and control that they might have had at home; as ward patients, the poor had no say in choosing their physicians. And though practitioners might have liked to refer more patients to hospitals, they were often afraid that doing so would mean losing the fee, and perhaps the case, because the staff might offer treatment without charge on the hospital ward.
It took time to establish new understandings about professional fees and control over patients. So at first, ether and antisepsis were adapted to the home and “kitchen surgery” continued. But performing surgery in the home became steadily more inconvenient for both the surgeon and the family, as the procedures became more demanding and more people moved into apartments. And the more busy surgeons became, the more costly was the lost time in traveling to the patient’s home.
To accommodate desires for privacy and fears of the hospital, many surgeons first moved their operations to private “medical boarding houses,” which provided hotel services and nursing. In the suburbs and small towns, doctors built small hospitals under their own ownership; surgery had now made hospital care profitable and permitted them to open institutions without upper-class sponsorship and legitimation. After 1900, as the old prejudice died out, most surgery moved inside hospitals.