The remaking of American hospitals began in the 1800s, and it was a remarkable process. Hospitals once served a very different role in society:
Medieval hospitals were conducted by religious or knightly orders and had a strong communal character; those who worked there were also bound together in a common identity and belonged to a common household. “Even when hospitals were taken over from the ecclesiastical authorities by municipalities in the later Middle Ages,” writes George Rosen, “they were not secularized. Essentially, the hospital was a religious house in which the nursing personnel had united as a vocational community under a religious rule.” In a different way, the almshouses of colonial America, which were the first institutions to care for the sick, retained a communal character. The colonial almshouse, David Rothman writes, provided a “substitute household: for people without a home who were poor or sick. “The residents were a family, not inmates.” Even the architecture of the colonial almshouse, which resembled an ordinary residence, reflected its conception as a household.
A key phrase above is “for people without a home.” For those who had family or were otherwise part of a community, care was provided in the home. Even the indigent poor were generally cared for in homes, until the government had a better idea:
In the colonial period, the almshouse was a secondary response to poverty and illness. As I indicated earlier, the colonists preferred to provide relief to the poor in their own homes, or to pay neighbors for taking care of them. But after about 1828, there was a shift in policy as states abolished home relief. By making the almshouse the only source of governmental aid to the poor, legislatures hoped to restrict expenditures for public assistance.
Eventually hospitals took over the role of taking in those of need of help and performing a sort of triage:
The contagiously ill they sent to the pesthouse, and the incurable and chronically ill, as well as those whom they thought wicked and undeserving, they sent to the almshouse. Such exclusions enabled the hospitals to restrict the number of patients they admitted and to keep down the reported mortality rates, since the hopelessly ill could be directed or transferred elsewhere before they became a blot on the hospital’s good name. This practice was encouraged by the medical staff, since the hospital would be less useful as a source of instruction to students if it filled up with chronic cases.
As industrialization progressed, the need for hospitals increased:
[Until 1870] hospitals had been formed mainly to take care of people who did not fit into they system of family care. The earliest hospitals were built chiefly in ports or river towns—Philadelphia, New York, Boston, New Orleans, Louisville—centers of commerce where strangers were likely to be stranded sick or where people were likely to be found working and living alone. Institutioinal charters and appeals for funds alluded to the needs of such people. In 1810, when Doctors James Jackson and John C. Warren circulated a letter to some of the “wealthiest and most influential citizens” of Boston to interest them in a hospital, they mentioned, as cases in need, journeymen mechanics living in boarding houses, widowed or abandoned women, servants, and others who had no adequate housing or kin to care for them.
As with other social institutions originally established to care for the needy, such as public schools and Sunday schools, those who were able to provide for their own needs in this area began to see the convenience of paying someone else to provide that care, thereby freeing them from the burden of family obligations. It wasn’t long before hospital care had become respectable, with middle-class families first offloading the care of relatives, then eventually turning to hospitals for their own care.
An interesting side note: American hospitals are apparently unusual in that a patient usually remains under the care of his own physician while in the hospital. In other countries the hospital takes full responsibility for the patient from his physician once he enters their care.