In eighteenth-and early-nineteenth-century America, birth, sickness, and death took place in the home. Furthermore, medical care was not dominated by physicians. Indeed, the small number of physicians found in such communities as Boston, New York, Philadelphia, and Charleston were not the sole or even the major providers of health care. Ministers, midwives, wives, and a variety of other laypersons played important roles in caring for the sick and dying.
Many of the "hospitals" that existed prior to 1830 bore little or no resemblance to their modern counterparts. The majority, particularly those in urban areas, originally were associated with welfare and penal institutions. Philadelphia, for example, established a pesthouse to confine sick immigrants and thereby prevent epidemics. Indigent residents who were ill or insane were cared for at the municipal almshouse, which later evolved into the Philadelphia Hospital. A similar situation prevailed in other urban areas. In New York City, the House of Correction, Workhouse, and Poorhouse that opened in 1736 became Bellevue Hospital in 1816. Combining the functions of almshouse, workhouse, and penitentiary, these institutions provided some semblance of care for sick and disabled inmates, most of whom were indigent and dependent. The existence of such institutions also provided physicians with opportunities to learn their craft and to train younger men.
As late as 1800, only two institutions in the entire nation provided inpatient care for the sick, namely Philadelphia's Pennsylvania Hospital and New York City's New York Hospital. The idea for the former originated with Dr. Thomas Bond, who subsequently enlisted the aid of Benjamin Franklin. The need to provide suitable accommodations to care for poor and sick individuals (as compared with those with resources to pay for private care), as Franklin noted, seemed pressing. Moreover, he was concerned with the fate of inhabitants "who unhappily became disorder'd in their Senses, wander'd about, to the Terror of their Neighbours, there being no Place (except the House of Correction) in which they might be confined." After receiving a charter and a modest subsidy from the provincial assembly, the Pennsylvania Hospital received its first patient in 1752. The idea of creating a hospital in New York City originated with Dr. Samuel Bard, who believed that such an institution would facilitate medical education and elevate standards of medical practice. Receiving a royal charter in 1771, the New York Hospital had no sooner opened in 1775 when a fire destroyed the building. The ensuing war prevented its reopening until 1791.
During the American Revolution, military hospitals proliferated to provide care for wounded and sick soldiers, but they were short-lived. In 1798 Congress passed legislation that provided for the establishment of marine hospitals in seaports; they furnished temporary relief for sick and disabled seamen. After 1800 the pace of hospital founding began to accelerate. In 1811 the Massachusetts legislature, following the lead of elite Bostonians, passed an act of incorporation that created the Massachusetts General Hospital, which opened in 1821. A decade and a half later, a comparable institution was created in New Haven, Connecticut, to serve the needs of the Yale Medical School.
The few hospitals that existed before 1830 differed in fundamental ways from their modern counterparts. Individuals with resources would never be found in a hospital unless insane, taken sick during an epidemic, or involved in an accident while in a city away from home. Nor did hospital therapeutics differ from what could be done in a home. Indeed, the hospital was an institution created by elites to serve the needs of the less fortunate. Power within these institutions did not reside in medical hands; prominent laypersons played a dominant role in both admissions and the shaping of policy. The overwhelming majority of patients paid no fees; the costs were borne by philanthropic contributions. A small number of patients paid for their board and were provided with more comfortable quarters. In general, given the lower-class makeup of the patient population, these institutions possessed a paternalistic character.
When the Pennsylvania and New York Hospitals were founded, the care of the insane was one of their primary responsibilities. By the early nineteenth century, however, separate institutions for the insane had become more common. Claims by such figures as Samuel Tuke in England and Philippe Pinel in France that environmental changes (that is, moral or psychological therapy) could reverse the course of the debilitating condition of insanity provided a rationale for institutionalization. Quakers played important roles in establishing the Friends Asylum in Pennsylvania in 1813 and the Bloomingdale Asylum as a separate part of New York Hospital in 1821. The McLean Asylum for the Insane (a division of Massachusetts General Hospital) opened in 1818, followed by the Hartford Retreat for the Insane in 1824.
Yet the structure, financial base, and goals of these private institutions were such that they could not become the foundation of a comprehensive system of hospitals serving the entire community. Consequently, during the 1820s and 1830s a movement to create public mental hospitals gained momentum. The first such institution, at Williamsburg, Virginia, had opened in 1773. By the 1820s South Carolina, Kentucky, and Maryland had created their own institutions. But the most important event was the establishment of the Worcester State Lunatic Asylum in Massachusetts. Opened in 1833, it set the stage for a phenomenal expansion of public mental hospitals throughout the United States. Indeed, the population of these institutions was considerably larger than those found in private and voluntary hospitals for much of the nineteenth century.
If anything symbolizes the contemporary American health care system, it is the modern hospital and its commitment to technology. Two centuries ago, however, the hospital was a fundamentally different institution, providing care for destitute, disabled, and dependent persons whose very survival was at risk. The emergence of the hospital in its modern form would have to await the scientific and technological changes that transformed America in the late nineteenth and twentieth centuries.