HOSPITAL, MODERN HISTORY OF THE

Although a few Renaissance institutions supplemented charitable assistance with professional medical care, the hospital's gradual medicalization occurred from the seventeenth century onward, within changing social and scientific frameworks. Three distinct periods can be identified within this development: (1) the early shift of the hospital from welfare to medical establishment, 1650–1870; (2) the evolution of a successfully medicalized institution for all social classes, 1870–1945; and (3) the creation of a specialized showcase of scientific medicine, 1945 to the present.

From Welfare to Medicine: 1650–1870

During the early modern period, hospitals in Europe's urban centers were charitable shelters for the poor and working classes, functioning primarily as instruments of religious charity and social control with minimal involvement of the medical profession. Whether the patients were Catholic or Protestant, hospitalization continued to be an opportunity for physical comfort as well as moral rehabilitation. However, in time of epidemics such as plague and syphilis, specialized hospitals were created to ensure the isolation of the sick and thus avoid the spread of contagion. Given the expanding institutionalization of charity, the decline of religious institutions, and new roles in the preservation of public health, hospitals increasingly came under lay control, including municipal governments, fraternal organizations, and private patrons.

After 1650, new geopolitical agendas designed to increase the power and prosperity of the emerging national states pressed hospitals into new roles. Human life was given greater financial value as population policies were aimed at increasing the number of inhabitants as a base for state power, economic development, and military strength. Proponents of emerging European mercantilism viewed labor as the key source of wealth and urged that the nation's workforce be mobilized and kept at an optimum state of productivity. Within such a framework, the desire to promote the health of citizens inspired new programs of public health, hygiene, and medical care.

At the same time, more optimistic visions of health preservation and rehabilitation elaborated by Enlightenment thinkers suggested that sickness, instead of an inevitable, sinful, and often long-term human burden, could be controlled and eliminated. In addition to their traditional moral and physical aims, hospitals were now envisioned as institutions for physical rehabilitation and cure, places of early rather than last resort, especially for military personnel and the labor force. This agenda implied a greater involvement of the healthcare professions with large sectors of the population hitherto without such contacts.

To implement their new health policies, national governments, local authorities, and corporate professional bodies organized efforts to reform the existing medical and surgical professions. Physicians and surgeons were granted new forms of access to hospitals and given new rules to guide their institutional activities. Early models for the medicalization process came from military and naval establishments that provided for the sick and wounded members of Europe's expanding military forces. Later, medical professionals working in civil hospitals also began to argue successfully that their management of patients provided a valuable addition to the rest and food traditionally furnished to inmates in religious shelters. During the late eighteenth and early nineteenth centuries, medical objectives dramatically reshaped hospital routines from admission to the discharge or death of the patient. Acute rather than chronic illnesses were preferred; young rather than old patients were accepted. Rehabilitation and cure were the new goals.

HOSPITALS AS TRAINING INSTITUTIONS. At the same time, surgeons—and later physicians—recognized the great opportunities hospitals offered to improve their clinical skills and thus increase their power and status. By the eighteenth century, shifts in scientific ideology emphasized the importance of empirical studies and the construction of knowledge based on observed facts. Surgeons in France and Great Britain were especially keen to acquire practical knowledge of anatomy, pathology, and clinical management. After the French Revolution, physicians in that country initiated a new strategy of professional and social advancement under the banner of what was generically called the medicine of observation. With significant numbers of sick people assembled in hospital wards, doctors could observe at the bedside the evolution of individual diseases and their diagnoses on a much larger scale than they could in private practice. Postmortem dissections performed on former hospital inmates provided further information on the pathology responsible for the symptoms. Moreover, patient management offered unequaled opportunities to check the usefulness of the traditional medical regimens, especially the effects of older remedies. Efforts to upgrade the preparation and uses of drugs involved clinical trials and statistical analysis. Hospitals became the focal points of comprehensive bedside research programs.

Finally, the expanding medical and surgical presence in European hospitals made such institutions increasingly attractive as places for education and training of rank-and-file practitioners. Hospitals were seen as "great nurseries" that could "breed some of the best physicians and chirurgeons because they may see as much there in one year as in seven any where else" (Bellers, 1714). In certain establishments, the authorities created special teaching wards where professors and attendants, followed by their students, made regular rounds of the patients. Instruction varied greatly, from passive observation to supervised and even independent, hands-on examination and management of the patients by students and apprentices.

REORGANIZATION OF THE HOSPITAL STRUCTURE. How did the hospital as an institution adapt to these new agendas? France possessed several types of organizations, including massive hôpitaux générales, or hospices, for the elderly poor, beggars, vagrants, incurables, and prostitutes. There were also small welfare establishments at the parish level for similar cases. In larger urban areas, the traditional Hôtels-Dieux now limited admissions to the sick but excluded incurables, the insane, and venereal cases. All original ward layouts were based on medieval principles, providing in a shelter as many beds as possible and still crowding three to four individuals into each bed. Hospital size was fiercely debated, with advocates of medicalization arguing for smaller institutions to prevent cross-infections.

In Great Britain and the young American republic, major population centers possessed a number of voluntary infirmaries, or private hospitals, founded and operated by local philanthropists and often financed by a system of yearly subscriptions solicited from local merchants and professionals. Except for accident cases, these establishments admitted only a very restricted number of the sick poor. These persons, recommended for admission by the subscribers, were judged by the community to be willing to work and thus deserving of hospital care and rehabilitation. In addition, there were a number of private special hospitals, especially in London after 1800, supported by contributions and patient fees and operating under the direction of medical professionals. By contrast, English "poor law" infirmaries were supported financially by parish taxes and linked to local workhouses, which provided free care to the sick poor deemed able bodied, or vagrant, and thus undeserving of other charitable assistance. Later, in the nineteenth century, many of these workhouse infirmaries evolved into municipal hospitals and were placed under the direction of salaried medical superintendents. At the same time, and with financial support from leading local citizens, Great Britain also created a string of small cottage hospitals, providing paid medical care to those who could afford it.

To support expanding medical services and teaching activities, nineteenth-century hospitals required more money and changes in their physical plants and administrative organizations. By the 1870s, hygienic principles had come to dominate the construction and functioning of new establishments, now equipped with single beds for the sick and providing ample ventilation in their pavilion-type wards. Isolation chambers, surgical amphitheaters, emergency rooms, morgues, libraries, and outpatient facilities became indispensable adjuncts. Medical control also shifted power from patients and caregivers to attending physicians, thereby creating conflicts between traditional charitable practices and scientific goals of disease identification and management. Medicalization implied a shift from the primary focus on shelter and food for the needy to the diagnosis and treatment of diseases exhibited by sick patients.

A Hospital for All Social Classes: 1870–1945

Thanks in part to advances in medical knowledge and technology, the medicalization process of Western society was significantly advanced before the end of World War II. By 1900, upper- and middle-class patients in Europe and the United States were seeking and paying for medical care in hospitals. Staffed by competent medical and nursing professionals, and equipped with clinical laboratories and other diagnostic tools, hospitals became the preferred destination of those who were acutely sick and in need of surgical and medical care. The newly created demand for hospital care, spurred by urbanization and industrialization, expanded further to include the needs of birthing and child care.

In the United States, such requirements were eagerly met by the establishment of a vast, decentralized system of voluntary hospitals fiercely competing for community resources, physicians, and their patients. Local private citizens provided the necessary funds and volunteer service required to create general community hospitals. Alongside schools, police stations, and firehouses, U.S. general hospitals became emblems of community life, the pride of Main Street. In Europe, many hospitals became governmental facilities managed by paid professionals.

The new hospital mission was a result of converging ideologies, policies, and needs, some traditional, others new. Religious values and charitable donations still played an important role in the early 1900s, while developing economic tenets based on capitalism suggested that the health of workers in the industrial world was of great importance both to the state and to the private sector. In the United States, new social conditions favored the creation and utilization of more hospitals. Urbanization was accelerating at a rapid pace, bringing an ever-increasing number of adults into crowded city quarters. Among them were waves of new immigrants with multiple healthcare needs and few resources. Industrialization, in turn, created a new panorama of occupational diseases and accidents. Without the means or family networks to get the necessary help, many sick or injured individuals were thus forced to seek medical care in hospitals.

Under the new banner of scientific medicine, hospitals became the institutions of first rather than last resort. Thanks to the increasingly sophisticated diagnostic and therapeutic procedures offered in hospitals after 1900, optimistic Enlightenment notions of physical rehabilitation and cure were becoming a reality. Radiology, electrocardiography, and the clinical laboratory greatly improved the ability of hospital personnel to refine diagnoses. In addition to providing rest and a healthier diet, hospitals focused increasingly on managing acute diseases, especially life-threatening conditions that required intensive and highly technical care. A new generation of chemotherapeutic agents and vaccines improved the odds of success in the battle against certain diseases. Following the adoption of anesthesia and antisepsis, hospitals became the primary centers for surgical operations. Surgeons recognized the advantage of centralizing their new and expensive equipment within the surgical suites of a hospital.

THE CHANGING STATUS OF NURSES, PHYSICIANS. For patient care, hospitals relied increasingly on a new generation of nurses, drawn from the middle class and trained in professional education programs based on the model established by Florence Nightingale (1820–1910). Shedding their previous low-status role of cleaning women and servants, these new hospital nurses gradually displaced the dwindling number of religious staff members who had traditionally performed patient services. In time, the Nightingale nurses became valuable assistants to the medical profession in patient management.

By the 1910s, more physicians joined hospital staffs, staking their professional reputations on the achievements of scientific medicine such institutions seemed to make possible. In U.S. voluntary hospitals, medical staff organizations remained flexible, bestowing admission privileges on both local general practitioners and specialists who could deliver paying patients. In Great Britain, however, traditional social and professional barriers between general practitioners, on the one hand, and hospital-appointed physicians and surgeons, on the other, created insurmountable barriers in voluntary establishments. Although referring their patients to hospitals, the former were not allowed to practice within them. As so-called consultants, the latter operated small units and exclusively took care of a specific number of patients.

Since the hospital was rapidly becoming the physician's primary workshop in the 1920s, medical goals, including specialization, education, and research, needed to become top institutional priorities. Twentieth-century hospitals witnessed a dramatic growth of specialized care through the creation of clinical departments, an increase in student doctors, called house staff, and the performance of clinical research. Such activities became central to educational and licensing requirements, and conferred prestige and higher professional status on those allowed to work in the most preeminent institutions.

THE CHANGING FOCUS OF HOSPITALS. Once again the hospital as an institution adapted to these new agendas. Some new hospitals were associated or affiliated with medical and nursing schools. Others, especially in the United States, sprouted between 1890 and 1920 in ethnic urban neighborhoods, or strategic suburban locations, their creation influenced by state and local governments, population, philanthropy, or industry. Sectarian Jewish, Catholic, and Protestant institutions, German- and French-speaking clinics, municipal and state hospitals, private establishments sponsored by railroads and universities—all formed a constellation of autonomous units across the U.S. landscape.

In Europe, governments became increasingly involved in sponsoring and managing hospitals. In Great Britain, the Public Health Act of 1875 encouraged municipalities to establish isolation hospitals for persons suffering from infectious diseases. The poor law infirmaries were gradually taken over by local health departments and converted to general hospitals. The National Health Insurance Act of 1911 eliminated the charitable character of the voluntary hospitals and brought their services under the umbrella of regional healthcare schemes.

In the United States, hospital organizations in the 1920s changed to serve the new medical objectives and compete for paying patients, an ever-greater source of needed revenue. The rapid growth of medical technology generated further budgetary pressures, forcing voluntary hospitals to redouble their fundraising efforts and use endowment income for capital expenditures. As they became individual corporations in a competitive healthcare market, demands for greater efficiency prompted hospitals to bolster their administrations and institute stringent financial measures. Institutional care became a commodity, a product to be furnished mostly to those willing to pay for it directly or through health-insurance policies.

By the 1930s, economic conditions stemming from the Depression forced the creation of new funding systems, such as the Blue Cross health-insurance companies, organized by physicians. As competition for philanthropic support and patient revenue accelerated, accountability and public relations dominated the hospitals' administrative agendas. Since each U.S. institution was the proud product of individual community efforts, cooperation among hospital administrations was resisted.

As the hospital became the preferred locus for the application of scientific principles to medicine, new ethical problems appeared. The medicalization of life processes expanded the range of life experiences now addressed as medical problems by health professionals in hospital settings: Birth and death, formerly events that occurred in the home, now took place in the hospital. Since the early nineteenth century, a depersonalized, disease- and organ-centered approach had already replaced earlier holistic notions of sickness. As hospital routines became increasingly technical and standardized, patients came to be seen as merely embodiments of diseases that were the primary objects of inquiry and treatment. This approach affected the nature of the physician-patient relationship, as professionals focused primarily on successful problem solving in diagnosing and arresting human pathology. The physician's moral authority, hitherto based on personal qualities, now became grounded in scientific competence. Clinical experimentation became rampant, sometimes abusive, with few safeguards provided for the patients.

The Hospital as Biomedical Showcase: 1945 to the Present

Following World War II, the hospital rapidly consolidated its position as the embodiment of scientific and technologically sophisticated medicine. An explosion in medical knowledge led to the expansion of diagnostic and therapeutic services at hospitals. This development had far-reaching implications for institutional access, cost, and quality of care as delivered to a broad spectrum of the public under various private and state-sponsored health plans. The hospital's mission continued to reflect converging agendas, including the religious, political, economic, and scientific goals set in preceding decades.

In the United States, the federal government's involvement in sponsoring hospital care gradually expanded as the demand for institutional beds and services multiplied. Beginning with the Hill Burton Act in 1946, the federal authorities supported the existing system of decentralized, private hospitals—first, through the provision of construction subsidies, and later, through reimbursement schemes for services, such as the Medicare and Medicaid programs in 1966. This supportive rather than regulatory role preserved a network of independent and competing municipal, sectarian, and academic hospitals in each community. In marked contrast with events in Europe, the 1950s through the 1970s witnessed an impressive growth in U.S. hospital facilities, including neonatology and intensive-care units, imaging facilities, and transplantation services. Individual hospitals continue to operate as independent business organizations within a burgeoning healthcare industry. Periodic institutional accreditation by a joint commission of the American Medical Association and the American Hospital Association ensures compliance with a number of performance standards.

To work in hospitals of their choice, all practicing physicians in the United States must secure admission privileges in such institutions. Most hospital care is indeed rendered by private practitioners who briefly visit the hospital to check on the status of their patients. This system allows the establishment of larger and more mobile medical staffs whose authority remains diffuse. To exert some measure of control, medical staffs usually create a number of committees to deal with the issues of credentials, admissions, education, and quality control. (Hospital ethics committees grapple with a host of issues, from informed consent and patient autonomy to advance directives and the definition of death.) The resulting administrative complexity and instability require a great deal of consensus building, achieved through frequent meetings and written communications. This record keeping effort is especially important among the attending physicians and more permanent hospital personnel to achieve a necessary degree of internal standardization of medical and administrative procedures.

Hospitals in Europe, even those owned by municipalities or private bodies, continue to be closely supervised by central governments. All hospital planning, construction, management, and recruitment of medical personnel remains subject to state control. In Great Britain, the government has assumed responsibilities for ensuring free access to hospital care as a social right. The implementation of the National Health Service Act of 1946 brought about the outright nationalization of all hospitals and placed them under the authority of regional boards appointed by the government and responsible to the Ministry of Health. In many European communities, the larger municipal and voluntary hospitals erected more than a century earlier remain in full operation. Greater administrative uniformity has allowed for smaller staff requirements. Given these hospitals' outdated physical plants, limited technology, and often a lingering stigma from their charitable past, well-todo patients still prefer smaller, privately owned hospitals or clinics, many of which are still owned or managed by religious orders.

European hospitals operate with closed, full-time medical staffs hierarchically organized within smaller, autonomous divisions, each of which operates its own clinical, diagnostic, and rehabilitative services. While such internal arrangements reduce administrative overhead and foster more stable relationships among patients, physicians, and nurses, the schism between hospital and private practice remains. In Great Britain, this decentralized staffing framework follows the traditional, voluntary models of allocating a specific block of beds to each hospital physician or consultant, who is assisted by a stratified junior medical staff in training for specialist status.

Financial Difficulties of Hospitals

Although outpatient facilities are quickly becoming an integral component of professional education, hospitalbased training continues to be the backbone of all medical education programs. Given the range of diagnostic and therapeutic options available, hospital practice remains at the center of biomedicine, providing the specialized clinical experience and technical proficiency required for today's professional status. With medical specialization and subspecialization on the rise, U.S. hospitals have expanded dramatically and have extended their residency training programs. As a result, physicians in training exercise greater management responsibility and are better remunerated than ever before.

Due to restrictive reimbursement schemes instituted by government and the private insurance industry, and the escalating costs of technologically assisted medical care, together with a gradual fragmentation of the medical marketplace, many U.S. hospitals find themselves increasingly under siege, victims, in part, of their previous success. Excessively bureaucratized and inefficient, their physical facilities overexpanded, hospitals are struggling to maintain their patient volumes as costs continue to increase. Unable to survive in a highly competitive environment, some institutions have already merged while others are closing wards or their doors altogether, thus forcing a major restructuring of the entire medical-care delivery system. Many hospitals are being reorganized into for-profit corporations, extending their services into networks of clinics and practitioners, and offering health insurance and service plans.

Conclusion

Ultimately, the evolution of the hospital in recent centuries poses the central question of whether care is still the primary function of this institution. While subjected to competing agendas—including religious beliefs, social control, secular philanthropy, scientific curiosity, communal pride, and economic autonomy—the hospital's original purpose was to shelter and comfort all sufferers in need. To a great extent, hospitals now restrict admission to seriously ill patients who require the most sophisticated diagnostic and therapeutic measures. The tilt toward acute episodes of physical illness, complex technological interventions, and the increasing costs of confinement have made hospital stays episodic and brief. Bureaucratization, financial constraints, and the pervasive presence of instrumentation only accentuate the essential impersonality of institutional care. The trade-offs are clear. Three centuries of medicalization transformed the hospital from a caring shelter for the poor into a diseaseoriented machine for the sick who can afford to be cured.

gÜnter b. risse (1995)

bibliography revised

SEE ALSO: Aging and the Aged, Societal Aging; Care; DNR; Ethics: Institutional Ethics Committees; Informed Consent; Long-Term Care; Medicaid; Medical Education; Medicare; Mergers and Acquisitions; Patients' Rights; Research Ethics Committees

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