Hospitals

Hospitals. The first hospitals in America were makeshift: military hospitals during the Colonial Era, and the Revolutionary War, and quarantine and inoculation hospitals during epidemics. By the early nineteenth century, the sick poor were often relegated to alms houses, many of which ultimately became tax‐supported municipal hospitals run by local governments. The first permanent institutions for the general care of the sick were organized in northeastern cities in the eighteenth and early nineteenth centuries and included Pennsylvania Hospital in 1751, New York Hospital in 1771, and Massachusetts General Hospital in 1821. These were not intended for the general public; popular opinion regarded medical treatment in an institution by strangers as a last resort, appropriate only for those who had no other choice.

The Nineteenth Century.

The number of hospitals increased during the Antebellum Era, partly in response to growing optimism about the recuperative powers of a regulated moral and physical environment. The new institutions included general‐care hospitals as well as a host of specialty hospitals or asylums: mental hospitals, lying‐in hospitals usually associated with foundling homes, and hospitals for the care and treatment of the blind. The link between poverty and hospitalization remained strong; whether municipally or privately owned, hospitals were primarily charity institutions.

After the Civil War, the number of hospitals increased dramatically, reaching approximately fourteen hundred by 1900. This rapid growth resulted as much from social upheaval as from medical advances. Amid surging immigration and rapid urbanization, local governments, benevolent groups, and churches organized hospitals for the growing ranks of the needy sick. Religious and ethnic groups founded hospitals for religious and cultural reasons. Mullanphy Hospital in St. Louis, the first Roman Catholic hospital in the United States, was founded by the Sisters of Charity in 1828; German Jews in New York City organized Mount Sinai Hospital in 1852. Hospitals mainly cared for the chronically ill, for whom the cultural aspects of daily hospital life were central. Religious hospitals rarely administrated distinctive therapeutics, but they did provide a comfortable and familiar environment—and gave visible proof that a denomination was caring for its own. Hospitals were also organized to provide treatment and clinical training for groups excluded or discriminated against elsewhere. Female physicians founded the New York Infirmary for Women and Children (1860) and the New England Hospital for Women and Children (1862). African Americans organized Provident Hospital in Chicago (189) and Douglass Hospital in Philadelphia (1895). In addition to bed care, many hospitals maintained outpatient facilities, or dispensaries. For the poor, these often represented the only professional medical care available.

By the late nineteenth century, three types of hospitals had evolved: municipal, proprietary, and voluntary. Municipal hospitals, typically larger than the others, were supported by public funds and managed by public authorities; many developed reputations for grim conditions and poor care. For‐profit proprietary hospitals, often owned by physicians, relied on patient payments. Voluntary hospitals derived most of their financial support from private philanthropy, supplemented in some cases by public funding. As expanding hospital populations outpaced traditional sources of funding, patients increasingly paid for their hospital stays. Ultimately this helped remove the stigma of hospitalization as a last resort for paupers.

Early Twentieth Century.

Hospital growth continued unabated in the early twentieth century with the number soaring to more than six thousand by the mid‐1920s. As the hospitals’ image as a charity institution faded, they advertised comfortable private rooms to attract patients. Unlike nineteenth‐century institutions, which mostly provided chronic care and treatment, these new hospitals typically welcomed the acutely ill as well as surgical and obstetrical cases. The number of women delivering their babies in hospitals increased, especially after 1914, when the introduction of the sedative scopolamine to induce “twilight sleep” offered the promise of painless childbirth. The professionalization of nursing proved crucial to the emergence of the modern hospital. Hospital nursing schools, which provided a supply of unpaid student nurses to staff wards, became essential components of the hospital economy. Hospital training for medical students also became the rule in this period. Efficiency, professionalization, and standardization came to dominate hospital development. Institutional and professional groups such as the American Hospital Association and the American College of Surgeons worked to modernize all aspects of hospital life, from record‐keeping to laundry practices. During World War I, the military relied on hospitals to provide medical services in Europe, with American hospitals and medical schools sending teams of physicians and nurses to replicate facilities at home.

By the end of the 1920s, deliveries and abortions, adenoidectomies, appendectomies, tonsillectomies, and the treatment of accident victims accounted for 60 percent of hospital admissions. By 1935, a third of Americans were born in and died in a hospital, but regional and class differences persisted. Rural areas and the South had relatively few hospitals. In an ironic twist, high fees now increasingly excluded the hospitals’ traditional patients, the poor. Proposals for compulsory national health insurance stirred powerful opposition, but voluntary hospital‐insurance plans, such as Blue Cross, flourished. Although hospital lobbyists were unsuccessful in efforts to include federal funding for privately managed hospitals among the New Deal's programs, the 1946 Hill‐Burton Act sought to improve hospital care and availability through federal grants to states for hospital construction. The federal government had provided health care for veterans since shortly after the Civil War, when the first soldiers’ homes were established for disabled veterans, but World War II spawned a vast new system of veterans’ hospitals.

Post–World War II Developments.

In the postwar era, hospitals assumed an ever‐greater medical and cultural role. The availability of antibiotics improved the safety and sophistication of hospital treatment and stirred optimism about the future promise of medical research. Technological developments expanded hospital services and altered hospitals’ physical organization, creating, for example, intensive‐care, coronary, and neurosurgery units. Hospital admissions in 1960 were double those of 1930. Hospitals even played a prominent role in twentieth‐century popular culture, as evidenced by a series of television programs extending over several decades, from Dr. Kildare, Marcus Welby, M.D., and the long‐running soap opera General Hospital to St. Elsewhere and the enormously popular E.R.

Hospitals employed huge numbers of workers, skilled and unskilled. Excluded from the gains made by other workers under New Deal labor laws, hospital workers, despite opposition from hospital administrations, began to organize in the 1950s. In 1974, federal prohibitions on striking by hospital workers were lifted.

Financial issues were central to further hospital development. Greater federal involvement in hospital finances resulted from the Medicare and Medicaid programs established in 1965, which reimbursed hospitals for the care of the elderly and the poor. In the 1970s and 1980s, as hospital costs climbed, many voluntary hospitals merged in efforts to cut costs, creating regional and national chains. The number of for‐profit hospitals rose from 414 in 1977 to 797 in 1997. The 1990s found America's hospitals in a state of flux and financial crisis. As they tried to economize, patient stays were shortened, surgery was more frequently performed on an ambulatory basis, medical testing was contracted out, and recuperating patients shifted to less‐expensive venues. Further, more medical care was delivered outside the hospital: in physicians’ offices, patients’ residences, nursing homes, and long‐term care facilities. Increasingly, the institution that had developed in the late nineteenth and early twentieth centuries known as the modern hospital seemed the product of specific historical circumstances, and one that might well evolve in radically different ways. For all their problems, however, America's more than six thousand hospitals (as of 1998), with over a million beds and 4.4 million staff and employees, remained fundamental to the nation's health‐care system and an integral feature of U.S. life.
See also Cancer; Childbirth; Death and Dying; Disease; Heart Disease; Medical Education; Medicine; Mental Health Institutions; New Deal Era, The; Philanthropy and Philanthropic Foundations; Roman Catholicism; Strikes and Industrial Conflict; Veterans Administration.

Bibliography

Gerald N. Grob , Mental Institutions in America: Social Policy to 1875, 1973.
Morris J. Vogel , The Invention of the Modern Hospital: Boston, 1870–1930, 1980.
Harry F. Dowling , City Hospitals: The Undercare of the Underprivileged, 1982.
David Rosner , A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1888–1915, 1982.
Charles E. Rosenberg , The Care of Strangers: The Rise of America's Hospital System, 1987.
Diana Elizabeth Long and Janet Golden, eds., The American General Hospital: Communities and Social Contexts, 1989.
Rosemary Stevens , In Sickness and in Wealth: American Hospitals in the Twentieth Century, 1989.
Vanessa Northington Gamble , Making a Place for Ourselves: The Black Hospital Movement, 1920–1945, 1995.
Joel D. Howell , Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century, 1995.
Christopher J. Kauffman , Ministry and Meaning: A Religious History of Catholic Health Care in the United States, 1995.
Guenter B. Risse , Mending Bodies, Saving Souls: A History of Hospitals, 1999.

Bernadette McCauley