The Growth of Hospitals in the 1700s

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The Growth of Hospitals in the 1700s

Overview

Throughout the eighteenth century hospitals opened in the larger cities of Europe and America as industrialization developed and the middle class expanded in those countries. These hospitals were very different from the kinds of hospitals seen in Western and Arabic cultures since early in the Christian era. By 1800 the hospital in the West was becoming an integral part of medical care and education in urban areas. Within another century, the hospital would be at the center of medical practice.

Background

A hospital can be defined as a location for the acceptance, care, and treatment of the sick. In ancient Egypt, Greece, and Rome healing was often associated with the temples of particular deities. The staff of Aesculapius, a walking stick branched at the top with a snake wrapped around it, has long been a symbol of medicine, and today is the official insignia of the American Medical Association. Aesculapius was the god of medicine in Greek and Roman mythology, and the snake was his symbol. By the fifth century b.c. several temples to Aesculapius were active in Greece.

At about the same time, secular healing in the tradition of Hippocrates (c. 460-377 b.c.) developed in Greece, and public physicians appeared in Athens. As the Roman Empire grew in later centuries, provisions were made for the care of sick slaves and soldiers, since the culture was so dependent on both. Throughout Europe and the Middle East in the centuries before Christ's birth, travelers attending festivals or making pilgrimages to holy sites received medical care if they became ill.

Care of the sick became an important element of the faith from the earliest days of the Christian era. Jesus had included an obligation to visit the sick as among the essentials for salvation. By the third century a.d., as it spread rapidly throughout the Roman Empire, Christianity assimilated the secular healer, or physician, and the healing shrines from pagan cultures. Some churches, such as that in Antioch around 340 under Bishop Leonitios, operated houses for the poor that included medical care as needed. Monks living together in monasteries cared for their own sick members, and sometimes constructed attached facilities for sick townspeople or travelers. Around 450, a monk named Theodosius built three structures near Jerusalem to house monks and poor and wealthy individuals who were ill. Thus by the middle of the first millennium a.d. buildings constructed especially for care of the sick had appeared in a number of locations in Christian Europe and the Middle East. These facilities seldom lasted more than a few years, often disappearing when a founder or sponsor died.

In the Arabic world, larger cities such as Cairo, Baghdad, and Damascus had hospitals by the tenth century. Over the next several centuries Arabic authors associated medical teaching with hospitals, while Christian writers did not. This practice appears to be one of several in which Islamic medicine eventually influenced its Western counterpart as empires and cultures rose and fell during the Middle Ages.

Throughout medieval Europe hospitals continued to appear as towns grew and trade increased. Most were associated with a church or monastery, and sponsored by a wealthy patron whose support demonstrated both social position and Christian charity. Patients in these small hospitals were either poor or elderly without local family support networks or travelers and pilgrims. Around 1400 several hundred such facilities operated in England alone; dozens of earlier such institutions had disappeared. These hospitals might have as few as two or three patients or as many as thirty.

A new model of a more complex hospital developed in such large trade centers as Florence, Italy, and Paris, France. By 1400 Florence had some thirty hospitals caring not only for the poor but also for growing numbers of tradesmen and merchants. Each hospital might be supported by a group of individuals or trade guilds instead of a single benefactor. The largest hospital in Florence at this time, S. Maria Nuova, had been founded in 1288 and by the fifteenth century had 230 beds served by six visiting physicians, a surgeon, and three junior staff members. Despite the size of this facility, medical care of this time was still extremely limited in its efficacy. Surgery would be performed for only a small number of acute injuries, since pain relief remained crude until the development of anesthesia in the 1840s.

Between 1106 and 1247 four hospitals—St. Bartholomew's, St. Thomas's, Christ's and Bethlehem—were founded in London in conjunction with monasteries. By the mid-1500s the monastery system was dissolving, and the hospitals had been sold to the city and reopened as more secular institutions. Support staff members were more likely to be recruited from former patients or local poor than from religious orders; this pattern would continue until well into the nineteenth century. St. Thomas had 203 beds by 1569, and several surgeons and physicians. Thus in the several centuries before 1700, hospitals in large European cities expanded in size and were transformed from largely religious to more secular institutions.

Impact

Another important aspect of hospital development in Europe appeared just after 1700 in the city of Leiden, in what is now the Netherlands. At the University of Leiden, medical professor Hermann Boerhaave (1668-1738) expanded and made systematic the practice of earlier teachers in both Leiden and Padua, Italy, who had taken their apprentices on rounds through patient wards at local hospitals. Boerhaave developed a ward of twelve patients at the Caecilia Gasthuis hospital for use in his medical teaching. His students followed him on rounds through the ward, observing his interactions with patients and listening to his comments on various diseases and conditions exhibited by the sick. This model of clinical rounds at university hospitals for the purpose of education continues today in medical schools around the world. Yet in Boerhaave's time interaction with patients was unusual in medical education.

Boerhaave's students soon spread his teaching methods to other European cities such as Vienna, Austria, and Edinburgh, Scotland. At the Royal Infirmary of Edinburgh in 1748, John Rutherford (1695-1779), a University of Edinburgh professor of medicine, persuaded the managers to let him organize formal medical teaching in the wards. Six years later, three more professors—Alexander Monro secundus (1733-1817), William Cullen (1710-1790), and Robert Whytt (1714-1766)—took over the separate ward organized by Rutherford and managed it in two-month rotations for several years.

In the late 1700s the French Revolution swept away many institutional structures in that country. Some historians have argued that hospital medicine changed radically as well. Other historians note that changes seen after the revolution, especially in the Parisian hospitals, had been developing in large European hospitals for decades or longer. Many of these changes did coalesce in the Paris hospitals by the early 1800s. Doctors in urban areas increasingly moved their practices and educational efforts into the hospitals. As physicians began to organize to protect their profession and increase their social status, hospitals served as a central location for these efforts. Parisian doctors such as Philippe Pinel (1745-1826), R.T.H. Laënnec (1781-1826), and Pierre Louis (1787-1872) began to correlate signs and symptoms in the sick with pathological conditions found during autopsies of deceased patients.

The number of hospitals in London and elsewhere in Britain continued to increase during the eighteenth century. Westminster opened in 1719 in London, followed by Guy's (1721), St. George's (1733), London Hospital (1740), and Middlesex (1745). In the provinces Winchester was established in 1736, and 20 more soon followed in major towns. Older towns tended to open hospitals first, followed by new industrial-era cities such as Manchester and Birmingham. In Scotland the Edinburgh Royal Infirmary opened in 1729. Medical staff were involved in these institutions from the beginning, and in Edinburgh provisions were also made for students.

In Austria, Emperor Joseph II initiated the Allgemeines Krankenhaus, a huge civic hospital complex near Vienna. Joseph planned to convert an almshouse just outside the city into a modern, 2000-bed hospital divided into sections for medical, surgical, venereal, and contagious patients. This hospital opened in August 1784, but immediately began to incur huge debts. Despite Joseph's death in 1790, the hospital remained open; by 1797 over 14,000 patients visited the hospital each year.

Hospital growth in the United States was much slower. By 1800 America had just five million in total population, with most people living in rural or frontier areas of the country. Only two significant hospitals had been established by that date. Pennsylvania Hospital in Philadelphia opened in 1752, and New York Hospital in 1771. In the first few decades after 1800 many more hospitals opened in the large cities of the northeast.

By the end of the eighteenth century the outlines of the modern Western hospital were in place in the urban areas of Europe and America. The religious impulse behind hospital creation in ancient and medieval times continued, but was supplemented by civic and private philanthropy. Doctors in urban areas moved some or most of their practices into the hospital setting. Many hospitals allowed local medical school faculty to use their facilities for clinical training to supplement classroom lectures or apprenticeships.

However, another century would pass before the modern hospital finally appeared. Throughout the nineteenth century hospitals remained a place primarily for the poor; wealthy individuals continued to receive care at home when possible. The development of anesthesia in the 1840s and the discovery of bacteria and the need for cleanliness several decades later meant that by 1900 more complex surgeries were possible in the hospital and survival rates were better. More complex anesthesia requiring bulky machines also developed by 1900, meaning that most surgeries had to be done in hospitals for the sake of both convenience and cleanliness.

A. J. WRIGHT