Rethinking Private-Public Partnership in the Health Care Sector: The Case of Municipal Hospital affiliation

By the late 1950s, New York City's public hospital system-more extensive than any in the nation-was falling apart, with dilapidated buildings and personnel shortages. In response, Mayor Robert Wagner authorized an affiliation plan whereby the city paid private academic medical centers to oversee training programs, administrative tasks, and resource procurement. Affiliation sparked vigorous protest from critics, who saw it as both an incursion on the autonomy of community-oriented public hospitals and the steamrolling of private interests over public ones. In the wake of the New York City fiscal crisis of 1975, however, the viability of a purely public hospital system withered, given the new economic climate facing the city. In its place was a new institutional form: affiliation and the public-private provision of public health care.

[In process]

At the end of the Middle Ages, in 1492, the Hôtel-Dieu de Paris was still and establishment of charity intended to receive thepoor which came there to find a shelter and some food. Three centuries later, just before the French Revolution, it became an establishment of care mainly destined to receive the patients, to feed them, take care of them and if possible cure them. This medicalization of the Hôtel-Dieu de Paris is related to the progressive emergence of the medical function, which resulted in the creation and the development of a doctor's and surgeon's profession, but also in the development of the apothecary and its drugs. In this context, the diet plays a central part, because it happens to supplies. It would not be until the eve of the French Revolution that it would be integrated in the doctor's prescription and became a dietetic item.

[Surviving handwritten signatures of Ignác Semmelweis]

We know only rather few samples of Semmelweis's handwriting and therefore it is important to carefully preserve those we have. The first collection of his manuscripts was published by Antall et al in 1968. During the following 47 years only rather few further samples of his handwriting have been published. Our present collection completes the former list with two previously unknown letters and with an earlier unpublished document signed by Semmelweis. The first document is a certificate written by Semmelweis in 1854 regarding the age of a woman who delivered her child at Szent Rókus Hospital in Pest. The second document includes a request from the Court of Justice towards the Medical Faculty's of the University of Pest regarding the body's opinion in a case of infanticide. The third document is a registration book of a student at the University of Medicine signed by Semmelweis in 1859. Present work attempts to list all of Semmelweis's handwritings known at this moment. The list includes 29 documents written by Semmelweis and further 16 documents signed by him.

[The beginnings of antituberculosis service in Stettin. Hermann Braeuning--the first director of the Tuberculosis Hospital in Stettin-Hohenkrug (Szczecin-Zdunowo)]

The beginnings of organized treatment for patients with tuberculosis (TB) in Stettin date back to the last decade of the nineteenth century and are traced to the Municipal Hospital in Stettin-Pommerensdorf (Szczecin-Pomorzany). Treatment of patients with TB in Pomerania improved with the opening of the Tuberculosis Hospital in Hohenkrug (Szczecin-Zdunowo). The author presents the history of the leading German Tuberculosis Hospital in Hohenkrug from its opening in 1915 till 1945 highlighting its important role in the health care system of the entire Pomerania. Biographical details of the first director of the Hospital, Professor Hermann Braeuning, are provided. The Tuberculosis Hospital in Hohenkrug (Szczecin-Zdunowo) quickly emerged as a modern research, educational, and therapeutic facility.

[Three centuries of surgery at Colţea Hospital]

The authors present the evolution of surgery at Colţea Hospital during the last three centuries. After a brief history of the Colţea hospital and its masters surgeons, the attention is drawn on the masters efforts to optimize the care, equipment and surgery techniques, things that became of national and world-wide importance.

[The municipality hospital at Nuremberg after the end of reconstruction (1958-1994)]

In 1897 the municipality of Nuremberg founded a large hospital in the northern part of the town. That hospital was partly destroyed by air-attacks in World War II but rebuilt rather quickly after 1945, and in 1958 it owned the same capacities, as far as hospital-beds were concerned, as before the war (1939). The older buildings of that hospital were modernized after 1960, and many new ones with much better facilities for the in-patients were added. After the war Nuremberg's population grew but slowly from 430,000 (1958) to roughly half a million after 1971. But people grew older, many spent some time in hospital. In the 1960s, the length of stay in this hospital was considerable, 25.8 days (1962) on the average. From then on it decreased to less than to days in the 1990s. The progress of medicine as an applied science was extraordinary in those decades, the therapies became more intensive--and more costly--, and many more doctors and nurses had to take care of more older and sicker patients. In 1994 a second big municipal hospital was founded, this time in the utmost south of Nuremberg. Some 1000 hospital beds were transferred from the old hospital in the north to the new one in the south and a little less than 1500 beds remained behind.

Städtisches Krankenhaus in Stettin (seit 1945 Szczecin)

The end of World War II created a new political situation in Europe. Stettin and the Western Pomeranian region became part of Poland. During the war, the municipal hospital and other hospitals in Stettin were almost completely destroyed. In spite of the great difficulties, the Polish authorities set up health services for the city of Szczecin and the entire province. In 1948, the Pomeranian Academy of Medicine (PAM) was created, which to this day plays an important role in the health care provided in the entire Pomeranian territory. In 1955, a 30-bed urological ward was opened in Pommerensdorf forming part of the Second Surgical Clinic of the PAM. The head doctor of the new ward was Dr. Alfons Wojewski, a surgeon and urologist from Gdansk (Danzig). Seven years after coming into existence, the urological ward was transformed into an independent Urological Clinic with 62 beds in 1955. Professor Wojewski organized the clinic right from the start, quickly raising it to the level of a modern scientific, teaching, and service facility. The authors describe biographical details of Prof. Alfons Wojewski.

The development of municipal general hospitals in English county boroughs in the 1930s

When thinking of spurs to hospital development in the first half of the last century, it would be easy to assume that the greatest watershed was provided by the 1946 National Health Service Act. In this article, however, we focus on an earlier and often overlooked piece of legislation, which had a perhaps equally significant impact on the development of hospitals in England and Wales. This was the 1929 Local Government Act, which changed both the ownership and the focus of many of the largest hospitals in the country. As Robert Pinker has observed, the act “radically altered the percentage distribution of hospital beds in the public sector”. Such observations notwithstanding, municipal medicine in the 1930s has not received the historical attention it deserves, an omission which this article seeks in part to remedy. The terms of the act in respect of hospital development were permissive, and the extent to which local authorities acted had a great effect on the way in which their municipal hospital services developed, and hence the beds and facilities available at the time of the nationalization of the health services. The reaction of local authorities to the act, however, depended partly on their own choices, and partly on constraints over which they had less control.

[Three Jewish Germans as chief surgeons in the Berlin-Friedrichshain Hospital--a historical reminiscence]

Three jewish Germans were between 1903 and 1933 continuously in charge of a department of surgery at the oldest municipal hospital in Berlin-Friedrichshain (founded 1874). They were A. Neumann (1865-1920), Moritz Katzenstein (1872-1932) and Max Marcus (1892-1983). A. Neumann described in 1907 the so-called omentum-majus-cuff. By this a drain is wrapped up and put into a perforated ulcus pylori, which cannot be treated by another procedure. M. Katzenstein in 1900 was the first in Germany who repaired a torn off meniscus by suture with a good result (The very first was T. Annandale in Edinburgh in 1883). Aside of this procedure, important for prevention of gonarthrosis, M. K. described new methods for repairing torn ligaments of the elbow and the ankle joint. He was a close friend of Albert Einstein during his years in Berlin. Max Marcus was after the death of M. Katzenstein the youngest chief surgeon in Berlin--but only until April 1933. Then he was expelled by the Nazis, because he was a jew. In June 1933 he immigrated to Palestine and became the leading surgeon there in the later Israel. After the end of World War II he refused coming back to Germany, though F. Sauerbruch spoke about him as the "great hope for the German surgery".

[Development of the Stettin municipal hospital. The beginnings of urology in Stettin (1.)]

The growth of the city's population, rapid advances in medical science, the increasing understanding of the importance of hygiene and, finally, the demand for health care led to the erection of a modern 353-bed municipal hospital complex at Pommerensdorf, Apfelallee, which was officially opened in 1879. From the very beginning of its existence, the municipal hospital was constantly in the process of extension and rebuilding. A hospital base was set up and new departments and clinics were opened. In 1937, the number of the hospital beds had increased to 1,004. The official existence of an independent urology department with 30 beds, first headed by Dr. Felix Hagen (1880-1962), dates back to March 1919. The aim of this new department was to carry out examinations and differential diagnoses, together with the department of internal medicine, for those patients from the urological surgery sector including evaluation for surgery. Surgical urology was the responsibility of the surgery department. The remaining cases requiring urological experience, such as those involving transurethral intervention, diseases of the bladder and urinary tract infection, were treated in the new urology department. As an auxiliary department, de facto dependent on the departments of surgery and internal medicine, urology could not develop properly and survive. In October 1935, the position of the head of the urological department was terminated, and urology was incorporated into the department of surgery. During the Second World War, between 1939 and 1945, as during the World War 1, a field hospital was set up in the municipal hospital at Pommerensdorf in Stettin.

[From administrator to laundrymaid - aspects of the conditions of the staff at the Municipal Hospital of Copenhagen (Kommunehospital) after the opening in 1863]

The opening of the biggest and most advanced Danish municipal hospital of its time took place on the 19th of September 1863 in the city of Copenhagen. The hospital had the capacity to host about 700 patients and was equipped with modern facilities such as water closets, electricity, running water and baths. The daily routines at this large institution had to be throughly organized. This article focuses on the working environment, the rights and duties of the staff and its hierarchical structure. From the historical source material we have been able to classify the staff members into five different groups: the administrative personnel, the medical personnel, the attendants, the caretakers and finally the housekeeping personnel. Many members of the staff lived at the hospital, and a chief physician who wished to leave the premises for more than 36 hours had to obtain the permission of the Mayor of Copenhagen. The instructions regarding the rights and duties of members of the staff, dating back to 1863, shows that a very strict staff policy was needed to keep the hospital running. As an example, the administrator had to stand surety for furniture and equipment used at the hospital along with the stock of goods, for which he was responsible. WOrking in the hospital was a dangerous job. As surety he paid 1000 Rigsdaler, which was more than his yearly salary. The risk of being infected by the patients (e.g. with smallpox) was always present, and the modern machinery, the boiling steam and the treatment of patients in the baths of white spirit, resulted in serious injuries and even deaths. The nature of the working conditions of the laundrymaids is well illustrated by the fact that they were likely to be so worn-out after only six months that they had to give up their job.

Denny-Brown, Boston City Hospital, and the history of American neurology

Harvard University's Neurological Unit at Boston City Hospital (BCH) became the premier center for neurological training in the United States during the middle part of the 20th century. During part of this period (1939-1967), it was directed by Derek Denny-Brown, who had been recruited from England by Harvard president James Conant. The training program that Denny-Brown initiated at BCH emphasized neurology as a medical specialty, independent of psychiatry and neurosurgery. This program, which reflected Denny-Brown's British training, was remarkably effective and served as a model for rest of the country.

The first intensive care unit in the world: Copenhagen 1953

After an extensive survey of the medical literature we present compelling evidence that the first intensive care unit was established at Kommunehospitalet in Copenhagen in December 1953. The pioneer was the Danish anaesthetist Bjørn Ibsen. The many factors that interacted favourably in Copenhagen to promote the idea of intensive care therapy, half a century ago, are also described.

[Annual report of the Subotica Municipal and Eye Hospital for 1889]

INTRODUCTION

The paper is the translation of the report of the Head physician of the Municipal Hospital in Subotica for 1889. It shows the number of patients, the number of checkups, the number of outpatients and inpatients, distribution by sex, age, place of residence, the frequency of patients by months and groups of diseases, the average length of treatment, the number of cured, unsuccessfully treated and deceased patients, the most significant surgeries, the number of doctors employed and a detailed survey of groups of diseases.

ANNUAL REPORT

From January 1, to December 31, 1889, 6.123 patients were treated, 5.141 outpatients and 982 inpatients; 24.644 visits, 69 patients on average, 2.884 men and 2.257 women; 662 under 1 year of age; 828 aged 1 to 5; 1.655 aged 5 to 20; 1.854 aged 20 to 80; 142 patients over 80 years of age. 4.260 patients were from Subotica and 881 from other parts of the country. 19.436 patient days were required, 19 3/4 on average. 747 patients were cured, condition improved in 132, 60 were unsuccessfully treated and 43 patients died. Cerebral and spinal cord diseases occurred in 73 outpatients and 38 patients (the same distribution: outpatients + inpatients goes for all diseases, respectively); nervous system diseases 82 + 18; ear diseases 139 + 2; eye diseases 1706 + 220; nose diseases 12 + 0; respiratory tract diseases 478 + 95; circulatory system diseases 35 + 13; lymphatic system diseases 51 + 5; mouth and throat lumen diseases 207 + 9; coronary diseases and diseases of intestinal mucosa 711 + 18; genitourinary tract diseases 252 + 66; skin diseases 440 + 107; muscle, gland and tissue diseases 104 + 23; joint diseases 75 + 16; bone diseases 56 + 20; acute infectious diseases 344 + 43; chronic infectious disease 143 + 137; general nutritional disorders 222 + 43; poisonings 3 + 2; childbirths 8 + 6.

The development of nursing at the General Hospital, Birmingham, 1779-1919

In 1996 the archives of many of the Birmingham hospitals were deposited in the Birmingham Reference Library. This has afforded nurse historians the opportunity to conduct research into the development of nursing in the city. This is to be welcomed as there is little published work regarding nursing in Birmingham. This paper examines the development of nursing from the Hospital's opening in 1779 until 1919. By the latter date, a modern system of nursing, consisting of a disciplined, salaried and well-trained staff, managed to a greater degree by nurses had emerged in the Hospital.

Midwifery in the Belfast City Hospital

The process of improving midwifery services for poor women in Belfast was a slow one. Traditional midwives were gradually supplanted by midwives who were trained and controlled by the medical profession, but it was many years before the problems of puerperal infection were brought under control in the new institutions.

[The eye department at Copenhagen municipal hospital. Part 3: the epoch of Braendstrup, 1957-1980]

Poul Braendstrup (PB 1912-80) was the best qualified to become head of the eye department at Kommunehospitalet (KH) in 1957, with an eminent great scientific production. He continued this work all his life. Three assistant doctors with different specialities were appointed 1966-72: M. Norn (external eye), K. Norskov (strabism) and Sv. E. Lorentzen (retina). Reasons for the ideal cooperation in the department are described (staff-meetings, christmas-staff-arrangements, meetings, courses etc). The number of operations increased steadily in the period, especially cataract-extractions. The newest techniques and instruments were used (cornea-grafting, vitreous surgery, xenoncoagulation (PB study tour in 1962) before laser-treatment etc). The scientific production increases, surpassing Rigshospitalet after 1967. The education was effective at all levels: In the eye-department, doctors evenings, A-and B-courses for eye specialists to become, referring eye specialists, students (from 1972 as an independent part (sect IV) of the University of Copenhagen with an ordinary professor from 1975). It was disturbing with the many removals at KH and at last the final total removal to KKHH (Hvidovre), causing loss of some of the best staff members, instrument breaks, increasing waiting lists up to one year, inconvenience for the patients and many other difficulties. This could be a warning against the continued great movings of departments in Copenhagen (H:S). The administration is criticised. PB's rationalisation of the duty-plan for all Copenhagen eye departments already from 1966 independent of the administration is mentioned.

The London County Council Nursing Service 1929-48: the significance of the nursing leadership

'On the vesting day of the National Health Service, the LCC handed over to the NHS the largest and most comprehensive hospital system under a single authority that existed in the world' (1). The careers of the Matrons-in Chief, Dorothy Bannon and subsequently Rosalie Dreyer, demonstrate that the LCC had been able to attract nursing leaders from the voluntary hospitals. Both were able to use their new position within the LCC hierarchy to promote the interests of nursing. They took this opportunity to develop a nursing service which became a model to rival the hegemony of the voluntary hospitals.

[The insulin preparation - Diasulin - that annoyed August Krogh]

After the two Canadian researchers, Banting and Best, had succeeded in extracting the pancreatic hormone, insulin, from bovine pancreatic tissue in 1921, August and Marie Krogh brought insulin to Denmark on 12 December 1922. With H.C. Hagedorn, who at the time was senior registrar in the III Department of Kobenhavns Kommunehospital (Copenhagen Municipal Hospital), August Krogh immediately began experiments to produce insulin, and already on 21 December, they succeeded in isolating a small amount of insulin from a bovine pancreas. August Kongsted, owner of Lovens Kemiske Fabrik (Leo Chemical Factory), paid the expenses for the experiments and afterwards helped to start the production of >>Insulin Leo<<. At the start, there was not enough insulin to treat all the diabetics in Denmark, and since Hagedorn was employed in the III Department of Kobenhavns Kommunehospital, this department was the first that had insulin at its disposal. Krogh made it clear that it would probably take several months, maybe even a year, before insulin would be available for all the diabetics in the country. The II Department of Kobenhavn Kommunehospital could not accept this, and as early as May 1923, this department began to treat diabetics with Diasulin Medicinalco, a pancreatic hormone preparation manufactured by H. L. Gad Andresen at Det Danske Medicinal- og Kemikalie-Kompagni (Danish Medicine and Chemical Company). Later Det Danske Medicinal- og Kemikalie-Kompagni began to sell Diasulin under the name Isulin Medicinalco.

[Health anthropology and hospital archiving. The Museum of Pathological Anatomy of the City Hospital of Trieste]

The preparations found in the Trieste Hospital Museum of Pathological Anatomy fit into the context of a medical semiotics which has its origins in the anatomical clinical method. The study of the practices involved in the museum preparation leads back to its purely diagnostic function inasmuch as it convalidates or contradicts the suppositions that, from the symptomatological case history, made from the study of the lesions and the diseased organ. This whole investigative process corresponds to a break in the field of scientific knowledge which marks the birth of a new approach to diagnosis and a new form of nosology, made possible by the great number of sick people and deaths available in a modern hospital. The Museum is permeated with empiricism, morphologism and localisation, and its exhibits fluctuate between macroscopic and microscopic anatomy, between organic and cellular pathology. In the exhibits of infectious and contagious diseases, one can see traces of the revolution brought about by bacteriology and laboratory techniques; in the considerable collection of malignant tumours, one can detect an oncological awareness which relates explicitly to a nosology based on the work of Virchow. The preparations which refer to pathologies that cannot be reduced simply to localisation illustrate an increasing awareness of functional medicine and clinical biochemistry. The Museum has the task of showing and teaching in order to train the hospital doctor. The Museum--through pathological anatomy--directed the community towards a knowledge of healthcare methods destined to change the morbidity and mortality rates due to a certain disease, in relation to those diseases typical of the times.

[Neurology in Paris hospitals, particularly the Salpêtrière before Charcot: Rostan on brain softening]

In the beginning of the 19th century, many studies were devoted to the diseases of the nervous system in France, long before the work of Charcot. The researches of Léon Rostan on the cerebral softening (1819, 1823) were based on the anatomoclinic method developed by the School of Paris whose most famous representatives were Corvisart and Laennec for the study of heart and lung diseases. The researches of Rostan were performed in the Salpêtrière hospital which was, at this time, an hospice for old women. Rostan was appointed Inspector of the Health service in the Salpêtrière hospital in 1812 then Head of a department in 1818. He was 28 year old when he published his book "Researches on the cerebral softening" in 1819. Rostan was the first to describe the spontaneous cerebral softening as a special anatomoclinic entity distinct from encephalitis and apoplexy. He compared this entity to the senile gangrene and stated that it was related to the ossification of cerebral arteries. He described the pathologic features of the brain softening and also its clinical symptomatology in opposition to that of apoplexy. The concept of brain softening according to Rostan was harshly fought by the followers of the Broussais's physiological medicine (from Lallemand, 1830 to Calmeil, 1859) who claimed that all brain softenings were due to the inflammation process and thus should be described as encephalitis. In opposite, the ideas of Rostan were accepted and developed by others such as Carswell in England (1835), Abercrombie in Scotland (1836) and Andral in France (1827, 1840). These authors agreed that some type of cerebral softening was related to a disease of the arterial system. Nevertheless, the modern concept of brain softening was not definitively accepted before the description of the thromboembolic mechanisms by Virchow in Germany (1856) with the help of the microscope, and the anatomoclinic studies of Proust, Laborde and Prevost and Cottard in France (1866). The book of Rostan was dedicated to the "Conseil Général des Hospices" which was created in 1801 to unify the administration of the hospitals in Paris and became the "Administration Générale de l'Assistance Publique à Paris" in 1849. One hundred and fifty years after its publication, the work of Léon Rostan was outstanding by its modernity of the form as well as the substance.