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Hospitals, History of

HOSPITALS, HISTORY OF

Hospital history in the Christian era is here discussed under three headings: (1) the Christian hospital to 1500; (2) the hospital from 1500 to the twentieth century; (3) the Catholic hospital in the twentieth century.

1. the christian hospital to 1500

The history of hospitals has been shaped by principles in accord with the teachings of Christ and the commandment of fraternal charity. The origin of the institutions of the early and late Middle Ages that we now call hospitals, was the hospice. The Christian virtue of hospitality (hospitalitas ) had broad significance, its application extending to embrace various forms of assistance, both individual and collective, and to meet a diversity of needs. Hospices sheltered travelers, gave help to the poor, the sick, the aged, orphans, abandoned children, and widows.

Diaconia. The earliest forms of Christian "hospital" assistance, organized from the 2d to the 5th centuries around active ecclesiastical centers, had their origin and development in the diaconate. The deacon, collaborating with the presbyter and bishop, had the explicit duty of carrying out the functions of hospitalitas. His duty was to help needy brethren in the name of the Christian community. Around the diaconia a variety of activities, primarily eleemosynary in character, gradually developed into centers of operation, known variously as xenodochia (inns for travelers), nosocomia (infirmaries), brephotrophia (foundling homes), orphanotrophia (orphanages), gerocomia (homes for the aged).

Although permanent charitable institutions were not established until later, the Church early concerned herself with collective assistance as such, depending on individuals to perform this task. Since the functions of deacons included, among others, the providing of material aid to all in need (the indigent, the homeless, widows, orphans, etc.), they could not exclude the care of the sick grouped in institutions. Historians of the diaconia agree in attributing a medical function to deacons; in some instances their duties were those of hospital workers or nurses in the strict sense. The diaconia existed in every city, even in the smaller ones, and very often their names signified that they were hospitals. The diaconiae of Rome in the late Empire were situated usually in municipal buildings located on spacious and convenient sites in the busiest sections of the city.

Byzantine and Western Xenodochia and Hospitals. A specific form of assistance, developing directly from the ancient concept of hospitality, provided for individuals who were obliged to make long journeys for personal or commercial reasons, or in fulfillment of a public responsibility. These works of Christian fraternal charity were intended primarily to help pilgrims on long and dangerous journeys of a religious character to the great sanctuaries of the faith, such as Compostella, Rome, and Jerusalem (see pilgrimages).

The xenodochium (from ξένος, stranger) was the first hospital institution attached to the diaconia. It was open to all in need of shelter, and was originally a hospice for travelers and pilgrims from distant places and in financial need. However, in most cases a change of emphasis gradually took place. Assistance to the sick took precedence over the provision of shelter that was limited by regulation

to three days. The name increasingly signified shelter for the sick and in time the xenodochium became synonymous with hospitale. Up to the 9th century in the West xenodochium was used in its Byzantine sense. The Latin word, hospitale, however, was gradually preferred, causing xenodochium to disappear by the 12th century.

Public assistance to the sick, already favored by the Church at the time of the institution of the diaconate, was subsequently encouraged by the directives of Emperor constantine i, who arranged for the systematic erection of hospitals. Reflecting his actions and the approval of the Council of nicaea (325), canon 75 of the pseudoapostolic Canones Arabici Nicaeni declared that in every city separate facilities were to be provided for pilgrims, the sick, and the poor.

Such were the origins of public hospitals, or rather of the institutions later to be called hospitals. As activities relating to the care and healing of the sick were extended and improved, the other forms of welfare activity originally included were eliminated from them. The first historical records of institutions of this sort date from the 4th century. A large hospital, the Basiliad, erected by St. basil near Caesarea in Cappadocia c. 370, is described by Gregory Nazianzus; the hospital of the Roman matron, fabiola, and another erected by the patrician pam machius at the mouth of the Tiber, are mentioned by je rome and others. Subsequently many similar institutions were built with the encouragement of gregory the great and other popes. Along with xenodochia for pilgrims, hospitals for the sick were constructed in various dioceses. Antioch and Alexandria had them, and at Constantinople the earliest hospital activity was associated with john chrysostom.

In the West episcopal hospitals were built in Merovingian Gaul during the 6th and 7th centuries; the famous hÔtel-dieu de paris, however, supposedly founded by St. landry in 651, can be documented only as early as 829. The hospital of Milan, specializing in assistance to foundlings, was founded in the 8th century by the priest Dateo.

Henceforth hospitals were under the supervision of bishops and their organization varied with the needs of the times. At first they were situated in monasteries, but as they branched out into dioceses, they were located near city cathedrals and in rural parishes in outlying areas. In the cities organizations similar to those of the city hospitals were founded near the cathedral chapters and the houses of Canons Regular. Later both religious and private institutions were established by kings and lords.

These different types of hospital organization developed under specific juridical regulations that determined their essential characteristics. At first ecclesiastical authorities ruled in these juridical matters, as the civil authorities were later to do. The generosity of private donors, under the supervision of bishops, encouraged the steady growth of hospital institutes, a noble work that was to continue to the present time.

In the early period of Christianity, the East played an important part in the history of hospitals. The Eastern Church already had its own bureaucratic organization strongly bound up with the institutions of the Byzantine Empire. The hospital specialization of the East was of great interest, even though it was not adopted in toto by the West. It disappeared during the progressive decadence of the Byzantine Empire, and hospital organization declined also in the West during the age of the barbarian invasions.

Western Hospitals through the Carolingian Age. Nevertheless, the technical and juridical experience of the Late Empire and of the early Middle Ages bore fruit in later centuries, influencing the affirmation of the medieval world that substituted its own laws for those of the early Christian period. Byzantine juridical tradition, together with the intellectual legacy of the patristic age, both depending on fundamental Gospel principles, helped to mold the thought of the early Middle Ages. Ecclesiastical bodies, such as bishoprics, parishes, and monasteries, on which the society was built, were responsible for the founding and organizing of hospitals. The work represented a moral and juridical obligation in justice and charity. The bishop had the obligation of hospitality, which he fulfilled, not in his own person, but through his priests living in common as "canons regular" in cities and rural parishes. It was they who set up the basic jurisdictional church organization of the Middle Ages from the 4th century onward. They represented the community of the faithful in the earliest civic and religious centers scattered over the countrysidesituated along the chief routes, near the centers of trade; in the vicinity of castles, which were seats of government; and in mountain valleys.

In the 8th and 9th centuries, hospitality found expression not only in dioceses and parishes, but also in the monasteries, especially after the period of Benedictine reform. It was considered a fundamental obligation of the monks to exercise hospitality toward travelers. At first it was limited to pilgrims, but it gradually took on the more permanent aspect of hospitality to the sick and the disabled. The Benedictine interest in medicine, evident in the medical manuscripts preserved in their libraries, is perhaps best illustrated by the work of constantine the african who provided Monte Cassino and the West with medical translations from Arabic and Greek.

Before the year 1000 an innovation had appeared with the founding of the first private lay hospitals. A few appeared at the peak of the Lombard era, but in the Frankish period their number increased rapidly. These foundations owed their existence primarily to feudal influences and to the Emperor who was the head of organized political society. There were also several imperial hospitals; accordingly, a considerable body of Carolingian legislation regarding hospitals is to be found in the capitula ries.

From Feudal Times to the Age of Communes. In the period following the depression of the 9th and 10th centuries and the weakening of the imperial concept, a form of particularism, typical of the Middle Ages, developed in government and was reflected also in hospital structure. The influence of centralized civil legislation practically disappeared and no longer shaped hospital organization. However, hospitals continued to spring up in great numbers through the 11th and 12th centuries. During this time the canonical legislation of the Church exerted a growing and more exclusive influence. Typical were the "roadside" hospitals, "bridge" hospitals, "valley" hospitals in the Alps and Apennines, and "port" hospitals on the seacoasts.

But where and how did these hospitals come into being and in what form? An interesting phenomenon of this period was the development of what might be called the "hospital guild," the universitas. It had points in common with the more familiar universitas or guild, related to the institutions of Roman law. These new institutions were guilds of the sick and the well alike, organized confraternities of laymen, usually living under a religious rule, who dedicated themselves to the care of the sick. But the sick also were considered to be active members of the hospital community, and as such participated in the financial if not the disciplinary administration of the hospital, which was under the direction and government of the magister. This typical medieval hospital organization is of great interest because it provided the first and most unique forms of statutes, many of them worthy of careful study. For with the establishment of hospital guilds, there emerged a body of hospital law, regulated by Canon Law through decretals, to which were added the interpretations of jurists (see hospitallers and hospital sis ters).

By the 12th and 13th centuries towns and communes began to grow in size and power. The men of the communes gave an important place to hospitals in the texts of their statutes, but respected the form and structure of hospital guilds, which were at least semi-religious confraternities. It was inconceivable in the Middle Ages for any individual or collective work of charity to be excluded from the discipline of ecclesiastical authority. The communes intervened in political and social matters, however, and sought to assert their influence on these activities.

Meanwhile the generosity of private individuals toward hospitals continued to increase, especially in grants of real estate. Many persons, both men and women, also offered their services to hospitals as nurses, oblates, and lay brothers.

Hospitals of Military Religious Orders. A new development appeared in the rise of military religious orders whose private hospitals were forerunners of many present-day hospitals. The military orders had gone to the Middle East during the crusades, joining military action in defense of the Holy Land to medical care of the sick and wounded. Among them were the Knights Hospitaller of St. John, founded early in the 12th century (see knights of malta), the teutonic knights, and the hospitallers of st. lazarus. The last-named order, also founded in the 12th century, was dedicated specifically to the care of lepers, and had a history all its own. It was founded in the East, but eventually spread to Europe where it established many hospitals.

Another order of the same period, specifically dedicated to hospital work, was the Order of the holy spirit, founded by guy de montpellier, propagated throughout Europe and established in Rome by innocent iii. A similar group with hospital statutes such as those of the Order of St. John had its seat at Altopascio in Tuscany. The military hospital orders of the Middle Ages disappeared after the loss of the Holy Land. Only one of these survived, the above mentioned Order of St. John, afterward known as the Knights of Rhodes and the Knights of Malta. It resumed its hospital activities in Cyprus, Rhodes, and Malta with the same spirit it had once displayed at Acre.

Rise of Large Hospitals. In the era of the city-states (signorie ) of the Renaissance, hospital organization was again transformed. The change, which reached its height at the end of the 15th century, consisted in the centralization of hospitals and the suppression of a great number of small hospitals and infirmaries. The latter had been inspired by the spirit of charityin itself a praiseworthy effortbut at the same time their proliferation reflected the anarchic and individualistic tendencies of the Middle Ages. There was a futile splintering of effort and initiative. Small hospitals existed often simply to provide sustenance to a few of the fratres of the surviving hospital confraternities, as well as to members of certain types of trade corporations. Some of the hospitals were convinced that they had established effective universitates attached to their own institutions, but many of them had meager resources and few beds.

The centralization of hospitals conformed to political trends of the modern state in the 15th century and to the spirit of the city-states and principalities. This phenomenon of consolidation is of historical and juridical interest for it represented the joining of the exercise of individual spiritual initiative with both traditional and newer forms of economic activity, involving all classes and social institutions, lay and ecclesiastic, individual and collective. Individual and concentric forces could not coalesce, however, without papal sanction and authorization. For ecclesiastical authority continued to have complete supervision and control over all such organizations. This principle had been affirmed in a famous decree of the Council of Vienne of 1311, issued by Pope clement v in the constitution Quia contingit (Conciliorum oecumenicorum decreta 350352). Besides papal sanction, the new trend needed local episcopal authorization, and in the area of civil jurisdiction, the authorization of the lords (which was decisive), as well as that of the communes. Henceforth, however, the communes were completely under the control of the lords, and their influence diminished until it was absorbed by royal authority.

By the end of the 15th century large hospitals had been established in the major cities throughout Europe, especially in northern and central Italy. Milan provided a typical example of this trend with the foundation of a hospital sponsored by Duke Francesco Sforza. But in many other European cities there were similar and equally interesting examples of territorial and disciplinary centralization, and of administrative reform involving both ecclesiastical and lay institutions.

The foundation of large hospitals necessitated the construction of new unitary structures or the adapting of old buildings, usually monasteries, and a consequent modification of hospital architecture. Formerly, in the small hospitals there had been a rectangular ward with an altar in the rear, following ancient traditions of Roman and Byzantine architecture. An example of the new 15th-century hospital structure was the Hospital of the Holy Spirit in Rome, on which many subsequent institutions of the same order were modeled. The typical shape of the building was cruciform. The ward usually had four arms with the altar in the center for the celebration of divine services.

Critique of Medieval Hospital Effort. Given the great body of hospital sources still in part unedited, it is difficult to assess the number of hospitals erected in the lands of western Europe. If England in the 14th century could count 600 hospitals, large and small, serving a population of 3,750,000 (1347), the more populous and socially advanced countries of France, Germany, and Italy had many more. The quality of medical and nursing service and the efficiency of administration, however, are the other side of the coin. Until the end of the 14th century, hospitals in Franceand presumably elsewhere were without resident physicians and surgeons. Before that time when professional service was needed, the physician was called in and paid by the day or by the visit. Generally, hospital care included attention to both the temporal and the spiritual needs of the patient. The prevailing view that all medieval hospitals practiced "bedcrowding" needs some emendation. The practice was indeed widespreadin the interest of saving space. But in the larger and better organized hospitals, in addition to a number of oversized beds, accommodating three and four patients, there were always single beds for the serious cases. The latter were also assigned separate wards where special-duty nurses attended their needs day and night.

Upon arrival, the patient was bathed "head and foot"a practice that perhaps had connotations more religious than sanitary. He was fed wholesome food of the same quality taken by the hospital personnel and, according to the statutes of many hospitals, at fixed times (11 a.m. and 6 p.m.)before the attendant brothers or sisters had eaten. Medication and treatment tended to be stereotyped, consisting of syrups, herb drinks, bloodletting, and baths. The death rate in medieval hospitals was moderate. At Saint-Jean en l'Estrés in Arras, serving from 2,000 to 4,000 patients annually, the average number of deaths per year between 1307 and 1336 was 102.

The status of medieval hospital nursing was proportionate to the status of medicine in the same period. Yet the religious orientation of most hospital institutions, founded on the traditional virtue of hospitality, generally guaranteed a higher type of bedside service than might be expected. Especially after the development of religious hospital orders of women, living by a rule adapted from the Rule of st. augustine, the sick were treated as "masters of the house." Abuses were, of course, recurrent; but episcopal supervision of both the finances and the internal deportment of the religious and lay personnel of the hospital was designed to reform any malpractice and restore the institute's original fervor.

The tendency for many medieval hospitals in the late Middle Ages, e.g., in France, to become secularized has been noted with some surprise. That this was the result of a growing antagonism between the lay and clerical world is an unwarranted conclusion. The development came about largely for financial reasons. Never affluent, the medieval hospital depended for its income on land (the original foundation and subsequent grants), on rents, decima, donations, annual fund-raising days (such as those approved by innocent iii for the hospital of the Holy Spirit in Rome), and by will and testament. Medical care in the Middle Ages, it should be noted, was free to the patient; the obligation for financing his recovery and his return to productive society was corporate. With the devastation of the Hundred Years' War and its concomitant impoverishment of many hospitals, the Church in France found it increasingly difficult to continue hospital service on the level demanded by the age. The depression of the 14th and 15th centuries increasingly led to urban, lay control of hospital administration and finance.

Bibliography: l. le grand, ed., Statuts d'Hôtels-Dieu et de léproseries (Paris 1901). j. j. walsh, The Catholic Encyclopedia, ed. c. g. herbermann et al., 16 v. (New York 190714) 7:480487. l. lallemand, Histoire de la charité, 4 v. in 5 (Paris 190212). h. leclerq, Dictionnaire d'archéologie chrétienne et de liturgie, ed. f. cabrol, h. leclercq, and h. i. marrou, 15 v. (Paris 190753) 6.2:274870. r. m. clay, The Mediaeval Hospitals of England (London 1909). w. liese, Geschichte der Caritas, 2 v. (Freiburg 1922). s. reicke, Das deutsche Spital und sein Recht im Mittelalter (Stuttgart 1932). g. e. gask and j. todd, "The Origin of Hospitals," Science, Medicine, and History, ed. e. a. underwood, 2 v. (New York 1953) 1:122130. e. nasalli-rocca, Il diritto ospedaliero nei suoi lineamenti storici (Milan 1956). j. imbert, Les Hôpitaux en droit canonique (2d. ed Paris 1958). d. knowles and r. n. hadcock, Medieval Religious Houses: England and Wales (New York 1953) 250324. m. t. bassereau, Hôtels-Dieu, hospices, hôpitaux et infirmeries au moyen-âge (Paris 1958). a. pazzini, L'ospedale nei secoli (Rome 1958). p. de angelis, L'ospedale di Santo Spirito in Saxia e le sue filiali nel mondo (Collana di studi storici sull' ospedale di Santo Spirito in Saxia e sugli ospedali romani; Rome 1958). b. tierney, Medieval Poor Law (Berkeley 1959). Atti del I e II congresso Italiano di storia ospitaliera (Reggio Emilia 1957; Turin 1962). Atti del I congresso europeo di storia ospitaliera (Bologna 1962). u. craemer, Das Hospital als Bautyp des Mittelalters (Cologne 1963).

[e. nasalli-rocca]

2. 1500 to present

With the dawn of the 16th century and of the modern era, new forms relating to a changing religious orientation developed in various countries. Ethical criteria and even the juridical organization that had governed the hospitals of Christian Europe in the Middle Ages underwent alteration. This transformation appeared in the change of concepts on which charitable institutions were founded, in the favoring of secularization, the dispersal of religious hospital institutes, and the intervention of absolute kings.

Prior to the Reformation provision for medical care was primarily a local responsibility, shared by the church and the town. The sick poor were cared for in the monasteries or in hospitals that were a combination alms-house, home for the aged, and shelter for the sick. Physicians and attendants were engaged by the community. With the advent of the Reformation and the rise of the absolutist state, management of hospital services became a municipal responsibility. The immediate cause of this transition was the confiscation of church property and revenues, but more remote factors had initiated the trend in this direction. The breakdown of the feudal system and the social unrest and economic changes following the Black Death in 134849 contributed to the decline of a rural economy in favor of growing urbanization. The decimation of the population by the plague created a premium on labor, and the availability of higher wages in the cities, combined with the rise of a mercantile class, attracted workers in large numbers.

Nevertheless, the hospitals of the Renaissance perpetuated in new forms a tradition that had already persisted more than 1,000 years. Nearly all modern hospitals, whether they were new or reformed or improved hospitals of former times, had their origins and inspiration in medieval hospitals. For whether medieval hospitals were founded to provide assistance of a general nature or specifically to provide collective care of the sick in the interests of society, they were imbued with the spirit of charity. Awareness of the essential need for fraternal collaboration by all who were united in faith in Christ was their foundation.

Evolution of the Function of Hospitals. The quality of hospital care during the 17th century was very poor. Hospitals were primarily almshouses, serving to isolate from the community those who were considered undesirable rather than providing medical treatment for the ill. However, a trend toward the study and teaching of medicine centered in the hospitals of this period was initiated in Holland with the introduction of bedside teaching in Leiden in 1626. Later in the century, under the leadership of Herman Boerhaave (16681738), a Dutch physician and professor of medicine at Leiden, this trend was consolidated and influenced other medical centers, especially in Edinburgh. Francis Bacon was one of its leading exponents in England, although the technique was not actually put into practice there until the 18th century. By the beginning of the 18th century the character and concept of the hospital was becoming more socially constructive, and there was a growing emphasis on its function of treating illness.

The investigations published by John Howard (172690), a prison reformer, by James Lind (171694), a pioneer of naval hygiene in England, and by M. Tenon, a professor at the Royal Academy in Paris, revealed the deplorable conditions in hospitals of the period and instigated needed reforms. A brief summary of Tenon's findings gives some idea of the conditions, typical in varying degrees, of the hospitals of the period. The mortality rate for the Hôtel Dieu was 25 percent, and the figure included six to 12 percent of the physicians and attendants; mortality for obstetrical patients was one out of 15 and for births one out of 13. Diseases of the 2,500 to 3,000 patients included smallpox, measles, rabies, dysenteries, and fevers of all kinds. In addition there were accident, surgical, and obstetrical cases. Segregation was provided by one ward for smallpox, one for obstetrics, and two for accident and surgical cases; all other patients, including the insane, were grouped indiscriminately. Beds were 52 inches wide and accommodated four to six patients, ranging from convalescent to dying. Surgery was performed without anesthesia under restraint by strapping and powerful attendants. Wards were unheated (except by pails of live coals, a fire hazard) and unventilated, and sanitary facilities consisted of five seats over a sewer per 583 patients, plus a few commode chairs for the nonambulatory. All waste was disposed of in these same sewers.

At the beginning of the 18th century the involuntary hospital, supported by the community and designed for the curable poor, appeared in England and France. The municipal hospital administered by stewards appointed by the city council dates from the same period. Toward mid-18th century special hospitals for the treatment of specific illness, e.g., venereal (lock hospitals), smallpox, chest, eye, and orthopedic diseases, were developed, as well as lying-in and mental hospitals, lazarettos, and hospitals for incurables.

In the American colonies a hospital for sick soldiers was built on Manhattan Island in 1633, but it was not until mid-18th century that hospitals functioning without interruption from their foundation were established. The oldest of these hospitals is Philadelphia General, which evolved from a public almshouse for the infirm and insane. The first incorporated hospital for the cure of the physically and mentally ill, receiving its charter from the King of England in 1751, was the Pennsylvania Hospital in Philadelphia. It provided city physicians with a facility for treatment of private patients and was not charitable in purpose. It is the prototype of the modern voluntary, nonprofit hospital. The New York General Hospital and the New York Dispensary were founded in 1791; and Bellevue, which originated as an infirmary in the public workhouse (1736), became a general hospital in 1816. It established the first city ambulance service in the world in 1869. In Boston, the Massachusetts General and the MacLean Hospital for the Insane were founded in 1813, and by 1825 there were general hospitals in Baltimore, Maryland; Cincinnati, Ohio; and Savannah, Georgia. The American Medical Association (AMA) was founded in 1847.

Mental hospitals, as such, date their development from later in the 18th century. For centuries prior to that time, ignorance, superstition, and moral condemnation dominated the treatment of the insane. They were confined in jails, workhouses, and so-called madhouses for the protection of the community. More humane and enlightened treatment was initiated by Philippe Pinel (17451826) in France and by William Tuke (17321822) in England. Pinel, a physician to the Bicêtre in Paris, replaced brutality with humane treatment for the mentally ill male patients under his charge. Tuke, a Quaker merchant, interested the Society of Friends in founding the York Retreat in 1792 to replace the York Asylum (1777). The new institution incorporated a regimen of care for mental patients based on Christian principles and common sense. It represented a major influence in effecting reforms throughout Great Britian, the Continent, and the United States. The Friends' Asylum in Frankford, Pennsylvania (1817) and the Bloomingdale Asylum in New York (1821) were patterned after it. Dorothea Dix (180287), an American philanthropist and reformer, worked for legislation and the establishment of proper hospital facilities for the mentally ill in the United States and was instrumental in the founding of St. Elizabeth's Hospital, Washington, D.C. (1855). She was directly responsible for the foundation or enlargement of 30 other mental hospitals. By 1870 there were approximately 50 public and 16 private mental hospitals in the United States, having a total capacity of 17,000 patients. This trend implemented the scientific study of various mental illness.

The development of military hospitals is also of significance. With the rise of national states in the 15th and 16th centuries, a form of military hospital emerged. Queen Isabella is credited with maintaining a field hospital service, and in the late 16th century there were stationary military hospitals in England and in Pamplona, Spain. France and Prussia, however, gave the first real impetus to the development of military hospitals on a large scale. In the United States by the end of the 18th century, permanent army, navy, and marine general hospitals had been established; and in the 19th century station hospitals were attached to army posts. Hospitals for sick and wounded soldiers during the Civil War embodied principles later applied to postwar civilian hospitals and adapted by the Germans during the Franco-Prussian War. Base and evacuation hospital units, composed of medical and nursing teams from civilian hospitals, were introduced in World War I.

Modern Hospial Care. In the latter part of the 19th century there began to emerge a type of health facility that was to evolve into the highly scientific, well-managed, 20th-century hospital. Many forces were developing that would change the character of the hospital from a forbidding, infection-laden last resort for the indigent dying to a modern, aseptic institution in which emphasis was placed on curative procedures.

Under the influence of Florence Nightingale and certain religious congregations of women, nursing became an art dedicated to giving continuous care to sick beings. This influence of improved nursing brought order and cleanliness to hospital wards and provided a means of giving, on a continuing basis, the care the physician prescribed. The discovery and use of anesthesia made possible longer and more delicate surgical procedures. In 1847 Ignaz Philipp Semmelweis (181865) of Vienna demonstrated that infections were transmitted by personal carriers; a few years later Louis Pasteur (182295), by his discovery of the reproduction of bacteria, originated the modern science of bacteriology and the beginnings of the hospital clinical laboratory. At the end of the 19th century Joseph Lord Lister (18271912), carrying Pasteur's work further, proved that wound healing could be hastened by the use of antiseptics.

The acceptance and use of these discoveries by physicians and nurses practicing in the hospital gave the institution a completely new image. Thus began the institutional evolution that made the hospital an environment where advancements in medicine would be attracted. Medical students and young physicians were sent to the hospital for basic and advanced education. Formal nursing education first reached professional status in the hospital and the hospital school. Physicians and hospital officials, mobilizing all of these forces, translated them into better patient care. Improved procedures and standards of care attracted patients in numbers that required a rapid and continuing expansion in facilities and services up to and beyond the mid-20th century. The United Federal government constructed an elaborate system of hospitals for veterans of military service in addition to large numbers of general and special hospitals. There developed a widespread awareness of the important role of the hospital in the health of the people. All types of hospitalsgovernmental, voluntary, and religiousaccepted responsibility for developing and giving the best possible care.

Bibliography: n. w. faxon, The Hospital in Contemporary Life (Cambridge, England 1949). a. c. bachmeyer and g. hartman, eds., The Hospital in Modern Society (New York 1943). g. rosen, Encyclopedia Americana 14:427433. j. j. walsh, The Catholic Encyclopedia, ed. c. g. herbermann et al., 16 v. (New York 190714) 7:480488. c. u. letourneau, "A History of Hospitals," Hospital Management 87 (1959), March, April, May, June.

[a. b. mcpadden/

j. flanagan]

3. catholic hospitals

Catholic health care began in America under the sponsorship of religious communities of women. As health services became institutionalized, the Catholic hospital evolved a parallel course with nonprofit, public, and investor owned institutions. Because Catholic health care institutions developed in concert with secular institutions, they are an integral part of the American health care establishment and share the concerns of other providers of health care. When the Catholic Hospital Association of the United States and Canada was organized in 1915, there were 541 Catholic hospitals in the United States. By 2001, Catholic hospitals were the largest group of notfor-profit hospitals, and accounted for 11 percent of all admissions to community hospitals.

After 1950 lay personnel began to take an increasingly important place in the operation and management of Catholic hospitals. Not only did they come to constitute the major part of the nursing and technical staff, but they held administrative positions as supervisors, department heads, accountants, purchasing agents, personnel directors, and assistant and associate administrators. By the late 1980s, lay administrators sat in board rooms of Catholic hospitals.

It became clear by the early years of the 20th century that the Catholic hospital could not concentrate on care of the indigent sick alone. Because the well-organized hospital had become the center for improved care, physicians tended to bring their patients to the hospital rather than to see them in their homes. Like other health care facilities Catholic hospitals found themselves assuming the responsibility of caring for patients who could pay for their care. Gradually all hospitals, including Catholic, were expected to serve the communities in which they were located by providing a level of care that reflected the advances in medicine, nursing, and paramedical services.

This acceptance of community responsibility necessitated a more complex administrative organization and forced the hospitals to conduct their activities in a more businesslike manner. General and financial administration became important functions in developing health services that were both apostolic and professional in nature.

Health Care Systems. The economic depression that began in 1929 sharply focused attention upon the difficulties many people had been experiencing in paying for hospital care. From this experience developed a program of prepaid hospital care: by paying regular monthly premiums individuals and families insured the payment of their basic hospital expenses in the event of illness. This program, known as the Blue Cross Plan, spread and a similar voluntary plan of prepaying doctor's bills, popularly known as the Blue Shield Plan, was developed. The success of these plans stimulated many commercial insurance companies to offer their own group health insurance programs.

In 1965 the federal government began funding health insurance for people over 65 years of age (Medicare) and supported health insurance for recipients of state welfare programs (Medicaid), making it the major health insurance agency in the country. In the nineties, Medicaid was separated from the welfare program and the state children's health insurance program (SCHIP) was added to make health insurance available to poor children whose mothers were not eligible for welfare.

Another force to be considered in the Catholic health care environment is the development of multi-institutional groups or systems, one or more hospitals owned, leased, or managed by a central organization. Although investor-owned systems dominate the multi-hospital establishment, local systems in the non-sectarian voluntary sector have joined together. There has also been system development under Catholic sponsorship. In 2001, there were 61 multi-hospital systems under Roman Catholic auspices. The Catholic systems are unique in that they offer a continuum of care which includes senior housing programs, adult day care, home health and hospice programs and community-based services, often linked to Catholic Charities. The emergence of the for profit hospital systems and the development of managed care as the dominant form of health insurance re-inforce competition, concern with return on equity, and innovative marketing and management techniques designed to attract cost-conscious physicians and insured patients to investor-owned and not-for-profit acute care hospitals.

Hospitals under Catholic sponsorship experience financially driven health care as a tension between mission and market. The awakened fiscal consciousness in all parts of the health community has stimulated mergers between Catholic and non-Catholic hospitals. Strengthening the essence and meaning of Catholic identity and sponsorship of hospitals is a continuing concern. In the years before the Second Vatican Council, Catholic hospitals were identified with the numbers of women and men religious in administrative and clinical positions. In 1965, 96.8 percent of administrators in Catholic hospitals were religious; by 1986, the figure was 38.9 percent, and the number continued to decline. It is no longer possible to explain the mission of Catholic hospitals by reference to the presence of religious sponsors in acute care hospitals.

The Catholic Mission. The charism that prompted attention to the sick as a work of mercy, the autonomy and decision making processes of the sponsoring religious communities, the age and declining numbers of religious women engaged in health ministry, and the growing secularization in the health care field threatens the continuation of large health care systems under Catholic auspices and Catholic influence in acute care. New structures, like the leadership development and mission integration programs that exist in Catholic systems and the revised ethical and religious directives for Catholic health care services, are being developed to present, monitor, and preserve the enactment of the Catholic health care ethic.

Bibliography: Health and Health Care: A Pastoral Letter of the American Catholic Bishops (Washington, D.C. 1981). "Is Religion a Competitive Edge?" Hospitals (April 20, 1987). r. a. mccormick, Health and Medicine in the Catholic Tradition (New York 1984). the catholic health association, Annual Report (St. Louis 200186); No Room in the Market Place: The Health Care of the Poor (St. Louis 1986).

[j. flanagan/

r. donley]

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