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

The modern name "hospital" must not be confused with that given to the institution which, throughout the Middle Ages in Europe, served the dual purpose of lodging poor or sick travelers and nursing the ailing poor. Hospitals of this nature were established as early as the fourth century c.e., and, according to Jerome (c. 347–c. 420), there was a continuation of institutions which had long been established in the Holy Land. The lepers' quarantine mentioned in the Bible cannot be taken as proof of the existence of hospitals, although, according to the Hebrew grammarian *Gesenius, the term beit ḥofshit ("house set apart"), used in ii Kings 15:5 to describe the dwelling of King Azariah after he was stricken with leprosy has the meaning of an infirmary or hospital in the sense of a place for the dressing of wounds. In talmudic times the term beita de-shayish ("marble room") is used for an operating theater, but this again is not synonymous with a hospital (see *Medicine, in the Talmud). It can be assumed that by the time hospitals were being established in Christian Europe, they were also in existence in Jewish communities where private hospitality and charity were inadequate. There is evidence of one of these dual-purpose institutions in what is now Yugoslavia in the fifth century, and of another in Palermo, in Sicily, in the sixth century.

The Hekdesh

In Germany, a Domus Hospitale Judaeorum is recorded in a Cologne document of the 11^th century. The fact that it is described in Hebrew as a *hekdesh ("a hostel for the poor") would suggest that it was intended as a lodging for travelers rather than a place for curing the sick. It has been suggested that the "Jewish inns" in medieval Spain and in Paris may have been similar establishments. The first definite evidence of a Jewish hospital in Spain comes from Barcelona, where in a manuscript of 1385 there is a description of some men as Procuratores et Rectores Hospitalem pauperum Judaeorum. At the beginning of the 13^th century there is mention of a Jewish hospital in Regensburg, and others are known to have existed in three other German cities: Munich (1381), Trier (1422), and Ulm (1499). By the 16^th century they had spread eastward to Vienna and Berlin. These were inns for foreign Jews where sick strangers may have been treated in a part of the building specially set aside for them. They were supported by the community, by benevolent societies (ḥevrot), and by charity boxes. While with the population growth in Christian Europe during the later Middle Ages the term "hospital" was confined more and more to institutions dealing exclusively with sick people, the Jewish hekdesh did not change its dual function. It was apparently a very primitive affair consisting of one or two rooms with a maximum of six beds, ill-equipped for nursing, and without any regular medical attention. It was sometimes also used for obstetric cases. The reason for the low standards was that most Jewish communities were small and poor, and they were socially insecure and subject to sudden expulsion, so that the provision of permanent facilities for the sick was a waste of money. It must also be remembered that the great physicians of the 16^th to 18^th centuries had no connection with hospitals. The hekdesh was last heard of in Eastern Europe at the beginning of the 20^th century, when the term was still used for mental asylums.

The Hospital in Europe

The transition to the hospital as known today began in Western Europe. From there it spread eastward with the 18^th-century Enlightenment, when Jewish communities could look forward to a permanent settlement and better economic prospects, and when at the same time the idea of the modern, scientific "house for the sick" (Krankenhaus) was taking root. A small hospital of this type was opened by the Sephardi community in London in the 1740s. Berlin, Breslau, and Vienna followed in the second half of the 18^th century, and the first Jewish hospital in France was founded in Paris in 1836. From then onward Jewish hospitals with general wards for the poor and private wards for the wealthier classes were built throughout Europe. By 1933 they existed in most countries, and usually had a high reputation. At this time there were 48 Jewish hospitals in Poland – nine percent of all hospitals in the country – having a total of over 3,500 beds, more than a thousand of them in Warsaw alone. Jewish hospitals of varying size were to be found in many towns in Lithuania, Latvia, and Romania, and in Salonika in Greece. In Germany, many towns of importance, such as Hamburg and Frankfurt, had their Jewish hospital. Italy's first Jewish hospital was established in Rome in 1881. The Jewish hospital in Vienna, built by the *Rothschilds, served not only the Austrian population but also patients from Eastern Europe. There was a Jewish hospital in Amsterdam from about 1840, and another in Basle, Switzerland. In England beds for Orthodox Jews were maintained by charitable organizations in a number of the great medical centers, such as the Middlesex Hospital in London. The first Jewish general hospital in the country was the Victoria Memorial Jewish Hospital, founded in Manchester in 1903. Two years later the Theodor Herzl Memorial Home for the Jewish Sick, later renamed the Herzl-Moser Hospital, was opened in Leeds. The London Jewish Hospital, in the East End, was founded in 1919. After the outbreak of World War ii in 1939 most of the Jewish hospitals in Europe, apart from those in England, disappeared. Those in East Berlin, Hamburg, Vienna, Amsterdam, and Paris were reopened after 1945. With the exception of that in Hamburg, they are all far smaller than in prewar days. There are Jewish hospitals associated with other communities throughout the world. However, with the spread of state medical services, much of the original motivation has gone. They now serve primarily to assist those patients who feel more comfortable in a Jewish environment and who wish to receive kosher food.

In the U.S.

The early purpose of Jewish hospitals in the U.S. was the treatment of Jewish patients, who it was believed needed a medical environment which was Jewish. In German Jewish immigrants' places of origin, medical care had long been a Jewish communal function, and it was they who founded the first Jewish hospital in the U.S., Jews Hospital (from 1869, Mount Sinai Hospital), in New York in 1852. It was followed in 1854 by the Jewish Hospital of Cincinnati, which in the traditional manner of the hekdesh also provided shelter for the poor and transients during its early years. Hospitals founded by American Jews before 1900 were paralleled in some large cities by new ones founded by East European immigrants, who sometimes expressed discontent with the "un-Jewish" atmosphere at the established hospitals. After approximately 1920, when Jewish patients needed the Jewish medical environment less and less and they began to lose their foreignness, the Jewish hospitals tended to find as a rationale the necessity of providing professional opportunities for Jewish physicians who were victims of severe discrimination in hospital staff appointments elsewhere.

Some of the Jewish-sponsored hospitals in New York included Maimonides Hospital of Brooklyn, the largest general hospital in the United States observing kashrut, and among the first American hospitals to perform open-heart surgery; Mount Sinai Hospital; Montefiore Hospital, known for treatment of prolonged illness, teaching, and research; and Long Island Jewish Hospital with its outstanding premature nursery center; Beth Abraham Hospital for chronic disease; the Beth Israel Hospital; Bronx-Lebanon Hospital; Brookdale Hospital; Hospital for Joint Diseases; and Jewish Hospital of Brooklyn. Other hospitals under Jewish sponsorship in the U.S. included the Michael Reese and Mount Sinai hospitals in Chicago; Cedars-Sinai Medical Center in Los Angeles; the Albert Einstein Medical Center in Philadelphia; the Jewish Hospitals in St. Louis, Cincinnati and Louisville; the Sinai Hospitals in Baltimore, Cleveland, Detroit, Miami, Hartford, Milwaukee and Minneapolis; the Beth Israel Hospitals in Boston, Newark, Denver and Passaic; Cedars of Lebanon Hospital in Miami; Menorah Hospital in Kansas City; Miriam Hospital in Providence; and the Touro Infirmary in New Orleans. Jewish federations also supported chronic disease hospitals in Long Branch, New Jersey, Montreal and New York; tuberculosis and chest disease hospitals in Denver and Montreal; and psychiatric hospitals in Los Angeles, New York, and Philadelphia.

When medical discrimination declined after about 1950, the Jewish hospitals, many of which by then had only 10% to 25% Jewish patients, tended to be rationalized once again, this time as a Jewish service to the community at large.

Jewish hospitals and health services are still supported by Jewish federations. In addition to general hospitals, these federations maintain nursing homes and homes for the aged and infirm. Their help also extends to family welfare agencies, mental health programs, vocational counseling, child care centers, and summer camps.

At present, Jewish physicians can obtain training and admitting privileges at hospitals throughout the United States, and Jews often occupy leadership positions on hospital boards and medical staffs. Furthermore, during the post-World War ii period, Jewish communities tended to move to the suburbs. The traditionally Jewish inner-city hospitals experienced weakened financial positions as their patient bases included increasing percentages of uninsured or Medicaid patients.

In 1975, there were 33 Jewish-sponsored acute-care general hospitals in the United States. However, by late 1999, due to demographic and financial trends, fewer than half of these were being operated under their original ownership or sponsorship. Thirteen of the original 33 Jewish-sponsored hospitals formed or joined existing partnerships with nonsectarian or other facilities. For example, Beth Israel Hospital in Boston merged with Deaconess Medical Center, and New York's Mt. Sinai merged with New York University Hospitals.

However, the sales contracts for such mergers often included stipulations for continuity of Jewish care, such as kosher food and ritual circumcision. Jewish chaplains (see below) at hospitals across the country continue to assist with these services, as well as leading Sabbath and holiday celebrations, providing Torahs, prayer books, Bibles, Sabbath candelabra and other ritual objects, and serving as spiritual and pastoral counselors as well as sources for guidance in making medical ethical decisions.

Some communities came up with innovative solutions to the sale of their hospital properties. In Pittsburgh, for example, the Jewish community put the proceeds from the sale of its hospital into an endowment fund to be used solely to help needy Jews. Jewish communities continue to be prime supporters of medical institutions regardless of religious or other affiliations.

Some Jewish sponsored-hospitals ultimately found that they were not economically viable or for other reasons shut their doors. Yet other Jewish facilities have succeeded in remaining important and prominent communal resources, such as Cedars-Sinai Medical Center in Los Angeles and the Jewish Hospital in Louisville, Kentucky.

[Levi Meier (2^nd ed.)

Chaplaincy

Chaplaincy provides spiritual support, counseling, and a Jewish connection for people in institutional or community settings outside of a synagogue. Chaplaincy may include crisis support to individuals or their families, worship services, help with ethical decision-making, staff education and support, training volunteers, and forging connections with synagogues and community organizations. Chaplains are trained professionals, including rabbis, cantors, and lay people, who provide this care. Currently, the terms chaplaincy, spiritual care, and pastoral care are often used interchangeably. The following does not focus on military chaplaincy (see *Military Service) nor on the university setting (e.g., *Hillel).

Chaplaincy is based on Jewish values such as bikkur ḥolim (visiting the sick; Sot. 14a). However, this is a general obligation for Jews, not a professional discipline. The first individuals began working in chaplaincy in the late 19^th century, and the field itself emerged in the late 20^th century.

The earliest examples of salaried Jewish chaplains involved service to people in public institutions. The New York Board of Jewish Ministers (now the New York Board of Rabbis) established a visiting chaplain program for prisoners in 1891 which continues today. In Britain in 1892, the London County Council appointed ḥazzan Isaac Samuel as Jewish chaplain to the Colney Hatch Asylum. Rabbi Regina Jonas, the first woman to be ordained, served as a chaplain in Germany in the late 1930s before her deportation and death during the Holocaust.

A number of Jewish hospitals and nursing homes in the United States had a rabbi on staff by the early 20^th century. Their roles generally focused on leading worship and providing kosher food. There was little recognition of patient care or counseling as key roles, nor did chaplains create a professional field.

The experience of World War ii, when over 300 rabbis served as U.S. military chaplains, advanced the civilian field as well. Between 1945 and 1955 Jewish chaplaincy programs through Boards of Rabbis or Jewish chaplaincy agencies expanded significantly in New York, Chicago, Los Angeles, and Philadelphia.

Initially, Jewish chaplaincy focused on serving patients in Jewish hospitals and nursing homes and in state-run prisons or hospitals, although not every Jewish-sponsored facility had a Jewish chaplain. As health care changed by the 1980s, chaplains also began to serve Jewish patients in non-Jewish and secular facilities, and a number of community chaplains were appointed to serve multiple institutions.

Jewish chaplaincy had few formal training programs. By the 1980s, some rabbis pursued chaplaincy as a career through Clinical Pastoral Education (cpe), an intensive supervised internship initially developed by Protestants but increasingly pluralistic.

In 1990 the National Association of Jewish Chaplains (najc) was founded. In 1993 the group decided that nonrabbis could be full members, opening the door to women and men who were not ordained. In 1995 the najc instituted a program of certification, recognizing advanced chaplaincy training and experience. The organization collaborated with non-Jewish pastoral care organizations in the U.S. and Canada to advocate for increased chaplaincy in health care and to establish joint standards for certification, training, and professional ethics. By 2005, the najc included some 300 professional members from all streams of Judaism. The large majority were rabbis, but members also included cantors and lay people with advanced Judaic and cpe training. A significant number were women, including most of the non-rabbis. From 1996 the najc published a journal, Jewish Spiritual Care.

Chaplains work with patients from all Jewish backgrounds, including the many who are unaffiliated. Large numbers of professional chaplains work for long-term care/geriatric facilities. Significant numbers also are employed in hospitals, hospices, and community chaplaincy. Smaller numbers work for secular or interfaith agencies or for government agencies, including prisons, facilities for people with mental illness, and the Veterans' Affairs department.

Chaplaincy is organized in a number of ways. Many facilities employ chaplains directly. Local Jewish federations often support community chaplaincy programs through Boards of Rabbis, Jewish Family Services, or specialized agencies. Some chaplaincy programs operate in coordination with Jewish Healing Centers.

chaplaincy outside the u.s.

Chaplaincy programs exist in Canada and the United Kingdom. In Israel, the field is largely unknown, although a number of individuals work independently in the field of spiritual support. (Even the vocabulary for chaplaincy as understood in North America does not exist in Hebrew. Terms suggested include temikhah ruḥanit, "spiritual support," and livvu'i ruḥanit, "spiritual accompaniment.") In 2005, joint meetings were held in Philadelphia and Jerusalem between American Jewish chaplains and Israelis from the health care and social service fields, as well as from various streams of Judaism.

[Robert P. Tabak (2^nd ed.)]

bibliography:

in europe: H. Friedenwald, Jews and Medicine, 2 (1944), 514–22; R.R. Marcus, Communal Sick Care in the German Ghetto (1947); A. Phillipsborn, in: ylbi, 4 (1959), 220–34; in the united states: T. Levitan, Islands of Compassion (1964), incl. bibl.; Council of Jewish Federations and Welfare Funds, Yearbook of Jewish Social Services (1969). add. bibliography: T. Weil, "America's Jewish-Sponsored Hospitals: Being Assimilated Too?" in: Social Work, 34 (1998–99), Wurzweiler School of Social Work, Yeshiva University, vol. 34 (Winter/Spring), incl. bibl.; The Dictionary of Pastoral Care and Counseling (1990), s.v. "Chaplaincy"; R. Tabak, "Jewish Chaplaincy: Into the Twenty-first Century," in: Journal of Jewish Communal Service (Fall 1997); D.A. Friedman (ed.), Jewish Pastoral Care: A Practical Handbook from Traditional and Contemporary Sources (2001, 2005²); J.S. Ozarowski, To Walk in God's Ways: Jewish Pastoral Perspectives on Illness and Bereavement (1995).

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

In eighteenth- and early-nineteenth-century America, birth, sickness, and death took place in the home. Furthermore, medical care was not dominated by physicians. Indeed, the small number of physicians found in such communities as Boston, New York, Philadelphia, and Charleston were not the sole or even the major providers of health care. Ministers, midwives, wives, and a variety of other laypersons played important roles in caring for the sick and dying.

Many of the "hospitals" that existed prior to 1830 bore little or no resemblance to their modern counterparts. The majority, particularly those in urban areas, originally were associated with welfare and penal institutions. Philadelphia, for example, established a pesthouse to confine sick immigrants and thereby prevent epidemics. Indigent residents who were ill or insane were cared for at the municipal almshouse, which later evolved into the Philadelphia Hospital. A similar situation prevailed in other urban areas. In New York City, the House of Correction, Workhouse, and Poorhouse that opened in 1736 became Bellevue Hospital in 1816. Combining the functions of almshouse, workhouse, and penitentiary, these institutions provided some semblance of care for sick and disabled inmates, most of whom were indigent and dependent. The existence of such institutions also provided physicians with opportunities to learn their craft and to train younger men.

As late as 1800, only two institutions in the entire nation provided inpatient care for the sick, namely Philadelphia's Pennsylvania Hospital and New York City's New York Hospital. The idea for the former originated with Dr. Thomas Bond, who subsequently enlisted the aid of Benjamin Franklin. The need to provide suitable accommodations to care for poor and sick individuals (as compared with those with resources to pay for private care), as Franklin noted, seemed pressing. Moreover, he was concerned with the fate of inhabitants "who unhappily became disorder'd in their Senses, wander'd about, to the Terror of their Neighbours, there being no Place (except the House of Correction) in which they might be confined." After receiving a charter and a modest subsidy from the provincial assembly, the Pennsylvania Hospital received its first patient in 1752. The idea of creating a hospital in New York City originated with Dr. Samuel Bard, who believed that such an institution would facilitate medical education and elevate standards of medical practice. Receiving a royal charter in 1771, the New York Hospital had no sooner opened in 1775 when a fire destroyed the building. The ensuing war prevented its reopening until 1791.

During the American Revolution, military hospitals proliferated to provide care for wounded and sick soldiers, but they were short-lived. In 1798 Congress passed legislation that provided for the establishment of marine hospitals in seaports; they furnished temporary relief for sick and disabled seamen. After 1800 the pace of hospital founding began to accelerate. In 1811 the Massachusetts legislature, following the lead of elite Bostonians, passed an act of incorporation that created the Massachusetts General Hospital, which opened in 1821. A decade and a half later, a comparable institution was created in New Haven, Connecticut, to serve the needs of the Yale Medical School.

The few hospitals that existed before 1830 differed in fundamental ways from their modern counterparts. Individuals with resources would never be found in a hospital unless insane, taken sick during an epidemic, or involved in an accident while in a city away from home. Nor did hospital therapeutics differ from what could be done in a home. Indeed, the hospital was an institution created by elites to serve the needs of the less fortunate. Power within these institutions did not reside in medical hands; prominent laypersons played a dominant role in both admissions and the shaping of policy. The overwhelming majority of patients paid no fees; the costs were borne by philanthropic contributions. A small number of patients paid for their board and were provided with more comfortable quarters. In general, given the lower-class makeup of the patient population, these institutions possessed a paternalistic character.

When the Pennsylvania and New York Hospitals were founded, the care of the insane was one of their primary responsibilities. By the early nineteenth century, however, separate institutions for the insane had become more common. Claims by such figures as Samuel Tuke in England and Philippe Pinel in France that environmental changes (that is, moral or psychological therapy) could reverse the course of the debilitating condition of insanity provided a rationale for institutionalization. Quakers played important roles in establishing the Friends Asylum in Pennsylvania in 1813 and the Bloomingdale Asylum as a separate part of New York Hospital in 1821. The McLean Asylum for the Insane (a division of Massachusetts General Hospital) opened in 1818, followed by the Hartford Retreat for the Insane in 1824.

Yet the structure, financial base, and goals of these private institutions were such that they could not become the foundation of a comprehensive system of hospitals serving the entire community. Consequently, during the 1820s and 1830s a movement to create public mental hospitals gained momentum. The first such institution, at Williamsburg, Virginia, had opened in 1773. By the 1820s South Carolina, Kentucky, and Maryland had created their own institutions. But the most important event was the establishment of the Worcester State Lunatic Asylum in Massachusetts. Opened in 1833, it set the stage for a phenomenal expansion of public mental hospitals throughout the United States. Indeed, the population of these institutions was considerably larger than those found in private and voluntary hospitals for much of the nineteenth century.

If anything symbolizes the contemporary American health care system, it is the modern hospital and its commitment to technology. Two centuries ago, however, the hospital was a fundamentally different institution, providing care for destitute, disabled, and dependent persons whose very survival was at risk. The emergence of the hospital in its modern form would have to await the scientific and technological changes that transformed America in the late nineteenth and twentieth centuries.

See alsoMedicine; Mental Illness; Penitentiaries; Poverty; Professions: Physicians .

bibliography

Dowling, Harry F. City Hospitals: The Undercare of the Under-privileged. Cambridge, Mass.: Harvard University Press, 1982.

Eaton, Leonard K. New England Hospitals, 1790–1833. Ann Arbor: University of Michigan Press, 1957.

Grob, Gerald N. Mental Institutions in America: Social Policy to 1975. New York: Free Press, 1973.

Rosenberg, Charles E. The Care of Strangers: The Rise of America's Hospital System. New York: Basic Books, 1987.

Gerald N. Grob

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