Taking the history of hospitals

How have hospitals become such huge institutions? Medical historian Jonathan Reinarz talked Chris Smith through the history of hospitals starting with the very first ones...

Jonathan - Well, I think the first hospital would have been much smaller than what we have today. You have to think - that moment when you have a large group of patients together in one place, and this often happened on military campaigns, for example, when you have empires expanding, like the Roman Empire. Hospitals might have been set up alongside camps to treat a large number of wounded soldiers at one time.  But also, across countries, you would have had these religious buildings like monasteries developed which had facilities, which we might describe as hospitals. A place which offered hospitality but often people who were very weak and weary from extensive travel who had maybe acquired some sickness and, eventually, people realised the benefits of having care organised in this sort of way.

Chris - Were hospitals initially for everybody or was this somewhere that only the needy went?

Jonathan - Absolutely! Now this is a very important distinction. From the earliest days hospitals were institutions for people who couldn't ordinarily afford to have a private practitioner treating them within their own home, and a home of a size which would have allowed one bedroom to be essentially set aside as a ward, or a private ward essentially. So yes the poor, but not all the poor.  In the sense that people were going to fund this institution often locally and what they wanted to ensure was that the health of people who worked in local industries and who had helped people locally develop wealth and power. So, essentially, these institutions were for a particular type of poor which many people described as "the deserving poor." And they were deserving because they had ordinarily worked but then became sick, and in order to avoid these people and entire families falling into destitution the best idea was to aid their recovery as speedily as possible by providing care in an institution like a hospital.

Chris - When did it dawn on doctors that actually having hospitals is a good thing because all the time that they are dealing with people in hospital, they're not having to do long journeys out to random places to see one person - they can see lots of people all at once and possibly learn lots of things at the same time?

Jonathan - Absolutely. I would say that one misconception is that these institutions were run for the poor with medical practitioners volunteering their time through altruism, that they simply wanted to help the poor.  It's clear that they offered a lot of benefits and for medical practitioners who ordinarily were collecting fees from paying patients, they quickly realised if they got a post at a local hospital, they would be recognised as the leading practitioners locally, so it advertised your expertise. So people would do this work free of charge because it set them apart from all the other competition and pretenders. It was a very crowded medical market place and if there were only a few hospital positions, well then people saw the advantage of having one of these.

But, at the same time, anybody that was associated with these institutions very quickly realised that they would see more patients of a particular condition than they might have seen during their entire career in private practice. And this is something that was reiterated by everyone who was involved in setting up some of the first specialist hospitals, so whether it was Moorfields Eye Hospital or a children's hospital, people emphasised that by spending a few weeks or even months on the wards, they would see more cases than any other private practitioner would have seen through their careers. And that immediately translated into expertise that you could have by affiliating yourself with hospitals, and people certainly recognised that advantage and that would lead a lot of practitioners to spend time in hospitals.

Chris - And, presumably, underpinned the whole ethos and idea of a teaching hospital?

Jonathan - Well absolutely. Once you get these teams together then one of the natural affiliations is to connect these hospitals with the medical schools locally. So, eventually, any reputable medical school would only be recognised in the Victorian period if it had a sizable teaching hospital connected to it, like Addenbrooke's, like Charing Cross, like any teaching hospital today.

It started with a certain number of beds, usually about a hundred. Not a dozen as might have existed in the first general hospital when it appeared locally, but guaranteeing at least a certain number of patients and enough space to bring an entire medical school into the hospital. So this tradition of walking the wards was very much there when you look at the first provincial medical schools in this country, for example.

Chris - And when did this seeming transformation occur which took us from this small stable with a handful of patients in it to the huge great institutions that hospitals are globally today?

Jonathan - Well, I think that that transition is really one that depends on the local economy and I think if you're talking about a hospital in a capital city, of course there's a lot of national pride involved. People will certainly invest in this sort of institution. You have to understand when these hospitals were first established, there were very few large buildings like this in most communities. People took notice and they often include hospitals in their visits; royalty coming from other countries to this country would have included a hospital visit on their visit and gradually as you see this kind of development in other countries, the primary institution to ensure is established is a hospital. So in a lot of other countries around the world it was clearly an object of civic pride and the bigger the hospital the stronger the economy, the stronger the nation. And especially in countries like China today, they build hospitals bigger than any we've seen before and that is just one more indication of how large and strong their economies have become.