Model of a hospital promoting the King Edward's Hospital Fund for London, England, 1932
Preventing infection in hospitals
Today, hospitals are central to the delivery of medical and surgical care. However, in past centuries most people would have avoided entering them. Hospitals were often a place of ‘last resort’ associated with poverty, infection and death.
Healing and gods - the start of hospitals
From as early as 4000 BCE there were places of healing associated with certain gods or deities, such as Asklepios in both the Greek and the Roman Empires. In India and Sri Lanka hospitals were established by the late 200s BCE. From the 100s BCE, valetudinaria were established in the Roman Empire; based on the archaeological evidence, it is sometimes unclear whether these buildings were used to house the poor, isolate the sick or provide medical care. Some may have offered medical treatment only to Roman soldiers, on whose health the empire depended, while others might have been rest-houses for the weak and dying. The idea of a hospital as a teaching centre, where doctors learned their craft, can first be documented for Baghdad in the 900s.
Christian hospices first developed in the East in the late 300s. Some, like those founded by the Order of St John, appeared along routes of pilgrimage and offered shelter to religious travellers throughout Europe and the Middle East. The idea of religious charity lay at the heart of the medieval and early modern hospital. Medicine and morality were closely tied. This was evident in the location of beds, which was often determined by the location of an altar. Medical care was usually delivered by monks and uns.
Christian hospitals: care rather than cure?
The Christian practice of charity in Europe was based on the relationship between Christ and the pauper. The emphasis in hospital was therefore on care rather than cure, and the common denominator of patients was poverty, not illness. The original religious nature of early hospitals is still alive, most often in their names. Notable examples include the Hôtel Dieu in Paris, originally established in the 800s, and St Bartholomew's Hospital in London, which was founded in the 1100s and still exists today.
Hospitals in the Islamic Empire
Religious motivations were also central to the development of hospitals in the Islamic Empire. There is a clear obligation in Islamic belief to treat the ill regardless of their background, religion or ability to pay. Hospitals, known as bimaristan, were open to all and were established in many urban centres, such as Cairo in 872 CE and Baghdad in 932 CE. Their functions seem to have been broader than those of European hospitals at the same time. They offered medical and surgical treatments, a place to recover or convalesce, treatment for the mentally ill, and care for the old. They were secular rather than religious, and employed Christian and Jewish doctors as well as Muslim ones. Such hospitals were constructed throughout the Islamic Empire, and by the tenth and eleventh centuries were large establishments, with outpatient clinics, pharmacies, and both male and female staff caring for patients.
The move away from religion in hospitals in the Middle Ages
In Europe during the Middle Ages, care for the ill gradually became less reliant on religious orders. During the Renaissance most European hospitals increased in size. Religious sisterhoods of nuns were sometimes in charge of nursing - in a number of cases these sisterhoods survived into the 1900s. Some institutions disappeared soon after they were built, but others were transformed into plague or leper hospitals, otherwise known as leprosaria. Civic hospitals, whether founded by confraternities or city states, developed beside medieval monasteries across Europe. Others, such as the Great Hospital in Norwich, survived despite all these changes and continue to offer services to their local communities.
The loss of monastic hospitals
The Reformation brought about the secularisation of hospitals. Some were dissolved and reformed under new conditions. In 1534, Henry VIII closed many of the larger hospitals and monasteries in England. The loss of monastic hospitals meant that others needed to provide for the sick. Throughout the late 1500s and early 1600s, voluntary charity was the means by which many hospitals were funded. Equally, although many poor and ill people required medical care, admission to hospitals was not always guaranteed. In most cases it was reserved for the ‘deserving poor’, those judged to be hard-working people who led ‘respectable’ lives. The charitable mission of most hospitals continues to this day, but their religious character has faded, while their role in the provision of health care has grown.
The new respect for medical and nursing staff
During the 1800s most hospitals became secularised. Medical and nursing staff also began to play a more prominent role at institutions. Throughout the early 1800s medical staff, rather than lay subscribers, began to select patients. Gradually, over the course of the century, greater numbers of resident medical staff were appointed. Surgical cases also began to outnumber medical cases.
Science and technological improvements in hospitals from the 1800s
Hospital services in Europe and North America changed dramatically in the late 1800s because of scientific and technological innovations, starting with the introduction of X-rays. Hospitals increasingly began to offer treatments that were not available elsewhere. For example, radium treatment for cancer was restricted to hospitals in the 1920s, mainly because of its expense. Invasive forms of surgery were also carried out more successfully in a hospital environment. Specialist hospitals for children and women emerged, complemented by more specialised medical and nursing staff.
The modern hospital space - the patient experience
While modernised in terms of medical equipment, the hospital was also transformed as a space, with electric lights, elevators, central heating and ventilation, and new regimes of cleaning and deodorising. Each change influenced the patient experience in its own way. Many feared new machines and equipment were alienating patients, simply reducing them to their ailments and those symptoms which the technologies could detect. In turn, practitioners were said to be losing sight of patients as individuals.
Cathedrals of medicine - hospitals in the modern age
The charitable mission of most hospitals survived into the 1900s and continues to this day. In most cases, however, their religious character has faded. Much of their finance now comes directly from municipal authorities who allocate greater amounts into institutional health care. Hospitals’ role in the provision of health care has therefore only grown. In the process, they have become highly medicalised and technological sites of both healing and research. They are also of central importance to the professional structure of medicine. As importantly, they retain their central place in the communities where they are based. Interestingly, they have been described as 'cathedrals of medicine', an expression that continues to invoke their religious origins. In the eyes of many patients and practitioners, they continue to offer miraculous cures, but most hospital staff concentrate on saving lives, not souls.
Related Themes and Topics
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G Risse, Mending Bodies, Saving Souls: A History of Hospitals (Oxford: Oxford University Press, 1999)
C Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987)