What Was The Characteristics Of Medical Services In Pre-industrial America

Patient at the Philadelphia Hospital (Philadelphia General Hospital) receiving eye handling, 1902The evolution of hospitals in the Western world from charitable guesthouses to centers of scientific excellence has been influenced by a number of social and cultural developments. These influences have included the changing meanings of illness, economics, geographic location, religion and ethnicity, the socioeconomic status of clients, scientific and technological growth, and the perceived needs of populations.[1]

A nursing tradition developed during the early years of Christianity when the benevolent outreach of the church building included not only caring for the sick but also feeding the hungry, caring for widows and children, clothing the poor, and offering hospitality to strangers. This religious ethos of clemency continued with the rapid outgrowth of monastic orders in the fifth and sixth centuries and extended into the Middle Ages. Monasteries added wards, where to care meant to requite comfort and spiritual sustenance. Religious orders of men predominated in medieval nursing, in both Western and Eastern institutions. [two] The Alexian Brothers in Germany and the Low Countries, for case, organized treat victims of the Blackness Plague in the fourteenth century. Also at this fourth dimension, cities established institutions for people with contagious diseases such every bit leprosy.

During the medieval and early Renaissance eras, universities in Italian republic and later on in Germany became centers for the education of medical practitioners. The thought that one could recover from illness too expanded,[3] and by the eighteenth century, medical and surgical treatment had become paramount in the care of the sick, and hospitals had adult into medicalized rather than religious spaces. They also grew in size. Big hospitals, consisting of a thousand beds or more, emerged during the early nineteenth century in France when Napoleon established them to house his wounded soldiers from his many wars. These hospitals became centers for clinical teaching. [4] Then in 1859, Florence Nightingale established her famous nursing school—so influential on future nurses' training in the United States—at St. Thomas's Hospital in London.

In the United States, cities established isolation hospitals in the mid 1700s, and almshouses devoted to the sick or infirm came into existence in larger towns. Yet, almshouses were not intended to serve strictly medical cases since they also provided custodial care to the poor and destitute. Benjamin Franklin was instrumental in the founding of Pennsylvania Hospital in 1751, the nation'southward first such establishment to treat medical atmospheric condition. Physicians also provided the impulse for the establishment of early hospitals every bit a ways of providing medical education and as a source of prestige. [v] For about of the nineteenth century, nonetheless, only the socially marginal, poor, or isolated received medical intendance in institutions in the United States. When middle- or upper-class persons fell ill, their families nursed them at habitation. [half-dozen] Even surgery was routinely performed in patient's homes. By late in the century, however, equally lodge became increasingly industrialized and mobile and every bit medical practices grew in their composure and complexity, the notion that responsible families and caring communities took care of their ain became more difficult to use. The result was a gradual shift toward the professionalization of health care practices that eventually included the evolution of a full and competitive commercial market for medical services that increasingly took place in hospitals. [seven] Nursing played a pregnant role in the move from home to hospital. Every bit historian Charles Rosenberg wrote in his classic book, The Care of Strangers, the professionalization of nursing was "perhaps the near important single element in reshaping the 24-hour interval-to-day texture of hospital life." [eight]

Privately supported voluntary hospitals, products of Protestant patronage and stewardship for the poor, were managed by lay trustees and funded by public subscriptions, bequests, and philanthropic donations. By contrast, Catholic sisters and brothers were the owners, nurses, and administrators of Catholic institutions, which, without a large donor base, relied primarily on fundraising efforts along with patient fees. Public or tax-supported municipal hospitals accepted clemency patients, including the aged, orphaned, ill, or debilitated. Some physicians established proprietary hospitals that supplemented the wealth and income of owners. Owners of not-for-profit voluntary and religious hospitals on the other mitt took no share of hospital income. Physicians likewise developed specialties such as ophthalmology and obstetrics and opened their own institutions for this new kind of practise. [nine]

Even so, argues historian Rosemary Stevens, at the beginning of the twentieth century, "the hospital for the sick was becoming 'more than and more a public undertaking.'" [10] A national census of chivalrous institutions, which included voluntary, religious, and public or governmental institutions, was published in 1910. Of all the patients admitted for that year, 37 percent of adults were in public institutions. [eleven] The same demography documented public appropriations according to class of institutions. Public funds included all those from federal, state, canton, or municipal sources. Of 5,408 institutions reporting (hospitals, dispensaries, homes for adults and children, institutions for the blind and the deaf), 1,896 (35 percent) were recipients of public assistance from i source or another. Looking just at hospitals, 45.6 percent of them received public appropriations, although they received the largest part of their income from patients who paid either or all of their hospital charges. However, for all institutions taken together, 31.8 percent of their total income was from public finds. These figures should be interpreted with circumspection, since hospitals in 1910 did not use the aforementioned cost accounting principles that we use today. Notwithstanding, the census data suggested that an awareness of the need for public support of hospital care was increasing. The actual amounts of public appropriations received during 1910, co-ordinate to geographic region, are shown in Table 1. Regional variations occurred, and there was a predominance of public help to hospitals in the Northeast.

Tabular array 1: Public Appropriations Received past Hospitals During 1910

Source: U.South. Agency of the Census, Chivalrous Institutions, 1910 (Washington, D.C.: Regime Printing Office, 1913), 73.

Other regional variations in hospital evolution reflected regional economic disparities, particularly in the South and Westward, where less private upper-case letter was bachelor for private philanthropy. This hindered the creation of voluntary hospitals. [12] Religious institutions were ofttimes the first ones congenital in these areas. Between 1865 and 1925 in all regions of the Us, hospitals transformed into expensive, modern hospitals of science and applied science. They served increasing numbers of paying middle-grade patients. In the process, they experienced increased fiscal pressures and competition.

One of the defining characteristics of hospitals during this period was the mode the ability of science increasingly afflicted hospital decisions. Past 1925, the American hospital had go an establishment whose goals were recovery and cure to exist achieved by the efforts of professional personnel and increasing medical applied science. Hospitals functioned with the advantages of x-rays, laboratories, and aseptic surgery, making hospital operating rooms, with all their technical equipment and specialized personnel, the safest and almost user-friendly places to perform surgery. [13] As nurses became more important to hospitals, and so hospitals became sites for nursing education. In hospital-based nurse training programs, nurses learned under the apprenticeship organization, with hospitals utilizing students to provide much of the patient care while graduate nurses went into private duty. During the Smashing Depression, however, equally fewer people could afford private duty nurses, more graduate nurses returned to piece of work in these institutions, although they worked at reduced wages.

Operating room scene at Philadelphia General Hospital, c. 1925

In 1932, during the nadir of the Great Depression, a hospital demography conducted by the Council on Medical Education and Hospitals revealed a shift of usage from privately endemic hospitals to public institutions. In that location were half dozen,562 registered hospitals, a decrease from the 6,613 reported by the previous census. Of the 776 full general hospitals run by the regime, 77.i percent occupied at capacity. By dissimilarity, only 55.9 percentage of the three,529 nongovernmental full general hospitals were filled. Still, between 1909 and 1932, the number of infirmary beds increased six times every bit fast every bit the general population (Effigy 1), leading the Quango to assert in 1933 that the country was "over hospitalized." [14] Meanwhile, patients were turning to a new method of paying for hospital charges equally Blue Cross insurance plans became more and more pop and accounted for a greater percentage of hospital financing.

Figure i: Infirmary Capacity and General Population, 1872-1932

Source: "Hospital Service in the United states of america: Twelfth Almanac Presentation of Infirmary Data by the Council on Medical Education and Hospitals of the American Medical Association," JAMA 100, 12(March 25, 1933): 887.

A surge of demand occurred later on World War II. Although federal, state, and local governments had given some back up to hospitals earlier in the century, the government became increasingly of import in the health care system later the war, adding huge amounts of money to hospital enterprises: The Hill Burton Act in 1947 provided funds for the construction and expansion of community hospitals. The National Institutes of Health expanded in the 1950s and 1960s, stimulating both for-profit and non-profit research. Moreover, Medicare and Medicaid, established in 1965, provided money for the care of the anile and the poor, respectively. [15]

For all its support, all the same, the costs of hospital care grew even faster. As Rosemary Stevens argues, from its inception, Medicare costs surpassed projections. In 1965, for example, Medicare costs were projected to be $3.1 billion. 5 years later on, however, they reached $5.8 billion, an increase of 87 percent. Less than 10 percent could exist linked to expanded utilization; 23 percent to rapid economical inflation; and the remaining two thirds to "massive expansions in hospital payroll and non-payroll expenses —including 'profits,'" with a doubling of average patient-day costs betwixt 1966 and 1976. [16]

In the 1950s, 1960s, and 1970s, rising public expectations for nursing and medical omnipresence as well as the recognition past nurse and physician reformers that some patient-care procedures were unsafe drove a reorganization of nursing care. In the hospitals themselves, intensive care units grew and machines became ever more prevalent. Both of these developments required greater expertise among nurses. Nursing education began the move from 3-yr hospital-based diploma programs to iv-year baccalaureate programs in colleges and universities. By 1965, over 90 percent of large hospitals and 31 percent of smaller ones had intensive care units staffed by increasingly practiced nurses. [17]

In 1970, the American Hospital Clan listed 7,123 hospitals in the United States, up 247 from 1960. During this decade, however, a major shift had occurred in infirmary utilization. The number of beds in federal, psychiatric, tuberculosis, and other long-term care facilities had declined, while, aided by government funding, community hospitals increased their bed capacity by 32.7 percent (Table ii). These nonfederal, short-term care institutions that were controlled past community leaders and were linked to the community's physicians to meet community needs represented 82.3 percent of all hospitals, contained over half of all hospital beds, and had 92.1 per centum of all admissions.

Table 2: Selected U.Southward. Infirmary Statistics, 1960 and 1970

Source: "The Nation's Hospitals: A Statistical Profile," Infirmary Statistics 45, Part two (August 1, 1971): 447.

Customs hospitals too offered more comprehensive and complex services such every bit open heart surgery, radioisotope procedures, social work services, and in-house psychiatric facilities. [xviii] The growth of these hospitals, along with the advent of new treatments and new technologies, contributed to escalating in-patient hospital costs, leading the federal government to impose wage and cost controls on hospitals in 1971. Indeed, the years afterwards 1965 and the passage of Medicare and Medicaid were pivotal for everyone in health intendance because of increased government regulation. Medicare incorporated a prospective payment organization in 1983, with federal programs paying a preset amount for a specific diagnosis in the form of Diagnostic Related Groups, or DRGs. [19] As third political party payers gained power and status, DRGs radically changed Medicare reimbursements. They also considerably contradistinct hospital decisions, with a focus irresolute toward greater efficiency. [20]

The 1980s also witnessed the growth of for-profit hospital networks, resulting in increased vulnerability of smaller not-for-profit institutions. More than 600 community hospitals closed. [21] It was at this fourth dimension that both for-profit and not-for-profit institutions began forming larger hospital systems, which were meaning changes in the voluntary hospital arena. A organization was a corporate entity that endemic or operated more than than one infirmary. This likewise has come up about with the advent of DRGs as single wellness care facilities seek to affiliate to cutting down on duplication of costs.

Cost containment was the theme of hospitals in the 1990s. The balance of power in these institutions shifted from caregivers to the organized purchasers of intendance, with Medicare and Medicaid condign a huge governmental influence in all types of hospitals. In the private sector, insurance companies began to take a more than active role in managing hospital costs. Health maintenance organizations, which contracted with a network of providers for discounted prices, increased in importance. The focus of care shifted to outpatient services, convalescent care centers for acute care, and hospices and nursing homes for the chronically ill. [22 ] Then in 1997, the Balanced Upkeep Act decreased Medicare payments to hospitals by $115 billion over 5 years, including a projected $17 billion reduction in Medicare payments to hospitals. [23]

At the plow of the twenty-beginning century, rising costs have forced many hospitals to close, including public hospitals that have traditionally served equally safety nets for the nation's poor. Some of the larger non-for-turn a profit corporations have bailed out public facilities through lease arrangements, such as the one between the Daughters of Charity'southward Seton Medical Middle and the public Brackenridge Hospital in Austin, Texas, that occurred in 1995. [24] These types of arrangements take had their own problems, however, such as the complications that ascend when a large secular organization such as Brackenridge tries to join forces with a infirmary whose policies are dictated by its religious affiliation.

If the professionalization of nursing has had the important result on the quality of the infirmary experience that Charles Rosenberg has suggested, the changes in the nature of hospitals take had a profound effect on the profession of nursing, since the vast majority of nurses practice in a hospital setting. The time to come of both the infirmary every bit an establishment and nursing equally a profession volition depend on the decisions we make in the coming years near how wellness care is provided and to whom.

References

[1] Guenter B. Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York: Oxford University Press, 1999).

[ii] Vern Fifty. and Bonnie Bullough "Medieval Nursing," Nursing History Review 1 (1993): 89-104.

[3] Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Noesis and Practice (Chicago: University of Chicago Press, 1990).

[4] Risse, Mending Bodies.

[v] Paul Starr, The Social Transformation of American Medicine (New York: Bones Books, 1982); James H. Cassedy, Medicine in America: A Short History (Baltimore: Johns Hopkins University Press, 1991).

[six] Starr, The Social Transformation of American Medicine; Charles East. Rosenberg, The Care of Strangers: The Rise of America'due south Hospital System(Baltimore: Johns Hopkins University Press, 1987).

[7] Barbra Mann Wall, "Healthcare as Product: Cosmic Sisters Face up Charity and the Hospital Market place, 1865-1925," in Commodifying Everything: Relationships of the Market, ed. Susan Strasser, 143-68 (New York: Routledge, 2003).

[eight] Rosenberg, Intendance of Strangers, eight.

[9] Rosenberg, Care of Strangers; Starr, The Social Transformation of American Medicine; Cassedy, Medicine in America.

[10] Rosemary Stevens, " 'A Poor Sort of Memory': Voluntary Hospitals and Authorities before the Depression," The Milbank Memorial Fund Quarterly, Health and Society lx (1982): 558.

[xi] U.S. Bureau of the Census, Benevolent Institutions, 1910 (Washington, D.C.: Authorities Printing Office, 1913): 69.

[12] Rosenberg, Intendance of Strangers, 110, 121; Starr, Social Transformation, 170-71.

[13] Rosenberg, Care of Strangers; Wall, Unlikely Entrepreneurs.

[14] "Infirmary Service in the U.s.: 12th Annual Presentation of Hospital Data by the Council on Medical Education and Hospitals of the American Medical Clan," Journal of the American Medical Clan 100, no. 12 (March 25, 1933): 887.

[15] Daniel Callahan and Angela A. Wasunna, Medicine and the Market: Disinterestedness v. Choice (Baltimore: Johns Hopkins University Press, 2006).

[16] Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (Baltimore: Johns Hopkins Academy Press, 1989, 1999), 286-87.

[17] Julie Fairman and Joan Lynaugh, Disquisitional Care Nursing: A History (Philadelphia: Academy of Pennsylvania Press, 1998).

[18] "The Nation's Hospitals: A Statistical Profile, Hospital Statistics 45, Part 2 (Baronial ane, 1971): 447.

[nineteen] Phil Rheinecker, "Catholic Healthcare Enters a New World," in Christopher Kauffman, A Delivery to Healthcare: Jubilant 75 Years of the Catholic Health Association of the United States, (St. Louis: The Catholic Health Association of the Us, 1990), 44; Mike Brennan, "Hospitals Competed in Changing Times," Everett Herald, August 15, 1993, n.p.

[twenty] Harry A. Sultz and Kristina M. Young, Health Care United states of america: Understanding Its Organization and Commitment (Sudbury, MA: Jones and Bartlett Publishers, 2006).

[21] Thomas R. Prince and Ramachandran Ramanan, "Operating Performance and Financial Constraints of Cosmic Community Hospitals, 1986-1989," Health Care Direction Review nineteen, no. iv (1994): 38-48.

[22] Stevens, In Sickness.

[23] Dana Beth Weinberg, Code Dark-green: Coin-Driven Hospitals and the Dismantling of Nursing (Ithaca, NY: Cornell University Press, 2003).

[24] Kim Sue Lia Perkes, "Seton, Austin, working on Brackenridge lease," Austin American Statesman, August 20, 1998.

Barbra Mann Wall is the Thomas A. Saunders III Professor of Nursing and Director of The Eleanor Crowder Bjoring Middle for Nursing Historical Research, University of Virginia School of Nursing.