Method: In addition to a literature review on postcards and their history and use, particularly in the depiction of health care, the author reviews the postcards in her own collection, which includes a variety of hospital postcards from this time period.

Postcards have filled a variety of roles since their introduction more than a century ago. First, as is the case today, postcards were used to send interesting images and details from travels to friends and loved ones back home. However, before the widespread availability of cameras, postcards were also purchased as souvenirs and reminders of one's own travel experiences. In the early 1900s, families would have had a postcard album proudly displayed for visitors in much the same way that today's families would have a photograph album or scrapbook. Postcards were a means to communicate locally as well as across the country before telephones were commonplace.

Postcards were a matter of civic pride during the early 1900s. At that time, even the smallest town used postcards as a way to market itself as a good place to work, live, and visit, and, thus, it is possible to find numerous attractive and inexpensive postcards from this era showing public buildings such as schools, courthouses, churches, and hospitals. According to many recent texts on historical research, postcards are a rich and underutilized primary resource, particularly for scholars and historians doing research on local or “nearby” history. Not only can the illustrations on postcards reveal a considerable amount of information about hospitals in the early twentieth century, but the messages, addresses, postmarks, and stamps can also offer a glimpse of the lives of ordinary citizens and their perceptions of the health care system.

The basic format of postcards stayed relatively stable during the next two decades. However, in the 1890s, small pictures began to encroach into the writing area. Many postcards from Switzerland, Germany, and Austria had multiple tiny drawings of churches, castles, and other interesting tourist places and the words “Gruss aus” (Greetings from) [1]. In January 1902, the British Post Office made a major modification in postcards, endorsing the standard that still exists today, with half of one side for a message and the other half for the address [1]. This format left an entire side of the postcard for pictures, hence the term “picture postcard.” The United States was a latecomer, adopting this new format in October 1907 [1]. US Postal Service records indicate that in 1908, the population of 88,700,000 Americans mailed 677,797,798 postcards [2].

The history of postcards is fascinating, and numerous books, articles, and price guides are available for collectors [3, 4]. In the early 1900s, postcards were as widely used for communication as email is today. The sheer number of available postcards, particularly postcards from the “golden age” of the early twentieth century, means that deltiologists must specialize and use some fairly narrow collecting parameters. It is estimated that deltiology is the third most popular collecting hobby in the world.

Postcards can be divided into two main categories, those depicting actual people, animals, places, and events, what can be called “view” postcards, and those that feature any number of stylized designs of people, birds, flowers, holiday themes, and animals, which may be referred to as “greeting” postcards. View postcards tend to be more popular with collectors and thus can be more expensive than greeting postcards. Hospital postcards from the early 1900s would fall into the “view” category, and this category has two distinct varieties to consider. One type of view postcard, called a “real photo” postcard, was printed from photographs taken by postcard photographers who traveled throughout the country taking photographs of streets, landmarks, buildings, people, events, and catastrophes. The other main type of hospital postcard is an artist-rendered postcard, usually in color, highly detailed and stylized to make public buildings and monuments look attractive. The artist-rendered hospital postcard will be the focus of this article, although the same principles can apply to real photo postcards of hospitals.

Postcards were a matter of civic pride during the early 1900s. Even the smallest town wanted to highlight its public buildings, accounting for the availability of postcards of courthouses, hospitals, churches, town halls, and even insane asylums, a term no longer even used in current medical terminology. While it seems curious to want to purchase or use a postcard of such institutions, their publication supports the notion that communities wanted to show that they had modern facilities for the treatment of those with physical and mental impairments. For example, the postcard of the Eastern Indiana Hospital for the Insane in Richmond, Indiana, indicates that a Mrs. Ellis, writing from Hartford City, Indiana, was on her way back from a trip (Figure 1). Likewise, the Southern Indiana Insane Hospital looks quite lovely, belying its purpose and what the conditions might have been for the residents at that time (Figure 2). The postcard's message indicates that the sender had just been to the Rockville (Indiana) fair and had a “dandy” time.

Most hospital postcards of the early 1900s are beautifully drawn with considerable attention to detail, and they depict benign, bucolic, and even inviting buildings and grounds. Only in more recent years do hospital postcards become institutional looking. For example, note the pleasant view of Mercy Hospital in Cadillac, Michigan (Figure 3), with the lovely trees, lots of windows, the attractive red brick, and all of the walkways. One can imagine the small wing of the building in the foreground with its bank of large windows as a sunny sitting room for patients. The infrastructure of the hospital, such as the chimney and smokestack, are located discretely in the background. The building could easily be a school or dormitory rather than a hospital.

The ready availability of hospital postcards from the early 1900s is compelling testimony to the stature that hospitals had during this era, as is the desire of postcard publishers, community leaders, and citizens to produce, disseminate, purchase, and use these postcards. The care with which these early hospital postcards have been rendered could certainly suggest the credibility and respectability afforded hospitals during this time, even those institutions that treated mental illness. The lowly postcard might in fact be a significant indicator of the changing nature of hospitals as public institutions and their role in the community at large [5–7]. When considered as perhaps a material manifestation of health care in the early 1900s, these postcards begin to evince a quiet dignity and an air of respectability and trust. This same quality is present in depictions of court houses, churches, libraries, and town halls on postcards of the time. These postcards have a certain timelessness and nostalgia, reflecting a time when a craftsman would take considerable pride and care in the artistic treatment of such public buildings, even for postcards.

A particularly intriguing postcard shows the various hospitals in the Barnes Hospital Group, St. Louis, Missouri (Figure 4). A line-up of stunning and colorful brick buildings with numerous windows, architectural details, and exceptionally fine brickwork is complemented by lush green lawns and neat rows of trees. Two lanes of now antique automobiles proceed in orderly fashion along a pleasant street. The postcard presents a model of efficiency, order, and convenience and could just as easily be a postcard of a college campus or cityscape. This view contrasts with the stark rendition of St. Luke's Hospital in New York City (Figure 5), which is more typical of what one might think about early twentieth century health care facilities. This facility appears forbidding, with straggly bare trees, piles of stone, and apparent construction in front of the hospital. On the other hand, the postcard of Johns Hopkins Hospital (Figure 6), postmarked 1916, shows a variety of architectural styles throughout a complex of attractive and dramatic buildings surrounded by gardens and walkways. The garden area in the foreground is rendered in exceptional color and detail. Note also the very early automobiles, the streetlamps, the horse-drawn wagon, and the man strolling along the sidewalk. Here is the history of health care in miniature, presented in its most positive light. Many of these decorative touches were probably added by the postcard artists to make the postcard more appealing.

It is also interesting to contrast some of the early postcards of hospitals with how these facilities appear today. Figure 7 is a postcard of County Hospital in Chicago, with a message on the back indicating that the sender was waiting to catch the train to the “Great West.” This hospital has recently been replaced by a brand-new facility. Figure 8 shows Butterworth Hospital in Grand Rapids, Michigan. Butterworth, now part of Spectrum Health, still sits impressively on top a hill overlooking the city but occupies several blocks and is a mixture of old and new buildings. Note the automobiles out front, the trees, the attractive facade, and the stately entranceway. Early hospital postcards often presented buildings from a distance, maximizing the opportunity to feature landscaping, walkways, and spacious lawns. Interestingly, many hospitals were named for their first benefactors or prominent families in the community, and postcards can help trace the history of hospital names, particularly as many become part of larger networks and corporate entities.

The winter scene on the postcard of the Mayo Clinic (Figure 9) is particularly beautiful and serene, with a statute in front and soft light from the windows and snow-covered trees. This comforting sight would certainly appeal to anyone contemplating treatment at the hospital. Contrast this view with the very severe, forbidding view of McLaren General Hospital in Flint, Michigan, circa 1963 (Figure 10). This close-up view of the building does not show the grounds, but the street and curbing, the dry-looking lawn, and the row of cars seem to accentuate the pale brick and unyielding utilitarian facade. By setting this postcard of McLaren Hospital next to the postcards of hospitals from the early 1900s, not only is it apparent how the depiction of hospitals has changed over time—from a pleasant, welcoming, and almost campus-like appearance to an institutional setting—but it is also apparent that the fine architectural details that made these early hospitals unique works of art that would have been a source of community pride have disappeared, leaving only useful buildings for the efficient delivery of services.

Figure 11 and and1212 present two different postcards of Reid Memorial Hospital in Richmond, Indiana. The perspective of the artist, the addition of large trees, the brightly colored red roof, and the softening of the tone of the brick make Figure 11 the more appealing of the two versions. Figure 12 was postmarked 1910 and was sent as a birthday card by senders claiming that they had not forgotten the recipient's birthday but did not have any birthday cards or stamps on hand.

Articles and book chapters on hospital postcards are available [12–15]. However, articles that cover specific professional groups depicted on postcards can be important for research on twentieth century health care [16–25]. Articles that discuss postcards depicting various types of medical syndromes and curiosities can also be useful [26]. The author does not collect postcards depicting particular health care professionals or humorous postcards, preferring instead the beautiful, colorful, detailed, and dignified renderings of hospital buildings themselves.

Health sciences librarians may have collections of postcards available in their libraries, in their institutions' archives collection, or through local museums, historical societies, and private collectors. Postcards are also inexpensive, durable, and easy to store, making them an excellent addition to a health sciences library's history of medicine collection. There are several articles and classification schemes for organizing postcards [27, 28]. Not only can postcards be useful for displays, table clinics, poster sessions, presentations, publications, and Websites, but they can also be excellent teaching tools. The author uses postcards as a teaching aid in her health informatics course, not only to illustrate the changing nature of health care over time, but also as an example of a communication tool that was as radical in its day as each new wave of information technology is today.

Many early postcards of hospitals included short descriptions of the facilities, providing useful information for historical research and verification of the publication date of the postcard. Some of these descriptions included the number of beds; specialty services; presence of a nursing school, pharmacy, or nutrition service; and information about the sponsoring organization or founders of the hospital. For example, a description on the postcard showing the ruins of the Retreat Hospital at St. Simons Island, Georgia, indicated that it was the hospital for slaves of the Retreat Plantation, that it was staffed by 2 full-time onsite nurses and a doctor who came as needed, and that $1,000,000 per year was spent for patient care. Likewise, a postcard showing an aerial view of St. Mary's Hospital in Rochester, Minnesota, noted a 900-bed capacity and 20 operating rooms, with the added boast that it was one of the largest private hospitals in the United States. Another postcard described its hospital as beautiful, with 500 beds, a nursing school for 250 students, a modern pharmacy, and a coffee shop.

Postcards also provide a record of the early names of hospitals, many of which were named after founders and city leaders such as Butterworth Hospital (Figure 8). This information is essential in a world where health care is increasingly controlled by large corporations, and original hospital names might be abandoned.

Many elements of postcards can be used for historical research beyond the illustration on the front of the postcard. Many deltiologists prefer cards that are pristine and unused, but postcards that have been written on and mailed present the richest source of information about the lives of ordinary citizens in the early 1900s. Even those that are ragged, folded, or torn, like the postcard in Figure 1, can be valuable additions to a collection when they are intended for scholarly research rather than merely for collecting and later selling or trading.

The names of the senders and recipients of postcards are indicative of another time, with names such as Ella, Gert, Minnie, Esther, Eva, Gladys, and Cecil, charming old-fashioned names rarely heard today. The addresses on early postcards are interesting as well. Typically, addresses on these postcards consist of only the name of the recipient, the city, and the state, with RR#1 (rural route) added occasionally. Street addresses were not usually provided on postcards from the early 1900s, evidence of a time when there were fewer people to keep track of and long before zip codes were necessary. The destinations for postcards are useful as well, with small towns as well as big cities represented. A quick review of the author's collection includes postcards intended for people in Rockville, Hartford City, Wabash, Alexandria, Tipton, South Bend, and Richmond, Indiana, and Detroit, Brighton, and Middleville, Michigan. It is also interesting to contemplate how many hands a postcard has passed through since its original purchase and how many lives it has touched.

Postmarks are another excellent source of information on early postcards. Not only do the postmarks confirm the date that postcards were sent, but they also show the place where the postcard was processed. This processing provides clues as to the movement of the postcard. For example, an early postcard of Johns Hopkins Hospital indicates that it was postmarked on June 29, 1916, in Baltimore and sent to Wabash, Indiana. If senders indicated their locations on the postcard, it is interesting to track the distance between the sender and the postcard's destination. However, many early postcards of hospitals have messages written on them but no addresses, stamps, or postmarks.

Stamps are also an interesting feature of postcards, although not a particularly accurate way to gauge the publishing date of the card. One-cent stamps were used until World War I, when the rate increased to two cents as a “war tax,” but the one-cent stamp again went in effect from July 1, 1919, until December 31, 1951 [29]. Clearly, the low cost of buying and mailing postcards made them an economical and convenient way to communicate in the early 1900s.

The most compelling information on a postcard is the written message. Usually these messages were written in pencil in very neat but tiny handwriting. Some of the messages were indeed from travelers providing details about their trips to family and friends back home. Many other messages concerned local happenings or social plans. Back before telephones, faxes, and emails, postcards were relied on as an inexpensive and efficient means of communication for acquaintances both near and far. Some of the most poignant messages were found on hospital postcards. Many of the messages provided up-to-date reports on family illnesses. For example, Minnie reported from Parkview Hospital in Fort Wayne, Indiana, that the operation was over, but her loved one was “real sick today and in a lot of pain. The operation was more perilous that we thought, but that the Dr. said he would be all right in time. We'll sure be glad to get out of here, but I don't know when.” Likewise, a postcard of St. Joseph Hospital in Flint, Michigan, sent from Delma, indicated that she had been “asked to tell you not to plan on Dad going to Canada. He had a slight stroke last week and isn't a bit well. So he could not stand the trip.” These messages not only reveal information about illness and treatment, but are also interesting given our current society's concerns about the confidentiality of health information. Here on these postcards, with names and addresses attached, are intimate details of the often grim reality of medical care.

Many postcards of early hospitals were obviously sent by nursing students or others in health-related education programs, reporting on their progress. For example, Pat at St. Vincent Hospital in Indianapolis, Indiana, wrote that she would go to bed at 12:00 tonight and that she scored 95% on her first real test in nursing arts, which she studied for until 2:00 a.m. Likewise, Theresa, corresponding with her mother on a postcard from the University of Michigan Hospital, noted a ride to Ypsilanti, 10:30 mass, lunch and dinner at Alta's house, and a carillon concert in the evening.

Many postcards of this era reported personal news and social activities, leading one to wonder why the sender chose to use a postcard of a hospital. For example, on a postcard of The Soldiers' Home in Washington, DC, postmarked July 15, 1912, Leon wrote to Pauline in Marietta, Georgia, that he “[m]et Nancy Reynolds in front of Treasury the other day and had quite a chat with her. Went by your old hanging out place on E Street.” On the other hand, many early hospital postcards were not written on at all, indicating that they were either acquired for the person's own collection, were purchased with good intentions but never used, or were part of an unsold inventory of a city or town's booster-ism that has since found its way into the collectables circuit. Unfortunately, by the middle of the twentieth century, other communication mechanisms were available to people, and the messages on hospital postcards become terse and less interesting for historical research. For example, the message on the postcard of McLaren General Hospital in Figure 10 indicated merely the birth of a baby, his name, and the first name of the person writing the message. An interesting question to ponder is: whether new forms of communication made postcards obsolete; if a more “scientific,” utilitarian, and less personal approach to health care meant that hospitals were no longer considered appropriate subject matter for postcards; or if the public's taste shifted to postcards depicting exciting and glamorous travel destinations rather than “ordinary” community buildings such as hospitals.