Because hospital trustees could no longer depend primarily on private benefactors to support their institutions and were instead forced to begin charging patients significant sums, it became necessary to organize and present the hospital to the public in a new way. If patients were to be encouraged to pay for services, the hospitals would have to offer them something different from the services provided at minimal or no charge to the indigent. Some trustees and hospital spokesmen began to organize distinct services for different classes of the population – sometimes separate services within a single institution, and sometimes entirely separate institutions for those who could pay and those in need of charity care.

Once separate private services were introduced, it became necessary to convince the merchants, white-collar workers, and skilled craftsmen who might be expected to use them that hospital care was superior to the treatment they had traditionally received at home, sometimes with the aid of private physicians and private-duty nurses. Accordingly, hospitals began to offer amenities like private and semiprivate rooms, private nurses, better food, and pleasant accommodations for those patients willing to pay the price. But more was necessary to attract to the hospital people who had long received private medical care in their homes. Hospital representatives began to advertise their improved services and also to encourage public newspaper reports from patients convinced of the superiority of hospital care. Often these reports portrayed the hospital as nothing more than a “hotel for rich invalids”.

As we have seen, the Progressive era brought major changes in the city's political and social arrangements. The demographic shifts, economic upheavals, and political reforms that undermined the cohesiveness of neighborhoods and their small hospitals also hurt the free-standing dispensaries and small walk-in clinics located throughout working-class neighborhoods. Like the small hospitals, dispensaries were nearly totally dependent upon the influence of local merchants and leaders to obtain city money for their survival. When power shifted from locally elected politicians to city officials and bureaucrats, and when the state comptroller's officials changed reimbursement regulations to favor large institutions, the freestanding dispensaries felt the pinch most severely.

The Progressive era's shift in the locus of decision making was accompanied by similar changes throughout the society. In commercial activities, large corporations replaced local businessmen. Everywhere, people tended to place greater and greater faith in large, impersonal, bureaucratic institutions, and to question the ability of smaller organizations to provide services. The locus of health-care services also shifted away from small-scale undertakings toward larger corporate institutions. Doctors' offices and the small dispensary were replaced by large hospitals with a wider base of financial support, more influential trustees, and a more extensive and sophisticated physical plant. Individual doctors moved to these larger institutions; dispensaries came to be regulated by the state; local merchant-trustees lost power to organized charity. The decline of the dispensary as a viable form of basic health-care delivery in the twentieth century reflects the move to corporate forms of health-care organization.

The neighborhood focus of nineteenth-century medical practice

Nineteenth-century American life revolved around small communities and narrow personal contacts. Most Americans lived in rural villages and towns that were essentially isolated from each other, and even those who lived in the city lived in highly structured communities separated from each other by culture, ethnicity, and sometimes language. Because there were no adequate transportation and communication systems early in the century, there was little chance for relationships beyond one's immediate neighborhood. In these so-called walking cities, life revolved around the local church, school, and other small institutions. Government was a neighborhood responsibility watched over by the local ward boss, who, as part of the political machine, was able to attend to the needs of the community.

A strong neighborhood focus of necessity characterized nineteenth-century medical practice as well. For much of the century, New York City was a highly congested series of neighborhoods spread between the southern tip of Manhattan and Fifty-ninth Street. Before the introduction of electric trolleys and elevated railroad lines, the horse was the major means of transportation. Although the city's gentry owned private carts and wagons for transportation, most of the working people depended upon slow and undependable horse-drawn trolleys, which had to negotiate streets that were continually “torn up, blown up or dug up” for construction.

This book began with a relatively simple premise: that the organization of health and hospital services was, in a variety of ways, a reflection of historically determined societal values and interests. It was my purpose to investigate these relationships and to understand how certain practices arose and how they changed over time. Of particular interest to me was the history of the relationship between patients, professionals, trustees, workers, and politicians, all of whom had different ideas and distinctly different goals at crucial moments when the modern health system was formed. To address the history of health care in any meaningful way it was necessary to understand the perspectives and interests of the different actors.

My own perspective was shaped by my experience as an administrator in New York's health system as well as by my training in the history of science and American social history at Harvard. It was this background that prompted me to use the tools of urban and social historians to analyze health policy issues of concern to health professionals. This book centers on the historical roots of distinctions in services based upon geography, income, race, and employment status – referred to as “access” and “availability” issues by planners and policy makers; the changing nature of trustee and staff relationships; and the development of new models of hospital and health care – which are often borrowed from business enterprises rather than from other social services.

Despite significant efforts to attract merchants and other white-collar workers by advertising comfortable accommodations and new services, hospital trustees were forced to admit that only a few more such patients actually came to the hospital. By and large the hospital was charging the very working-class patients who had previously used its services without charge, and these patients were bringing in only limited funds. Trustees came to realize that even if middle-class clients were influenced by pleasant accommodations and advertising, they were still the patients of private doctors and would enter the hospital only at those doctors' suggestion. Because family doctors would actually determine whether professionals, businessmen, and other people able to pay used the hospital, trustees came to see the necessity of forming an alliance with them.

For reasons related to their status in the hospital, even the most enthusiastic trustees could not help but have reservations about increasing the privileges of physicians. Throughout the nineteenth century, hospital trustees had direct control over the institutions they served, and their role was to function as the community's judge of who was worthy of admission to the facility. Once admitted, patients found that the trustees visited them regularly and took a personal, albeit paternalistic, interest in them. By the end of the century a number of things had caused control to begin slipping out of the trustees' hands. When hospital stays were shortened, trustees found it more difficult to oversee the physical and moral improvement of patients.

By the end of the Progressive era, Manhattan and Brooklyn had gone through a radical transformation. Clearly, Brooklyn was no longer the “City of Churches” nor the “City of Homes.” Its nineteenth-century rural, bucolic flavor was gone. Manhattan had become the center of finance and industry for the entire country. New York was a highly industrial, crowded city with a large portion of its population composed of immigrants and their children.

Manhattan, the home for millions of immigrants, thousands of banks and commercial enterprises, and a score of millionaires, became the undisputed economic capital of an increasingly powerful country. Brooklyn, once known for Henry Ward Beecher and his Plymouth Church, became known for its massive bridges and factories. Even the local baseball team had to change its name to conform to the new reality. The Brooklyn Robins, named for the team's original owner, became the Brooklyn Dodgers by the 1920s, as trolley dodging became a widespread popular sport and as robins were replaced by pigeons in the downtown area. Soon the Dodgers would be nicknamed the Brooklyn “Bums,” in a further reflection of the growing city's urban, working-class character.

It is paradoxical, perhaps, that just as New York was emerging as a working-class city, its charity and other health institutions began to turn away form the poor and to remodel their services around the needs of wealthier clients.

“What do you mean ‘no room’? If you want to [admit me] badly enough you'll find a place.” This was the complaint of a Jewish immigrant to the superintendent of Mount Moriah Hospital in New York's lower East Side in 1909. Mount Moriah was a “penny hospital,” supported by the “pennies” of working people who were members of the Galicia-Bokovina League, a society of Eastern European Jewish workers who had emigrated to the United States in the preceding decades. In this particular hospital the superintendent himself felt “upset that … many applicants [were] rejected for lack of space,” because he understood that people who lived in cramped quarters would find it difficult to accept being turned away from a hospital for such a reason. “I have five children and three boarders in the same four rooms,” remarked one applicant for admission. If space is tight in the hospital, the patient argued, the superintendent should “push the beds together and squeeze in another.”

Mount Moriah was an extremely small hospital cramped between “two adjoining tenements” and supported by the local immigrant working-class community to care for its own members. Because the administration was informal and there was relatively little hierarchy in its social relationships, patients felt confident that the superintendent would take their complaints seriously. Whereas patient care in other institutions sometimes seemed harsh and cruel, Mount Moriah's administrators had a personal relationship with their patients.

New York and Brooklyn community hospitals and dispensaries were organized and run by local church groups, merchants, and other organizations and leaders. These sponsors lent to their institutions the ethnic or religious flavor that made the services unique. Rarely, if ever, were the trustees and governors important on the regional, state, or national level. When the forces of industrial and economic change, commercial development, or demographic reorganization and political upheaval altered the relationships and neighborhoods in which these institutions were located, the hospitals found themselves subjected to pressures well beyond their control. In the face of these growing pressures, smaller institutions sometimes moved away or reorganized, or perhaps went out of existence.

For some Manhattan hospitals, the story was different. Some hospitals were larger, had more political power, and were more secure financially. Their lay governors and trustees often came from older and more prominent New York families who controlled and owned significant portions of the city and provided access to benefactors, legacies, and landholdings. Given the enormous financial and political resources of these institutions and their trustees, it is not surprising to find that when they came into conflict with the forces of urbanization and capitalist development that seriously disrupted smaller facilities, the outcomes were substantially different. Although larger hospitals and institutions were often pressured to move by realtors, they generally had more control over where they moved and how they affected neighborhoods than did community hospitals.

Although internal economic and organizational struggles altered the structure of many turn-of-the-century hospitals, some changes were the result of new policies in city government. Changes made during this era in the system of municipal reimbursement to the hospital have remained important until today and have had significant long-term effects. Local control and some forms of decision making passed from hospital trustees and their ward boss representatives to city administrators, who defined more narrowly the hospital work they would reimburse. Ultimately, changes in the municipal reimbursement system resulted in a loss of autonomy for many hospitals and a loss of funds so severe that some were forced out of existence.

The Tammany machine and flat-grant payments for charity

In the years after the Civil War, control over New York's political machinery moved to the infamous Tammany Hall led by Mayor William Marcy Tweed, Richard Croker, and Charles F. Murphy. With only brief interruptions totaling ten years, Tammany politicians controlled the mayor's office, the administrative machinery, and the patronage jobs of New York's government for nearly three-quarters of a century. Unlike the later Progressives, who appealed for financial support to the upper- and middle-class populations of the city's neighborhoods, the Tammany machine based its power on its ability to gain political support from the working populations of highly diverse communities. Tammany's power was its local ward structure and, most particularly, the ability of its ward boss to gather votes and support in his district.

The most significant pattern in the history of American biochemistry prior to 1940 is its close connection to clinical medicine. The first generation of American biochemists to acquire international reputations were known for their achievements in clinical biochemistry; for example, Otto Folin, Stanley Benedict, and D. D. Van Slyke. Most departments of biochemistry were in medical schools and their prosperity depended on their service roles in medical instruction and clinical research in hospital laboratories and research wards. Biochemists regarded clinical medicine as a crucial source of important and fundable research problems, employment for their students, and political support for their profession.

This view may appear to contradict the idea, developed in Chapter 7, that biological chemists liberated themselves from clinical medicine in the period of reform. The drama of succession should not distract us from the underlying continuity. Biochemists freed themselves from a particular kind of relationship only to reestablish the relationship on a new basis. What had been either a hybrid or dependent role became a more or less equal partnership. In the process, clinicians as well as biochemists were obliged to adapt their disciplinary ideals.

As long as there was little opportunity for medical chemists to build a specialized discipline, there was no great problem of reconciling divergent disciplinary goals. Many of the old medical chemists were clinicians, so no role conflict existed there. The rest were applied chemists, who practiced their profession in a context dominated by clinicians and seldom doubted the propriety of clinicians calling the tune.

“General biochemistry” differed from “chemical physiology” in both scope and emphasis. It was a broadly biological program, taking as its domain all forms of life: microbes, plants, invertebrates, and higher animals. It was concerned ultimately with fundamental processes – growth, development, energy transformation, and biochemical control – rather than special problems of human physiology and pathology. General biochemists looked to more varied constituencies: zoologists, botanists, microbiologists, as well as physiologists and pathologists. This broad conception of biochemistry was both an intellectual design and a political strategy for discipline building. Breadth and diverse audiences legitimated independence from physiology and provided access to wider institutional support systems.

General biochemistry required a broader base of support than that provided by service roles in physiology and medicine. Consequently, it was limited prior to 1945 to a few institutions: F. G. Hopkins's school, Rudolf Peters's at Oxford (an offshoot of Cambridge), David Keilin's group at the Molteno Institute, and a few small research units. Endowment and favored connections to external patrons of basic research freed these groups from dependence on a single source of support and recruits, namely medical teaching. An undergraduate degree program in biochemistry gave Hopkins an unusually large and diverse pool of recruits. The broader programmatic missions of government councils and private foundations found expression in the researches they supported. Just as chemical physiology was congruent with its limited basis in medical physiology, independence from service roles facilitated more general, avant-garde research.

Although the realities of biochemists' careers were shaped by medical service roles, their aspirations were less bound to the quotidian. From time to time, biochemists have claimed that biochemistry is not limited to medicine but comprises the chemical aspects of all the biological and medical disciplines. This conception of biochemistry as a basic biological discipline had its roots less in useful applications than in reductionist ideologies; it looked less to the present than to the future. Russell Chittenden's 1908 presidential address to the American Society of Biological Chemists exemplifies this biological program:

By 1920 departments of biological chemistry were established in most American medical schools. They were equal in status with the older biomedical disciplines and had an equal claim on student time and university resources. Europe had the superstars, but in the United States, even the average medical schools had good facilities and resources for research. Philip Shaffer's ideal in 1915 was a permanent staff of four and a budget of $14,000, including $4,000 for teaching and research. In 1920 Alonzo Taylor had two assistant professors and a budget of $19,650, and a similar plan was proposed by Columbia to the General Education Board. Folin's staff included an associate and an assistant professor, an instructor, and three teaching assistants; his budget was about $16,000, including $4,400 for expenses. Folin eschewed the older pattern of one professor with a retinue of student assistants and technicians. Each professor developed his own line of research and shared equally in training graduate students. In size and general policy, these were typical of the leading departments circa 1920.

The best standard department was a complex institution. In addition to teaching 70 to 120 medical students, Folin's staff managed five to seven doctoral candidates per year, one or two foreign researchers, and two or three advanced medical students. About ten physicians spent a month or so each year on research projects, and Folin kept close contacts with local hospitals.

The “heroic” period of medical reform in America was dominated by individuals who cultivated German ideals in a hostile environment. Strategies were improvised; success depended on special local circumstances. After 1900 medical reform was increasingly a collective enterprise, led by national organizations and carried out systematically on a regional or national scale. The Association of American Medical Colleges organized the first survey of colleges in 1900, and the Council on Medical Education of the American Medical Association organized for reform in 1904. The celebrated Flexner Report of 1910 was backed by the Carnegie Foundation, and Flexner pursued his reform ideals as an officer of the Rockefeller General Education Board. Strategies were orchestrated and standardized, and reform spread rapidly from leading schools to every medical college. Institutions that did not meet the new standards were allowed to perish. The number of medical schools reached a peak of about 160 between 1900 and 1906 and then plummeted to about 80 in the 1920s (see Table 6.1). Medical institutions were radically restructured to support new ideals and roles. A national market in the biomedical sciences was created in which competition for the best faculty and well-trained students accelerated the transition from the old system to the new. Not since the reform of German universities half a century before had there been opportunities on such a scale for the creation or re-creation of biomedical disciplines.