HOSPITALS

HOSPITALS. From their inception in Byzantium, hospitals evolved within a Christian religious framework of hospitality and charity, providing primarily shelter, food, and a good death with spiritual salvation. Often, medical services were marginal, contracted to deal with associated physical disabilities and pain. With poverty endemic by the late fifteenth century in many areas of Europe, the emphasis shifted away from broadly dispensed hospitality to the "poor of Jesus Christ." Charity was no longer conceived as either private or religious. With almsgiving dwindling because of wars and economic crises, social welfare needed to be reformed and rationed, a function increasingly delegated by the church to the contemporary secular powers. Thus, after 1500, new welfare policies cut across religious boundaries and followed patterns closely tailored to local urban conditions. Charitable assistance was channeled through existing social structures such as parishes, confraternities, and municipalities to benefit schools and several types of hospitals.

Institutions such as almshouses and retirement homes retained their traditional custodial functions while leper and pesthouses functioned primarily as segregation tools for persons suffering from particular diseases considered contagious. At the same time, the hospital's role was recast on the basis of ideas derived from Renaissance humanism as one aiding physical recovery and restoration. This change affected certain urban hospitals of northern Italy, reflecting a more positive vision of health and its importance in Europe's new economy. Acutely ill patients were admitted and subjected to medical treatments for the purpose of rehabilitation and possible complete cures in larger establishments such as the 250-bed Santa Maria Nuova Hospital in Florence. Patient populations were composed of young, unattached laborers whose economic wellbeing was closely linked to physical health. The regular presence of practitioners in the wards signaled a decisive shift toward a greater institutional role for medicine and surgery. Physicians visited regularly, experimented on patients with traditional and new remedies, and preserved their newly gained clinical experience in casebooks. They also created disease classifications, occasionally instructed medical students, and subjected deceased and unclaimed inmates to anatomical dissections. In 1539, for example, Giovanni B. da Monte (1498–1561), professor of medicine at the University of Padua, began taking his apprentices to the local Ospedale di San Francesco for the purpose of seeing patients afflicted with diseases he was lecturing on.

By the late 1400s, several cities in southwest Germany established special hospitals—the socalled "pox houses"—for the care of men and women afflicted by a seemingly new disease variously referred to by Germans and Italians as "morbus gallicus" or French disease. Fear of an impending epidemic, together with the dramatic symptoms and lethal outcome of what was presumably an acute and highly lethal form of venereal syphilis, mobilized municipal authorities, private philanthropists, and specialized physicians. They opened a number of facilities exclusively devoted to a series of medical treatments, including the 122-bed "pox house" in Augsburg founded in 1495. Like their Italian counterparts, these institutions were located within urban walls and featured permanent medical staffs represented by physicians, barber-surgeons, and apothecaries.

The Protestant Reformation created a new relationship to both God and the community. Individuals were given the right to charitable assistance together with obligations to contribute and assist others through local and national systems of relief financed by subscriptions or taxes. Divine Providence, not the quest for indulgences, was to be the path toward salvation, leading to the collapse of hospital patronage as an instrument of salvation. In Protestant countries, institutionalized health care became restricted to smaller infirmaries and dispensaries supported by local governments or community organizations. In Catholic Europe, the Council of Trent (1545–1563) made specific efforts to eliminate widespread administrative fraud perpetrated by religious personnel, including hospital administrators. Thus the church reorganized religious hospitals and closed small, poorly endowed institutions, accelerating an ongoing, two-century-old consolidation process. In their place rose privately endowed, large general hospitals or shelters, often run by local confraternities. These establishments were designed to house together diverse groups of needy people, including orphans, chronic sufferers, mentally ill individuals, and the elderly. The sick poor found medical care in "God's hostels" (Hôtels Dieu ) and other institutions.

Placed under civic authority, most European hospitals became involved in novel schemes of social control and medical assistance. A work ethic adopted by both Protestants and the Catholic Counter-Reformation viewed daily labor as a spiritually fulfilling communal obligation. In selecting its welfare recipients, modern European society thus sought to identify those it considered deserving of assistance—including medical care—through a series of means tests. Most of the deserving poor were modest and law-abiding working people, stable residents seemingly content with their status in society as bestowed by Divine Providence. By contrast, homeless paupers and strangers, as well as drifters, vagrants, and beggars were characterized as undeserving of social welfare, identified with social unrest and crime. In the eyes of the Catholic Church, however, the distinction between worthy and unworthy poor remained blurred. All were considered sinners who needed to be saved. Indeed, spiritual salvation remained the ultimate objective of Catholic hospitalization, and religious ceremonies continued to be central to hospital life, leading to tensions with medical caregivers.

To fulfill their social contract and be productive, early modern European workers needed to remain physically healthy, or, if sick, be assisted in their recovery. Living in crowded and unhygienic conditions, urban populations increasingly fell prey to an expanding panorama of diseases affecting especially the young and the aged. Although Protestant values conferred an active role on individuals pursuing their own healing, help and assistance was to be always available. Outpatient relief in the form of home care and provision of medicines by visiting nurses were furnished to support the "deserving" poor's legitimate status in society. Local efforts designed to stem such assaults on health were encouraged and greatly valued. Belief in Divine Providence encouraged medical activities considered divinely approved instruments to assist in recovery. In turn, hospitals were now considered places of early rather than last resort.

During the seventeenth century, the medicalization of hospitals accelerated, as Europe witnessed the emergence of modern national states. Within the new mercantilist context a growing and physically able population was believed to be essential for achieving political, military, and economic goals. With labor viewed as the key source of power and wealth, efforts to enhance the productivity of a country's citizenry inevitably included the workers' health. Prevention and rehabilitation became national goals. The result was an impressive network of general, military and naval hospitals as well as institutions for housing individuals classified as invalids. Reformers such as William Petty (1623–1687) stressed the importance of medicine and the participation of physicians and surgeons in such care.

Writing in the eighteenth century, Enlightenment thinkers crafted an optimistic view concerning the preservation and rehabilitation of human health. Despite popular perceptions about the fateful inevitability of sickness and disability, French philosophes and others insisted that disease could be controlled, removed, and even prevented by the prompt and deliberate application of traditional dietary, medicinal, and behavioral means. In Protestant countries, belief in Divine Providence supported medical assistance, while Catholic Europe continued to stress spiritual salvation over bodily rehabilitation. Merging traditional religious and secular philanthropic motives, however, state and municipal governments, voluntary associations, and corporate bodies all joined forces to implement a program of public assistance designed to mend bodies while still saving souls. In Britain, local "alliances against misery" comprising private individuals, including businessmen, bankers, lawyers, physicians, and surgeons, came together to establish new voluntary hospitals. Governmental and private organizations aimed at better infant and maternal health, creating lying-in and children's institutions.

By the 1770s, the British voluntary hospital movement was already in full swing, while Continental establishments expanded their services. Hospitals became ideal settings for a greater medical presence, providing physicians with access to vast sectors of the population hitherto left outside the scope of mainstream medicine. Early leaders of this hospital development were John Aikin (1747–1822) who considered the hospitalized sick poor as ideally suited for "experimental practice," John Howard (1726–1790), a widely traveled prison and hospital reformer, and Jacques Tenon (1724–1816), who viewed hospitals as symbols of Enlightenment civilization. Others provided the necessary impetus for bedside medical research and improved clinical skills. Indeed, hospitals were now seen as "nurseries" capable of "breeding" better medical professionals. Informal methods of clinical teaching, brought from Italy to Holland a century earlier, became part of academic instruction pioneered by the University of Leiden. There, at the St. Caecilia Gasthuis, Herman Boerhaave (1668–1738) held "practical exercises," making rounds, questioning, examining, and prescribing remedies for the carefully selected patients. The routine also included the questioning of students, performance of autopsies on those who had died, and efforts to correlate specific postmortem findings with previously detected symptoms. Later, other academic institutions in London, Edinburgh, and Pavia followed this model, although the potential inherent in hospitals to furnish new clinical and pathological knowledge capable of revolutionizing medicine was only fully realized after 1800 in Parisian institutions. In sum, the early modern period witnessed the decisive transformation of the hospital from a religious shelter to a space exclusively devoted to medical interventions.

See also Apothecaries ; Boerhaave, Herman ; Catholic Spirituality and Mysticism ; Catholicism ; Charity and Poor Relief ; Medicine ; Poverty ; Public Health ; Reformation, Protestant .

BIBLIOGRAPHY

Primary Sources

Aikin, John. Thoughts on Hospitals. London, 1771.

Blizard, William. Suggestions for the Improvement of Hospitals and Other Charitable Institutions. London, 1796.

Tenon, Jacques. Memoirs on Paris Hospitals. Translated and edited by D. Weiner. Canton, Mass., 1996. Originally published 1788.

Vives, Juan L. Concerning the Relief of the Poor. Translated by M. M. Sherwood. New York, 1917. Originally published 1526.

Secondary Sources

Brockliss, Lawrence, and Colin Jones. The Medical World of Early Modern France. Oxford, 1997.

Finzsch, Norbert, and Robert Jütte, eds. Institutions of Con-finement: Hospitals, Asylums, and Prisons in Western Europe and North America, 1500–1950. Cambridge, U.K., and New York, 1996.

Foucault, Michel. The Birth of the Clinic. Translated by A. M. Sheridan Smith. London, 1973.

Granshaw, Lindsay, and Roy Porter, eds. The Hospital in History. London, 1989.

Grell, O. P., and Andrew Cunningham, eds. Health Care and Poor Relief in Protestant Europe, 1500–1700. London, 1997.

Risse, Guenter B. Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh. New York, 1986.

——. Mending Bodies—Saving Souls: A History of Hospitals. New York, 1999.

Guenter B. Risse

HOSPITALS

HOSPITALS. Hospitals are institutions in which illnesses, injuries, and disabilities are diagnosed and treated. Deploying advanced medical technology, modern American hospitals are capable of providing medical services beyond those available in physicians' offices or outpatient facilities. In the United States, hospitals are operated either privately or by government entities. Some private hospitals operate for profit; others are operated by religious or secular charitable organizations on a nonprofit basis. Hospitals may function independently or participate in multihospital systems or networks.

The first American hospital was established in 1752. Subsequently, sustained growth in the quantity and quality of American hospitals has been fostered by technological and educational advances, government policies, and public and private health insurance mechanisms that have generally shifted the burden of paying for hospital services away from the individual patient.

The development of American hospitals may be traced through five historical stages. In the formative stage (1750–1850), private charitable organizations established voluntary hospitals that treated patients free of charge while, at the same time, public almshouses (which also provided nonmedical social services to poor, mentally ill, dispossessed, and disabled individuals) were gradually transformed into public hospitals. Next, the era of specialization (1850–1890) gave rise to specialized hospitals (for example, children's hospitals) and nursing emerged as a trained profession. The subsequent era of surgery (1890–1930) was spurred by the introduction of anesthesia and aseptic practices, which facilitated rapid growth in surgical practice, and thereby expanded the role of for-profit hospitals. In the era of insurance and expansion (1930–1975), the emergence of hospital insurance, Medicare, and Medicaid changed the way hospital care was financed. These programs, along with expanded federal assistance for the construction of new community hospitals and Veterans Administration hospitals, financed a proliferation of new and expanded hospitals. Finally, in the era of cost containment (1975–2000), earlier trends toward expansion and deployment have been largely reversed and replaced by countervailing trends towards hospital consolidation, diversification, and integration.

1750–1850: The Formative Era

Traditionally, care for the sick was one of many social services that public almshouses provided to the poor and dispossessed. In the eighteenth century, certain public almshouses evolved into public hospitals by focusing on caring for the sick. In this manner, Philadelphia Almshouse became Philadelphia General Hospital, New York Alms-house became Bellevue Hospital, and Baltimore County Almshouse became part of Baltimore City Hospitals.

In 1752, the Pennsylvania Hospital became the first permanent general hospital specifically chartered to care for the sick. In 1791, New York Hospital followed; in 1821 came Massachusetts General Hospital. These voluntary hospitals did not generally charge fees, but instead were supported by charitable donations. Although most patients admitted for treatment in voluntary hospitals were poor, the admissions process was selective. Patients deemed contagious, immoral, or otherwise undesirable (alcoholics, for example) were transferred to almshouses. Such selectivity was designed to reduce the hospital's mortality rate and to improve its reputation. Despite these efforts towards respectability, however, people of means generally stayed away from hospitals.

1850–1890: The Era of Specialization

For several reasons, the ability of hospitals successfully to treat illness and injury substantially improved during the mid-nineteenth century. First, Florence Nightingale's success in promoting cleanliness and proper ventilation on hospital wards improved hospital mortality rates years before germ theory explained why. Second, nursing schools were established during this period, graduating trained professional nurses who made indispensable contributions to hospital care. Third, in the 1870s, Johns Hopkins University adopted systematic clinical instruction and investigations. Consequently, hospitals became central to medical education and scientific training as well as treatment.

As hospitals became more successful at treating illness and injury, they gradually transformed from storehouses where the impoverished could convalesce (or die) into medical treatment centers of choice for individuals from across the social spectrum. As part of this transformation, specialty hospitals emerged. Some were developed to pull children, mentally ill, and disabled people out of almshouses and into institutions dedicated to serving their particular needs. In addition, specialized religious and ethnic hospitals were established by certain religious and immigrant groups. These hospitals arose in response to actual discrimination and also to satisfy certain unique needs of group members—last rites among Catholics and kosher meals among Jews, for example.

During this time, ward-style hospitals in which relatively poor patients were attended by the hospital's on-staff physicians remained the norm. Slowly, however, private rooms were added, attracting middle-class and wealthy patients who retained their choice of physician.

1890–1920: The Era of Surgery

The groundwork for the era of surgery was laid by two important mid-nineteenth-century developments. First, in 1846, Dr. William Morton introduced anesthesia at Massachusetts General Hospital. Then, in 1867, Dr. Joseph Lister demonstrated antiseptic surgery in London. These two demonstrations set the stage for the emergence of surgery, which would thrust hospitals into their central role in treating illness and injury.

Dr. Lister's method of performing antiseptic surgery was soon superseded by aseptic surgery, which involves creating a sterile surgical field rather than sterilizing at various points during a procedure. As aseptic surgery proliferated, surgical mortality rates plummeted. However, sterile surgical fields required a more complex environment than most home kitchens or doctors' offices could provide. Consequently, by 1900, almost all surgery was performed in hospitals. Pressure on hospital bed space caused by the increase in surgical admissions forced hospitals to admit sick patients only during the acute phase of their illness rather than for their entire treatment. With sicker patients in residence for shorter periods, the costs of providing hospital care predictably increased.

As mortality rates fell and positive results emerged, more people were willing to pay for surgery. Accordingly, patient fees gradually replaced charitable donations as hospitals' primary source of revenue. This shift generally enabled physicians to wrest control over hospital admissions away from hospital board members. However, not every physician was able to obtain hospital admitting privileges. In response, some physicians built their own hospitals or increased pressure on existing hospitals to open their facilities to all physicians.

1930s–1960s: The Era of Insurance and Expansion

Until 1929, private hospitals were financed exclusively by charitable contributions, patient fees, or both. In 1929, however, Baylor University Hospital successfully introduced prepaid hospital care when it offered fifteen-hundred schoolteachers the opportunity to purchase up to twenty-one days of hospital inpatient care per year (whether used or not) for six dollars per person. Other hospitals followed suit, some issuing joint offerings that allowed subscribers to preserve greater choice among hospitals and physicians.

The need for prepaid hospital care became more acute during the Great Depression, when private voluntary hospitals faced a crisis of declining occupancy and decreased charitable contributions while public hospitals swelled with nonpaying patients. To survive this crisis, in 1932 a number of private hospitals agreed to provide certain hospital services for a fixed payment regardless of the cost of delivering the services. These prepaid services plans, which functioned like hospitalization insurance, provided blanket coverage for a list of services rather than reimbursing the hospital for each service provided. The plans, known as Blue Cross Plans, remained under the control of the voluntary hospitals.

Blue Cross Plans charged standard rates without regard to a policyholder's income. Not surprisingly, the plans attracted mainly middle-class subscribers. Yet Blue Cross Plans proved viable, and kept the voluntary hospitals viable too. Indeed, the financial success of Blue Cross Plans induced commercial indemnity insurers to offer similar hospitalization coverage to groups and individuals. By the 1950s, more Americans obtained hospitalization coverage from commercial insurers than from Blue Cross. Even while Blue Cross plans and private hospitalization insurance proliferated, however, many poor and elderly Americans who were the most vulnerable to sickness and its costs remained uninsured.

Beginning in the late 1940s, public and private hospitals began to receive additional financial support from Congress. In 1946, the Hospital Survey and Construction Act (Hill-Burton Act) funded the construction of many new community hospitals nationwide. In 1965, Congress authorized the federal Medicare program, which pays for hospital and medical care for individuals aged sixty-five or older and those with long-term disabilities. Shortly thereafter, Medicare was supplemented by Medicaid, a joint federal-state program that provides medical and hospital insurance to low-income people under sixty-five and to those who have exhausted their Medicare benefits.

1975–2000: The Era of Cost Containment

The introduction from the 1930s through the 1960s of Blue Cross Plans, private health insurance, Medicare, and Medicaid all contributed to pushing consumer demand for medical and hospital care to unprecedented levels. As the overall demand for health services escalated, so did overall costs, which consumed 15 percent of the gross domestic product in 2001.

Insurers responded to escalating health care costs by creating new mechanisms, including managed care, to control costs and access to services. Some managed care plans employ utilization review, require pre-authorization of hospitalization, or negotiate for reduced fee payments to participating providers in exchange for patient volume. Alternatively, to discourage excess medical services, other managed care plans pay participating physicians a fixed monthly fee per patient, regardless of the services used. These new insurance mechanisms have reduced average hospital lengths of stay and occupancy levels. By moving health services from hospitals to outpatient settings wherever possible, managed care plans have diminished the role of hospitals in the American health care system.

Hospitals have responded to these changes by diversifying their activities, increasing on-site outpatient services or even providing outpatient services off-site. Hospitals also have affiliated with one another to create multihospital systems and networks, and have vertically integrated with physicians through a variety of organizational structures. These organizations were intended to offset the negotiating power of the insurers, but have met with only limited success, if that.

At the start of the twenty-first century, hospitals continue to play an unparalleled role in providing essential medical services, facilitating medical research, and training new physicians. However, whether hospitals will retain their central role in American medical care is open to question.

BIBLIOGRAPHY

Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.

LindaDynan

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

hospitals. Since Christian tradition emphasized care for one's neighbours rather than their isolation because of disease, monastic infirmaries functioned alongside lay endowments founded on earth to buy grace in heaven; medieval hospices provided care and hospitality for the aged, infirm, and travellers, and were not necessarily devoted just to the sick. The dissolution of the monasteries (1538–40) not only ended hospital building in England for almost two centuries but transferred responsibility for much health care from the church to secular hands. St Bartholomew's, St Thomas's, and Bethlem were sold to the city of London, which claimed that the sick poor would suffer if the hospitals ceased to exist but also had regard to their endowments. Despite subsequent growth in London's population, however, it still had only two hospitals of significant size.

With the expansion of both population and the middle classes in the 18th cent. there came a surge of new establishments, initially in the older towns, then the manufacturing centres. The Westminster was established in 1719, to be followed by Guy's (1721) and St George's (1733); Edinburgh Royal Infirmary (1729) was deliberately planned to accommodate students. The mid-Georgian period saw a great proliferation of provincial hospitals and infirmaries—Bristol (1735), Bath (1737), Addenbrooke's, Cambridge (1740), York (1740), Exeter (1741), Northampton (1743), Liverpool (1745), Worcester (1746), Newcastle (1751), Manchester (1754), Gloucester (1755), Radcliffe, Oxford (1759), Salisbury (1767). Still set in the context of charity, social rather than medical criteria determined admission to these voluntary hospitals. Benefactors, whose names were published, were given rights to admit patients according to their contribution, and often sought to exclude the socially ‘undeserving’ (drunkards and prostitutes). Incurables, fever cases, and venereal patients were excluded from the general hospitals and sent to peripheral town sites such as lock hospitals. Treatment was free, but patients had to conform to strict rules and assist when convalescent. As towns grew, the number and size of hospitals increased, while less-established practitioners set up new institutions such as dispensaries. Entrepreneurs challenged traditional patterns with specialized establishments (Royal National Orthopaedic Hospital, Moorfields Eye Hospital), supported by new explanations of disease; the initial hostility of the general hospitals lessened as they themselves set up specialist departments.

The introduction of general anaesthesia in the 1840s increased the practice and scope of surgery, but high infection rates and deaths from ‘hospital diseases’ undermined confidence; the medical profession, unsurprisingly, opposed any ideas of hospital disbandment in order to reduce mortality. Florence Nightingale's advocacy of good ventilation led to pavilion-plan buildings on elevated sites, but Lister's antiseptic approach had more impact in transforming both surgery and hospitals. As medical science progressed, hospitals became increasingly complex because of newly developed diagnostic sciences and techniques such as bacteriology, pathology, and radiology. Hospitals themselves began to lose their charity status and became more attractive: patient demand came increasingly from the better off, workhouse infirmaries took away the poorest patients, whilst the image of nursing was being transformed. Cottage hospitals, established for rural patients, gave the general practitioner access to beds as well as retaining fees that would otherwise have been lost, insurance schemes increased entitlement to admission, while nursing-homes were essentially small private hospitals for the middle classes. Playing a central role in health care by the 1920s, hospitals were under the firm control of the medical staff, but developed financial crises as staffing and medical technology costs rose. The idea of scientific management, to increase institutional efficiency, had been introduced in the late 19th cent., but change was slow.

Despite reluctance at being taken into state service, hospitals formed an important arm of the newly formed National Health Service in 1948, emphasis on their role having continued as recent changes seek to move more treatment back into the community. Interventionist and invasive, but now perceived as essential centres for medical education and advances, and prestigious for ambitious staff, hospitals are now very costly, and increasingly regarded more warily through waiting-list times, league tables, and occasional scandals. They remain a popular subject for television programmes.

A. S. Hargreaves

hospital institution for the care of the sick, maintained by private endowment or public funds or both. General hospitals minister to all types of illness, while special hospitals are concerned with only one disease or group of diseases. Many hospitals are maintained solely for the treatment of military personnel and veterans. Once a pesthouse for the care of the indigent and the friendless, with a quality of treatment and nursing from which few emerged alive, the hospital has flourished with the progress of medicine and surgery. Toward the end of the 19th cent. hospital care was revolutionized by the discovery of anesthesia, improvement in sanitation, establishment of hospital nursing schools, and other advances. Hospitals in large cities have become huge medical centers equipped not only to treat the ill but also to further the education of the medical staff, train a nursing staff, perform vital research into the cause and cure of disease, and help the patient with convalescent and social problems.

hospital (hist.) hostel, hospice XIII; asylum for the destitute or infirm XV; institution for the care of the sick XVI. — OF. hospital (mod-.hôpital) — medL. hospitāle, sb. use of n. of hospitālis, f. hospit-; see prec. and -AL1.
So hospitality XIV. hospitable XVI. f. medL. hospitāre receive as a guest. hospitaller member of certain charitable religious orders XIV; spiritual officer of a hospital XVI. — OF. hospitalier — medL. hospitālārius.

hospital originally, a house for the reception and entertainment of pilgrims, travellers, or strangers; any of the establishments of the Knights Hospitallers. Also, a charitable institution for the housing and maintenance of the needy; an asylum for the destitute, infirm, or aged (now chiefly in surviving proper names).
hospital blues a name for the uniform worn by wounded soldiers in the wars of 1914–18 and 1939–45.
Hospital Sunday the Sunday nearest to St Luke's day (18 October).

hospital (hos-pi-t'l) n. an institution providing medical or psychiatric care and treatment of patients. community h. a small hospital, which may be staffed by general practitioners, providing care for patients for whom home care is not practicable. day h. a hospital at which patients are under medical supervision during the day but do not stay overnight. district general h. a hospital that provides sufficient basic services for the population of a health district. See also trust.

hos·pi·tal / ˈhäˌspitl/ • n. 1. an institution providing medical and surgical treatment and nursing care for sick or injured people. 2. hist. a hospice, esp. one run by the Knights Hospitallers.

hospitals. Christian hospitals were founded from the 4th cent. onwards and became numerous in the Middle Ages, when they were commonly associated with monastic orders. Most medieval hospitals in England were almshouses for the aged.

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