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By Christopher Bailey, Colten Bracken, and James S. Newman, MD, FACP
This is but a brief review of ten hospitals of historic significance. Many hospitals have had a great impact on the health of our country—from The Queen's Hospital in Hawaii to Bellevue in New York—and even more around the world. If you fail to find your own favorite here, don't despair. You can write up a short history of your institution of choice and send it our way.
1. A temple of Aesculapius
Aesculapius made his debut in Greek literature as the ideal physician, but over time morphed into a divine status—worshipped as the son of Apollo and a god of healing. The shrines to Aesculapius were situated near fresh water springs, with beautiful landscapes and spiritually uplifting locations, and a statue of Aescuplaius as a prominent feature. In this atmosphere, health could be expected to return to the ailing petitioner. The patient would bring gifts to the temple such as votive offerings, and offer prayers and animal sacrifice. Supplicants would enter the snake-filled temple and hope for a god-given dream, which would be interpreted by the priests and developed into a therapeutic plan. The plan would generally include rest, a proper diet and recreational activities. Some therapeutics such as bloodletting or purging were sometimes included. If a patient got better, it was divine healing; if not, it was the patient's own fault.
2. A Roman valetudinarium
The Romans invested in the care of unique and specific populations. They created what has been called the precursor to the hospital, a valetudinarium, to care for the empire's slaves and soldiers. This tradition stretched from the days of Julius Caesar to the middle ages. Valetudinariums were built within Rome for the care of its increasingly valuable slaves during economically depressed times. Previously, sick slaves were often taken to a city square and left to die. Roman soldiers, who viewed death in battle as an honor, feared the various illnesses that afflicted them off of the battlefield. Generals were responsible for the well being of their soldiers, and their valetudinariums were constructed on the northern edges of the empire within fortresses. Roman soldiers were paid very little, and fringe benefits such as plunder and free health care made military service much more appealing.
3. The Hôtel Dieu
As the Roman Empire crumbled, the northern areas of it became city-states and approached the care of their people in different ways. The Parisian Hôtel Dieu was founded in 651 AD, financed by wealthy individuals hoping to find forgiveness for their transgressions by donating funds for the housing and care of Paris' poor. As such, the Hôtel Dieu (God's Hostel) was subject to budgets that ebbed and flowed with the area's economy. In 1505, the local municipality was placed in control of the Hôtel Dieu, marking a shift where the care of the poor and sick, previously a religious duty, became a secular one. The need for this care was great, and by the late 18th century, it was estimated that 3,500 patients were packed, shoulder to foot, in its 1,200 beds. It was in this setting that Marie-Francois Xavier Bichat advanced the study of tissues with his groundbreaking work in histology and pathology. He wrote, “Life is the sum of forces which resist death.” He was also the spiritual father of the clinicopathologic school of medicine, which greatly impacted western medicine.
4. The Pantokrator Hospital
In 1136 AD, the few hospitals that did exist were most certainly a place of last resort for the destitute. Yet in Constantinople, the Pantokrator Hospital was founded as the chief institution of the medical profession, employing the very best and brightest physicians around. There was even a medical school with ambitious young doctors trained there. Built by the Byzantine Emperor John II Komnenos, the Pantokrator (“Lord Almighty” in Greek) was accompanied by a monastery and a library. The medical side of the institution housed a gerontochium, or house for the elderly, as well as a leper sanatorium. Even though it later became a mosque when the Byzantine Empire fell, much is still known about the Pantokrator due to the existence of its typikon, or operation rules. These spell out everything from the vegetarian diet that was to be given to each patient down to how the physicians were expressly forbidden to undertake any service outside the hospital.
5. The Mansuri Hospital
Completed in 1284 AD in Cairo, the Mansuri Hospital was built by King Al-Mansur, who earlier was hospitalized himself and as a result vowed to build the greatest hospital ever. This begs the question of how bad his hospital food must have been. But great his hospital was, treating upwards of 4,000 patients per day. Islamic hospitals were called bimaristans, Persian for “place for the ill.” There was a moral imperative to provide for all those who were afflicted. They turned no one away, even non-Muslims, and many patients were even given a stipend to compensate for lost work during their hospitalization. The sole source of revenue for the enormous hospital budget came from waqfs, pious bequests of the wealthy and ruling class. Of particular note, the Mansuri Hospital had separate areas, or wards, where patients with different ailments were treated, and during their stay they were treated to entertainers and music therapy.
6. The Pennsylvania Hospital
It is with pride that we list the first operating American hospital (even if it was not officially on American soil yet). In 1751, the charter was granted for the Pennsylvania Hospital. It was established as a place “to care for the sick-poor and insane who were wandering the streets of Philadelphia,” a booming city of 15,000 lives.
Pennsylvania Hospital's Pine Building in 1861. Photo courtesy of Pennsylvania Hospital.
The idea for a hospital in Pennsylvania was inspired by Dr. Thomas Bond's time spent at the Hôtel Dieu in Paris, but it did not come to fruition until he enlisted the political muscle that was Benjamin Franklin. Franklin argued “for the Relief of such Poor as are afflicted with curable Diseases.” Within a short period, the Pennsylvania Hospital began admitting patients. Great care was placed into the design and rules of the facility. Pharmacy and nursing, patient means, and need for isolation beds were considered. The modern physician would recognize many administrative items as well, such as strict credentialing, means testing, utilization review and most importantly, fund raising.
7. Die Allgemeines Krankenhaus
The Hôtel Dieu's continuing influence was also evident in the immense Allgemeines Krankenhaus, commissioned by Austria's Emperor Joseph II in 1783. The drama contained within the 1,500 bed “General Hospital” of Vienna was as gripping as any soap-opera script. In 1847, Ignaz Semmelweis, a physician in the hospital's First Obstetrical Clinic, reduced the mortality rates of puerperal fever (typically about 20%-25%) to under 1%. He did this by instituting hand washing by physicians and students with a chlorinated lime solution prior to and between examinations. Semmelweis' determination to improve the care of his patients was equaled only by his inability to work with his superiors, and his methods were not adopted at Allgemeines Krankenhaus. Unwilling or unable to publish his findings in a timely manner, Semmelweis spiraled into exhaustion and mental illness, dying in a sanatorium just a few years before his methods were vindicated by the work of Pasteur and Lister. This hospital was also home to the father of pathology, Rudolf Virchow.
8. St. Mary's Hospital
One hundred years after the founding of Allgemeines Krankenhaus, a tornado ripped through Rochester, Minn., devastating the town. Inspired by the event, Mother Alfred of the Sisters of St. Francis approached William Worrall Mayo (father of William and Charlie Mayo) to staff the hospital the sisters proposed to build. Although he ultimately agreed, his initial response was that Rochester was too small, and that it would not be a success. That kind of positive thinking resulted in the construction of St. Mary's Hospital. The Protestant Mayos and the Catholic sisters worked together to create a facility to care for patients without regard to religion or sex. St. Mary's was one of the pivotal centers responsible for the transformation of hospitals, at the turn of the century, from places where the indigent and extremely sick would go to die to premiere centers for healing and patient care. The first patient was admitted in 1889, at a cost of a dollar a day (more for a private room). One important innovation was the elevator. It was based on a hydraulic system and implemented by Dr. Charlie Mayo. The water that raised the elevator was released with its descent and pumped to a tank on the roof, where it provided the water for the toilets.
9. The Johns Hopkins Hospital
Bequeathed by the Baltimore merchant Johns Hopkins, designed by John Shaw Billings (of New York City public library fame), staffed by several luminary Williams (William Osler, William Halstead and William Welch), the hospital incorporated state-of-the art concepts such as ventilation. The hospital became a great site of bedside teaching. Perhaps it's best to quote Osler himself from Aphorisms, describing what a hospital should be: “The type of school I have always felt the Hospital should be: a place of refuge for the sick poor of the city—a place where the best that is known is taught to a group of the best students—a place where new thought is materialized in research—a school where men are encouraged to base the art upon the science of medicine—a fountain to which teachers in every subject would come for inspiration—a place with a hearty welcome to every practitioner who seeks help—a consulting center for the whole country in cases of obscurity.”
10. The hospital of the future: 1964
What will be the future of the hospital? Thus was the question asked a half-century ago, in an era before shortened lengths of stay and outpatient procedures, audits and alternative care. Futurists of the time suggested many changes in the structure and function of the hospital. Perhaps it would be an inverted diamond, saving the grounds for parks and walkways, perhaps under the sea. Maybe patients would be transferred around the facility in personalized capsules. In the era before ICUs, who would have predicted the complexity of care we provide to the high-acuity patients now admitted? Perhaps we are not yet practicing under the sea, or in outer space. But we do walk around with tiny computers in our hands that can pull up all the knowledge in the world; patients swallow telephoto capsules to image their GI tracts; we transplant hearts—and much more. Their fantasies are our reality and the hospital of the future will likely be different than we ever might expect.
Mr. Bailey and Mr. Bracken are second-year medical students at Mayo Medical School. Dr. Newman is a hospitalist at Mayo Clinic in Rochester, Minn., and ACP Hospitalist's editorial advisor and humor columnist.
Franklin B. Some Account of the Pennsylvania Hospital. Baltimore: The Johns Hopkins Press; 1954.
Garrsion FH. An Introduction to the History of Medicine, 4th edition. Philadelphia and London: W.B. Saunders Co.; 1929.
Rosenberg C. The care of Strangers: The Rise of America's Hospital System. Baltimore: Johns Hopkins Press; 1987.
Risse G. Mending Bodies, Saving Sosuls: A History of Hospitals. New York: Oxford University Press; 1999.
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