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This is an abridged version of the Classic Article by E.A. Codman, A Study in Hospital Efficiency: As Demonstrated by the Case Report of the First Five Years of a Private Hospital . The full article is available as supplemental material for the abridged version in the online version of CORR ®. An accompanying biographical sketch of E.A. Codman is available at DOI 10.1007/s11999-012-2750-4 . The Classic Article is © 1918 and is reprinted courtesy of Thomas Todd Co. from E.A. Codman. A Study in Hospital Efficiency: As Demonstrated by the Case Report of the First Five Years of a Private Hospital . Boston: Thomas Todd Co.; 1918: 4–10,108,162.

This biographical sketch on E.A. Codman corresponds to the historic text, The Classic: A Study in Hospital Efficiency: As Demonstrated by the Case Report of the First Five Years of a Private Hospital (1918), available at DOI 10.1007/s11999-012-2751-3 .

At the end of the Revolutionary War, the United States government acquired the Northwest Territory, including the city of Cincinnati. Given the city's position on the Ohio River, and the subsequent development and introduction of steamboats in the early 1800s, Cincinnati became a major center for commerce and trade. With a population of over 115,000 in 1850, Cincinnati was the sixth largest city in the United States—larger even than St. Louis and Chicago—the first major city west of the Allegheny Mountains, and the largest inland city in the nation. The city's growth and importance is mirrored by the history of one if its prized institutions, Good Samaritan Hospital—the oldest, largest, and busiest private teaching and specialty-care hospital in Greater Cincinnati and a national leader in many surgical fields.

The period 1820–60 marked an era of transition and diversity in Ireland that rapidly transformed the face of Irish society. Inextricably linked with these processes was the expansion of Ireland's private asylum system. This system diverged from its British counterpart both in the socioeconomic cohort it served and in the role it played within the mental health-care system as a whole. The implementation of the 1842 Private Asylums (Ireland) Act, the first legislative measure geared exclusively toward the system, highlighted the growing importance of private care in Ireland as well as providing for the licensing and regulation of these institutions for the first time. To date, historians of Irish medicine have focused almost exclusively on the pauper insane. This article aims to shift this emphasis toward other categories of the Irish insane through exploration of the Irish private asylum system, its growth throughout the period, and the social profile of private patients. I shall also interrogate the trade in lunacy model through exploration of financial considerations, discharge and recovery rates, and conditions of care and argue that while Irish private institutions were a lucrative business venture, the quality of care upheld was apparently high. Finally, I shall argue that Irish private asylums catered primarily for the upper classes and briefly explore alternative provisional measures for other non-pauper sectors of society.

The private psychiatric hospital market has exhibited great volatility over time. From 1976 to 1992, the number of hospitals more than doubled, while in the decade following, the number of facilities dropped by half. Recently, however, the industry has begun to grow again. The evolution of this market reflects the response of a private industry with access to capital markets to changes in both the supply of substitutes and the demand for services. Most recently, the limited supply of facilities and expanded demand for psychiatric services have spurred renewed growth. The two leading firms today, Universal Health Services, Inc., which rode the market crest and downturn since the 1980s, and Psychiatric Solutions, Inc., a newer entrant, have employed different strategies to take advantage of these opportunities. The rapid responsiveness of the private psychiatric hospital market, as exemplified by these two firms, presents significant potential for shaping future mental health policy.

After a brief discussion of early-and mid-nineteenth-century hospitals, this article focuses on the years between 1880 and 1939, when those facilities underwent a major transformation and the proportion of hospital deaths steadily increased. During both periods, private hospitals refused admission to many seriously ill people and discharged others when death approached. City hospitals dumped poor patients with advanced disease on chronic care facilities and especially on almshouses. With each transfer, the quality of care sharply declined. And trips from one institution to another often inflicted additional suffering; some accelerated death.

Since hospitals are often at the center of health care services, their foundation and evolution provides valuable insights into local political, economic, and cultural contexts. Based on Western and Chinese sources, this essay employs a transnational approach to explain the establishment of the Tung Wah or Oriental Dispensary in San Francisco. This article describes the institution's aims, financing, and combined operation of Western and Chinese medical staffs in an environment of racial discrimination and political power struggles, as well as deep social and cultural divisions during the early twentieth-century plague epidemic.

Connecticut was the exception among the Northeastern and Middle Atlantic states in not founding a public institution for the insane until after the Civil War when it opened the Hospital for the Insane at Middletown in 1868, a facility previously neglected by scholars. The state had relied on the expedient of subsidizing the impoverished at the private Hartford Retreat for the Insane that overtaxed that institution and left hundreds untreated. Despite abundant evidence to the contrary, well meaning officials oversold the idea that the Middletown site would promote cures and be cost effective. A number of unanticipated consequences occurred that mirrored fundamental changes in nineteenth-century psychiatry. The new hospital swelled by 1900 to over 2,000 patients, the largest in New England. Custodianship at the monolithic hospital became the norm. The hegemony of monopoly capitalism legitimated the ruling idea that bigger institutions were better and was midwife to the birth of eugenic responses. Class based psychiatry—the few rich at the Retreat and the many poor at Middletown—was standard as it was in other aspects of the Gilded Age. Public policy toward the insane poor in Connecticut represents an outstanding example of the transition from antebellum romanticism to fin de siècle fatalism.

There has been no comprehensive history of the scope and roles of private psychiatric hospitals in the USA. This paper documents the origins, functions, support, and contributions of private psychiatric hospitals from their beginnings in the eighteenth century through 2003. An interesting feature of nineteenth century psychiatry was the interplay between private and public institutions which reveals a pattern of the public purchase of private beds that is conceptually much like what we have today. From the early twentieth century through 1970, advancements in somatic treatments, new ways of using the hospital milieu, the introduction of antipsychotic medications, the shift from institution-based to noninstitution-based loci of acute and long-term treatment and care, the beginnings of day hospitals and a shortage of psychiatrists and nurses, all impacted upon the private psychiatric hospital. While the private psychiatric hospitals expanded in number and in responsibilities during these decades, at the end of the 1960's their future was a matter of serious debate. A comprehension of the history of the private psychiatric hospital since 1970 is based on an understanding of the impact of for-profit hospital chains, managed care, the privatization of traditionally public services, the requirement for \"treatment in the least restrictive alternative,\" further erosion of the use of any form of inpatient treatment, and an overall decrease in expenditures for mental health services. The future of the private psychiatric hospital may well be based on its ability both to maintain its traditional, patient-centered approach and to create innovative, effective, efficient, novel systems of care and treatment.