The evolution of the hospital in America traces medicine’s shifting role in American society, and its interventions—for better and worse—into the lives of its citizens. More than a place to heal, hospitals have a complex political, social, and cultural history that both responded to and shaped every era in American history. By studying hospitals, we can perceive the material, human consequences of design, and trace the ways medical institutions have governed bodies and space in the U.S. Here are 10 facts about hospitals you should know.
- The first hospitals established in America were modeled after European ones, which were closer to workhouses or penitentiaries than to the therapeutic and scientific centers of today. Only the destitute and indigent were forced into hospitals. Anyone with means preferred to be cared for at home. The hospital usually cited as America’s first is the Pennsylvania Hospital, chartered in 1751. (Read Ben Franklin’s 1754 account of it here.) However, Marks and Beatty suggest an even earlier hospital existed at Jamestown, as far back as 1612. It contained 80 beds and was staffed by “keepers”—likely male nurses..
- Marine Hospitals were instrumental in the consolidation of the early American State. The 1798 “Act for Relief of Sick and Disabled Seamen” established a tax on the wages of merchant seamen with which the federal government established and operated a series of Marine Hospitals. While these operated much like other early hospitals by accepting local poor patients, they served primarily for the rehabilitation of sailors. Gautham Ra
o explains that Marine Hospitals, which were modeled after similar British institutions, served to maintain an adequate maritime labor force, necessary for the development and expansion of the young state’s imperial and economic interests. Rao argues that the program “fit squarely within the main themes of early American statecraft—associative structure, tax and revenue power, local influence, and contested centralization.” Marine Hospitals provided a basis on which essential functions of the U.S. federal government were later elaborated, and constituted the first federal welfare program.
- Hospitals began to adopt their modern form in the mid-18th century, as young adults left family homes and moved to cities. As women got jobs outside the home, and living space became increasingly
compact, hospitals began to provide for a growing middle-class the healing functions previously handled by the family. As suburbanization increased travel times between work and home, working family members became less and less available to care for the sick at home. In this way, the emergence of modern hospitals reflected the segmentation and professionalization of services previously provided in the domestic sphere.
- Hospitals’ designs reflect the social as well as the scientific conditions of their construction. In the second half of the 19th century, the “pavilion plan” dominated hospital design in North America, wherein patients would live in large, shared dormitories designed to let in light and circulate fresh air. This was in order to dispel “miasma”—an atmosphere thought to be the cause of infection. Even as the germ theory of disease gained acceptance, “pavilion plan” hospitals remained the norm into the 1930s. Starting in the early 20th century, newer hospitals were designed with the goal of segregating patients from each other, both as an antiseptic medical principle and as an effort to appeal to new, paying middle-class customers. Some hospitals began to advertise themselves as akin to hotels, evoking luxury and domesticity. In Medicine by Design, Annmarie Adams discusses Royal Victoria Hospital in Montreal, a large public hospital which had two separate entrances. One—high on a hill overlooking manicured gardens—was for the paying middle- and upper- class patients, while the other—for its working class and poor patients—ran into the hospital through a tunnel nearly 60 feet below it, out of view and almost underground. As hospitals expanded their reach and services, they transformed from a last-resort site of destitution to an institution of civic pride and high regard that served the varying needs and expectations of different classes of patients.
- Hospitals were starkly racially segregated after the Civil War. Black Americans’ access to hospitals was either limited to “colo
red” wards or to a handful “black hospitals,” both offering vastly inferior care than that which was available to whites. In 1948, Mississippi had only five general hospital beds per 100,000 black citizens. Further, many hospitals subjected black patients to non-consensual scientific testing and forced sterilization as part of racist eugenic efforts at population control.
- The designs of maternity wards reflected and transmitted cultural notions of motherhood. At the Royal Victoria Hospital, Adams notes, the maternity ward catered to two competing versions of birth popular in the early 20th century. One held that birth was a natural event to be treated as routine and normal. The maternity ward for middle-class patients was accordingly decorated to suggest a “homelike” environment, with comfortably furnished social space for the patients designated “maternity lounges.” At the same time, the architects responded to residual notions of birth as pathological, which manifested as “extensive record keeping and observation,” as well as the institutional regimes of a rehabilitative hospital. In William Rosengren and Spencer DeVault’s fascinating 1958 study, “The Sociology of Time and Space in an Obstetrical Hospital,” they examine the ways American maternity clinics were spatially organized. They note—similarly to Adams—that expecting patients were coded somewhere between “ill” and “not ill.” They examine the ways nurses, doctors, and patients behaved differently in “backstage” areas like offices or break rooms than they did in “onstage” areas such as the labor room, in which delivery nurses were segregated from other personnel by non-functional barriers denoting their authority. Rosengren and DeVault also suggest what they call an “ecology of pain,” remarking that, “spatially there appeared to be a kind of gradient as to the legitimation of pain, with the greater sanctioning of pain found the closer the ‘place’ is to the delivery rooms.” They note that it is the delivery room where nurses and doctors were most able to medically manage pain with anesthesia and were not required, as in other spaces of the clinic, to respond to patients’ pain affectively and emotionally. The space of the clinic is thus organized in order to maintain a professional, “affectively neutral” attitude towards patients.
- During the Cold War, American maternity wards began to deploy a clinical practice called “rooming-in”. Shortages of hospital staff and a high birth rate meant that it became effective for hospi
tals to have infants stay in mothers’ rooms rather than in a central nursery. Elizabeth Temkin explains that this practice resonated with a post-Hiroshima fear of science and a cultural imperative to privilege individuality and family over uniformity and autocracy: “In other words, only Nazis would insist on feeding infants on a schedule in an impersonal central nursery. Rooming-in was not just a floor plan for the maternity ward, it was the basis of democracy.” This development demonstrates the ways hospital designs are negotiations among medical technology, institutional circumstance, and the political moment. It also suggests the power the hospital holds as a national imaginary—a place where the nation is alternatively healed and born.
- 99% invisible: the blue yarn.
An episode of 99% Invisible about the redesign of Virginia Mason Medical Center in Seattle according to the principles of a Toyota assembly line. The results, in many ways in line with “modern,” patient-focused thought, suggestively recall some principles from 19th-century medical philosophy: the
value of natural beauty, limits on mobility, lots of light. But the redesign also suggests a reconsideration of the hierarchy implied by the “backstage/onstage” nature of modern medical care, as well as the temporalities of treatment. (You can find another great 99% Invisible, this one on an iconic 19th-century cancer hospital in New York, here. )
- Since the dawn of the field, psychiatric hospitals in America have operated on the notion that a patient’s environment is instrumental in the therapeutic treatment of mental illness. In the second half of
the 20th century, however, psychiatric consensus shifted towards outpatient treatment, pharmaceutical management, and deinstitutionalization. Carla Yanni puts it this way: “The profession needed to disassociate itself from the once-grand claims of environmental determinism, because, quite evidently, the environment had not determined many cures.” But Yanni notes that the shift in focus to non-institutionalized patients has left those that previously depended on the structure of the hospital—the poorest, most severe cases—without adequate care. The elimination of the hospital, for all its faults, threatens its original mission of public welfare. Yanni discusses a new kind of institution gaining popularity in American cities. Called “clubhouses,” such organizations provide community and social services to the mentally ill without the institutional and repressive strategies that have historically characterised psychiatric hospitals.
- In a New York Times op-ed published last year, Dhruv Khular argues that “bad hospital design is making us sicker.” He suggests rooming patients together exacerbates hospital-acquired illness, and notes that money potentially saved fighting infections could offset the cost of housing patients individually. He advocates design changes that lower sound levels and make patients less prone to falls. He also offers evidence for the therapeutic value of access to nature in treatment settings. Khular’s perspective suggests that future design decisions could be based on research and critical attention to the built environment. At the same time, his concerns resonate with over 200 years of American hospital design and culture by weighing the values of community vs. individuality, idealizing “natural” healing, and affirming the sense that in America, effective and mutually beneficial hospitals are crucial for a healthy democracy.
 Geoffrey Marks and William K. Beatty, The Story of Medicine in America (New York: Charles Scribner’s Sons, 1973), chap. 5.
 Alexander Hamilton wrote in 1787: “As a nursery of seamen it now is, or when time shall have more nearly assimilated the principles of navigation in the several States, will become an universal resource. To the establishment of a navy it must be indispensible.” (Alexander Hamilton, Federalist, no. 11, 65—73; press pubs.uchicago.edu/founders/documents/v1ch7s13.html)
 Gautham Rao, “The Early American State ‘In Action’: The Federal Marine Hospitals, 1789-1860,” in Boundaries of the State in US History, ed. James T. Sparrow, William J. Novak, and Stephen W. Sawyer (Chicago: The University of Chicago Press, 2015), 47.
 Morris J. Vogel, “The Transformation of the American Hospital,” in Institutions of Confinement: Hospitals, Asylums, and Prisons in Western Europe and North America, 1500-1950, ed. Norbert Finzsch and Robert Jütte, Publications of the German Historical Institute (New York: Cambridge University Press, 1996), 45–46.
 The cross-contamination of patients was called “hospitalism.” (Vogel, 46.)
 Not to mention religions. Hospitals operated by people of particular faiths were an important feature in the emergence of modern hospital systems in the mid-18th to 20th centuries. For an account of the emergence of Catholic hospitals, see Bernadette McCauley, Who Shall Take Care of Our Sick? Roman Catholic Sisters and the Development of Catholic Hospitals in New York City (Baltimore: Johns Hopkins University Press, 2005).
 Coli Gordon, Dead on Arrival: The Politics of Health Care in Twentieth-Century America (Politics and Society in Twentieth-Century America) (Princeton: Princeton University Press, 2003), 149.
 Harriet A. Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Harlem Moon, 2006), chaps. 8–11.
 Annmarie Adams, Medicine by Design: The Architect and the Modern Hospital, 1893-1943 (Minneapolis: University of Minnesota Press, 2008), 48.
 William R. Rosengren and Spencer DeVault, “The Sociology of Time and Space in an Obstetrical Hospital,” in The Hospital in Modern Society, ed. Eliot Freidson (New York: Free Press, 1963), 266–92.
 Rosengren and DeVault, 285.
 Elizabeth Temkin, “Rooming-In: Redesigning Hospitals and Motherhood in Cold War America,” Bulletin of the History of Medicine 76, no. 2 (Summer 2002): 285.
 Discussed in Marks and Beatty, The Story of Medicine in America, 64–70. Benjamin Rush, considered the father of modern psychiatry, believed that “good health depended on the social, political, and economic environment as well as on physical factors.”
 Carla Yanni, The Architecture of Madness: Insane Asylums in the United States (Minneapolis: University of Minnesota Press, 2007), 146.
 Yanni, 147.
 Yanni, 153–58.
 Dhruv Khullar, “Bad Hospital Design Is Making Us Sicker,” The New York Times, February 22, 2017, https://www.nytimes.com/2017/02/22/well/live/bad-hospital-design-is-making-us-sicker.html.